Strategie si tehnici operatotii in meningioamele de etaj anterior

8/10/2019 Strategie si tehnici operatotii in meningioamele de etaj anterior

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CURS REZIDENTIPROF. UNIV. DR. GORGAN RADU MIRCEA

IUNIE 2009

www.neurochirurgie4.ro


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Elementele care concura la stabilirea strategieichirurgicale in meningioamele de etaj anterior albazei craniului sunt:

1) localizareaemisfer dominant,nedominant, dezvoltarea bilaterala

2) marimea leziun ii- sub 3 cm diametru,peste 3 cm diametru

3) estimarea imagist ic a properato rie ainsert iei du rale- localizarea acesteia,intinderea, profunzimea eroziunilor osoase.



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4) rapo rtu r i le cu s inu su ri le aericefrontale,etmoidale, sfenoidale

5) rapo rtu ri le cu magis tralele arteriale sivenoaseanterioare (ACI, ACA, a Com,ramurile A sy, sinusul cavernos)

6) gradu l de compresie al parenchimulu icerebral, modificarile ischemiceconstituite imagistic si vechimea acestora



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7) estimarea bilan tulu i circ ulato r regional datde hipervascularizatia regionala caracteristicameningioamelor

8) aprec ierea ind irecta a gradu lu i decons isten ta si vascularizatie al tumor i iinfunctie de explorarile imagistice

9) parametri i cl in ici, bio log ici, neuro log ici ai

pacientulu isi asteptarile acestuia10) experienta ch irurgulu i, dotarile serviciului si

calitatea ingrijirii postoperatorii



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Tehnica chirurgicala va fi adaptata in

functie de particularitatile fiecarui caz!



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-frontolateral

-pterional

-bifrontal -endoscopic

trans-sfenoidal

-supraorbitarkeyhole

-aborduri

combinatecraniofaciale incazul invazieilameicribriforme



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Emisfer dominant,nedominant,dezvoltareabilaterala

Sant olfactiv,tubercul selar,sinus cavernos,invazie orbitara

http://images.google.ro/imgres?imgurl=http://img.medscape.com/fullsize/migrated/511/120/nf511120.fig8.gif&imgrefurl=http://www.medscape.com/viewarticle/511120_5&usg=__gcAPgVLH1RKhvSFmdb8ZVh0c2gU=&h=570&w=675&sz=312&hl=ro&start=12&um=1&tbnid=g1BQCDubCX3gvM:&tbnh=117&tbnw=138&prev=/images?q=anterior++meningioma&hl=ro&sa=G&um=1http://images.google.ro/imgres?imgurl=http://img.medscape.com/fullsize/migrated/511/120/nf511120.fig8.gif&imgrefurl=http://www.medscape.com/viewarticle/511120_5&usg=__gcAPgVLH1RKhvSFmdb8ZVh0c2gU=&h=570&w=675&sz=312&hl=ro&start=12&um=1&tbnid=g1BQCDubCX3gvM:&tbnh=117&tbnw=138&prev=/images?q=anterior++meningioma&hl=ro&sa=G&um=1http://images.google.ro/imgres?imgurl=http://img.medscape.com/fullsize/migrated/511/120/nf511120.fig8.gif&imgrefurl=http://www.medscape.com/viewarticle/511120_5&usg=__gcAPgVLH1RKhvSFmdb8ZVh0c2gU=&h=570&w=675&sz=312&hl=ro&start=12&um=1&tbnid=g1BQCDubCX3gvM:&tbnh=117&tbnw=138&prev=/images?q=anterior++meningioma&hl=ro&sa=G&um=1


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sub 3 cm diametru, peste 3 cm diametru,

leziuni gigante>6 cm diametru

http://radiopaedia.org/cases/meningioma-olfactory-groove-/images/5104http://radiopaedia.org/cases/meningioma-olfactory-groove-/images/5098http://radiopaedia.org/cases/pituitary-fossa-meningioma/images/16870


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localizarea acesteia, intinderea,

profunzimea eroziunilor osoase.



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Frontale, etmoidale, sfenoidale



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http://journals.lww.com/neurosurgery/pages/imagegallery.aspx?year=2003&issue=09000&article=00002&ImageId=FF2http://journals.lww.com/neurosurgery/pages/imagegallery.aspx?year=2003&issue=09000&article=00002&ImageId=FF1


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ACI, ACA, a Com, ramurile

A sy, sinusul cavernos

http://radiopaedia.org/cases/meningioma-olfactory-groove-/images/5104http://radiopaedia.org/cases/meningioma-olfactory-groove-/images/5110http://radiopaedia.org/cases/meningioma-olfactory-groove-/images/5110http://radiopaedia.org/cases/meningioma-olfactory-groove-/images/5104


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Anastomozele abundente intre: arterele etmoidale anterioare si

posterioare

ramuri colaterale meningealeprovenite din ACI

artere frontale si sfenoidale dinACM

ramuri distale din artera maxilarainterna prin arterele sfenopalatine

rezulta anastomoze patente cuartera oftalmica iar riscul de orbiredupa embolizarea colateraleloreste maxim



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Modificarile ischemice constituite imagistic

si vechimea acestora



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Hipervascularizatia regionala

caracteristica meningioamelor

http://www.uhrad.com/mriarc/mri036c2.jpg


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Aprecierea indirecta a gradului de

consistenta si vascularizatie al tumorii in

functie de explorarile imagistice-calcificari



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Parametrii clinici, biologici, neurologici aipacientului

Anosmia

Paraliziile de oculomotori

Scaderea acuitatii vizuale

Sindromul frontal

Deficitele motorii

etc

http://www.mdconsult.com/das/article/body/0/jorg=journal&source=&sp=11345248&sid=0/N/181599/f0328001a.jpg


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Abo rdu l endonazal-pentru leziuniretrochiasmatice

Abordu l supraorbi talkey-hole-pentru leziunisub 35 mm situatedeasupra portiuniisupraclinoidiene a ACI

Limite!



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Fistu le LCR

Mucocele

Infecti i

Hematoame-ramolismentehemoragice

Ischem ii-infarcte



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Rezectiile Simson 1 sunt rareori posibile

Rezultatele chirurgiei depind de:

Starea clinica si neurologica a pacientuluiMarimea tumorii si vascularizatia piala

Gradul rezectiei tumorale

Edemul cerebral preoperator

Gradul si vechimea afectarii nervilor cranieni

Gradul de malignitate al leziunii



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Strategie si tehnici operatotii in meningioamele de etaj anterior

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