RU2235549C1 - Method for protecting anatomic formations in the brain when removing extracerebral tumor with laser - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves separating intact cerebral structures with sheet wadding of 3-4 mm in thickness when removing extracerebral tumors by means of Nd-YAG laser of 55-60 W power. The wadding is impregnated with patient blood.

EFFECT: enhanced effectiveness of treatment; reduced risk of brain injuries.

2 cl

Description

The invention relates to medicine, namely to neurosurgery, and can be used to improve the clinical results of the treatment of patients with eccentric cerebral tumors.

A known method of protecting important anatomical formations of the brain during laser operations aimed at removing extracerebral tumors (Y. A. Zozulya, S. A. Romodanov, V. D. Rozumenko. Laser microsurgery of brain tumors / Journal of Neurosurgery named after N.N. Burdenko, Moscow: Medicine, pp. 3-7, 1988). When removing an extracerebral tumor (auditory nerve neuromas) using a CO ₂ laser, the authors recommend wrapping them in thin cotton strips moistened with physiological saline to prevent thermal damage to important anatomical brain formations (nerves, arterial vessels, brain stem).

A significant disadvantage of this method is that this method of protecting important brain formations is used in laser operations using a CO ₂ - rather than an Nd-YAG laser. The use of this method using this wavelength (10.6 μm) is justified, since the laser beam is completely absorbed in the surface layers of the physiological solution of quilted jackets and does not penetrate deeper. An Nd-YAG laser with a wavelength of 1.06 μm has a significantly higher tissue permeability (up to 1 cm) compared to a CO ₂ laser and is not absorbed by water. Therefore, this type of protection of the anatomical formations of the brain would not only be ineffective, but also harmful. In this case, the brain stem and arterial vessels would undergo serious thermal damage, which would undoubtedly lead to a pronounced neurological deficit, a significant aggravation of the condition of patients, and in some cases, death.

Closest to the claimed is a method of protecting anatomical formations of the brain with Nd-YAG laser removal of an extracerebral tumor (meningioma), described by Edwards M.S., Boggan J.E., Fuller T.A. The laser in neurological surgery. Neurosurgery 59: 556-566, 1983). The authors use it to remove convexital meningiomas using an Nd-YAG laser. To protect the surrounding brain tissue, they use moist cotton moistened with saline or furacilin, or a hemostatic sponge.

This method is not applicable when removing an extracerebral basal tumor using an Nd-YAG laser, since this wavelength penetrates much deeper into the tissue and it will not be absorbed by the physiological solution of the padded jacket, but will go unhindered deeper into the brain stem or the great vessels and cause them to be irreversible thermal damage, which will lead to a violation of its vital functions.

The objective of the proposed method is the elimination of thermal laser damage to important anatomical brain formations (trunk and main arterial vessels) with total removal of extracerebral tumors, reduction of brain trauma during their surgical resection.

The technical result is achieved due to the fact that to protect the anatomical formations of the brain using blood-soaked quilted coats that absorb the radiation of an Nd-YAG laser.

The solution of this problem allows you to achieve a positive therapeutic effect - to save the patient’s life, reduce his stay in bed and significantly improve the postoperative results of treatment of this group of patients.

The problem was solved due to the fact that quilted jackets 3-4 mm thick are impregnated with the patient’s blood and delimited by them the anatomical formations of the brain. In this case, the radiation of a Nd-YAG laser with a power of 55-60 W is absorbed by the blood.

The method was carried out as follows.

Clinical tomographic examination and intraoperative confirmation of an extracerebral tumor in a patient, for example, basal brain meningioma, underwent surgery using an Nd-YAG laser. For this, after trepanation and dissection of the dura mater at the stage of microsurgical removal of the tumor, it was removed using an Nd-YAG laser. Depending on the area of the exposed area of the tumor, its surface treatment was performed with a defocused beam of an Nd-YAG laser with a power of 55-60 W and a diameter of 3-4 mm for 4-5 minutes. This effect led initially to coagulation of the tumor vessels, and then to “boiling” of the dense stroma of the tumor tissue to a depth of 0.5 cm. At the same time, it turned from dense to soft, well-destructible, bloodless and easily removed by ultrasound tissue. Depending on the size of the tumor, and it ranged from 5 × 5 × 5 cm to 10 × 10 × 10 cm, from 9-10 to 16-18 such sequential manipulations were performed: "boiling" a certain volume of the tumor with a laser and subsequent removal of this volume of ultrasound . The laser is used to remove the lateral and middle sections of the tumor.

