内镜下经鼻切除颅底肿瘤术中高流量脑脊液漏的处理*

Treatment of high-flow cerebrospinal fluid leak after endoscopic endonasal resection of skull base tumor*

摘要:

目的??探讨内镜下经鼻切除颅底肿瘤术中高流量脑脊液漏的处理方法及疗效。方法?回顾性分析2013年5月-2016年1月使用内镜下扩大经鼻入路（EEEA）切除的48例术中出现高流量脑脊液漏的颅底肿瘤患者的临床资料。肿瘤切除后采用含带蒂鼻中隔黏膜瓣（HB瓣）的多层颅底重建技术，术后予以腰大池置管引流、抗感染等治疗。结果?上述病例术中以鞍上池开放最为常见，第三脑室开放17例；颅底硬膜缺损位于蝶骨平台至鞍底42例，鞍底3例，斜坡3例，缺损面积均大于2 cm2。术后发生脑脊液漏4例（8.3%），并伴随颅内感染，1例予以延长脑脊液引流时间和加强抗感染后治愈，余3例再次内镜下修补，原因分别为带蒂鼻中隔瓣移位和部分坏死，其中成功2例，死亡1例。术后随访5个月～3年，颅底组织愈合良好，无脑脊液漏、颅内感染发生。结论?采用含HB瓣的多层颅底重建技术是一种有效的处理内镜颅底外科手术中高流量脑脊液漏的方法。

Abstract:

Objective?To discuss the treatment and its therapeutic efficacy of high-flow cerebrospinal fluid leak after endoscopic endonasal resection of skull base tumor. Methods?The records of 48 patients with skull base tumor operated on with extended endoscopic endonasal approach from May 2013 to January 2016 were retrospectively reviewed. After lesion removal they all had high-flow cerebrospinal fluid leaks, and we use artificial and autologous free material and vascular pedicled nasoseptal flap to reconstruct skull base defect, then lumbar drainage and anti-infection were employed. Results?Large opening of suprasellar cistern was commonly seen, opening of third ventricle was seen in 17 cases. There were 42 dural defects located between planum sphenoidale and sella floor, 3 dural defects located at sella floor and 3 dural defects located at clivus, the size of these dural defects were all bigger than 2 cm2. There were 4 cases had cerebrospinal fluid leak after surgery, accompanied with intracranial infection. One case was cured with extending cerebrospinal fluid drainage time and enhancing anti-infection, another 3 cases were repaired under endoscope again, we found that reason of cerebrospinal fluid leak were the movement and partial necrosis of vascular pedicled nasoseptal flap, 2 cases were saved and one case was dead. All cases healed well, with no delayed cerebrospinal fluid leaks or intracranial infections during the 5 months to 3 years follow-up period except dead case. Conclusion?Multilayer skull base reconstruction including vascular pedicled nasoseptal flap is an effective method for the treatment of high-flow cerebrospinal fluid leak in the endoscopic skull base surgery.