Further, when removing the medial or posterior meningiomas adjacent directly to the brain stem and the main vessels of the brain (internal carotid artery, anterior and middle cerebral arteries), to eliminate unwanted thermal effects on these important anatomical formations, which could not only significantly deepen neurological symptoms, but also lead to the death of the patient, they were protected by wrapping 3-4 mm thick padded coats soaked in the patient’s blood.

An example of a specific implementation.

Patient A, born in 1951, I / B No. 2669/2000, was admitted to the clinic of neurosurgery with a diagnosis of Giant meningioma of the olfactory fossa.

From the anamnesis: he became ill about 3 years ago, when he began to notice headaches in the frontotemporal region. Gradually, headaches grew, there was a decrease in memory, vision ("fog before the eyes"). Six months before hospitalization, the first generalized epipressure developed, which then began to be repeated at a frequency of 1 time per month. An MRI of the brain was performed on an outpatient basis, which revealed a tumor at the base of the frontal lobes. Hospitalized in a neurosurgery clinic for surgical treatment.

In the neurological status upon receipt of focal neurological symptoms in a patient, with the exception of bilateral anosmia, it was not detected. The patient was inadequate, uncritical of his condition, untidy.

Significant amplification of finger impressions in the frontal region was revealed on the survey R-grams of the skull in 2 projections.

EEE - rough focal symptoms in the form of a focus of slow activity in the frontal lobes on both sides.

ECHOEG - displacements of the median structures of the brain were not detected. Signs of severe intracranial hypertension.

Eye examination: Vis S = 0.6

D = 0.5 without correction of visual acuity.

The fields of vision for white and red are slightly concentrically narrowed. On the fundus stagnant discs on both sides.

Brain MRI: a basal meningioma of the olfactory fossa measuring 9 × 9 × 9 cm, causing compression of the anterior horns of the lateral ventricles and deformation of the corpus callosum.

On the basis of clinical and tomographic studies, the patient was diagnosed with a giant extracerebral tumor (meningioma) in the olfactory fossa.

November 27, 2000 the patient was operated on: Osteoplastic trepanation in the frontal region from two sides, total removal of meningioma of the olfactory fossa.

In the position of the patient on the back, a bilateral osteoplastic trepanation was made in the frontal area with the folding of bone flaps on the temporal muscles. The dura mater (i.e.) is sharply tense, almost does not transmit the pulsation of the underlying brain. It is opened by a linear incision along the superciliary arches. The frontal lobes are edematous, proliferate into a defect so that Under the magnification of 4.4, a small traction of the right frontal lobe was made posteriorly and upward. On the basis of the anterior cranial fossa, a giant cherry-gray tumor of very dense consistency with a well-defined capsule (meningioma) was found.

An Nd-YAG laser was used to remove this giant meningioma of the olfactory fossa. For this, the exposed lateral portion of the brain meningioma was treated with a defocused beam of a 55 W Nd-YAG laser with a diameter of 3-4 mm for 4-5 minutes. After this, bloodless removal of this tumor volume was carried out using ultrasound. Using a laser scalpel in this mode allowed us to coagulate the tumor to a strictly limited depth, since high temperatures, reaching 100 ° C, were created in the exposure zone. At the same time, it turned from dense to soft, well-destructible, bloodless and easily removable by ultrasound tissue. Thus, further removal of the tumor was carried out.

The destruction and suction of this soft, non-bleeding tumor tissue occurs using an ultrasonic aspirator (ultrasound). Given the size of the tumor according to MRI (9 × 9 × 9 cm), 14 such sequential manipulations were performed: “boiling” a certain volume of the tumor with a laser and subsequent removal of this volume of ultrasound. The laser was used by us at removal at all stages. When removing the lateral and middle sections of the tumor with a laser, the probability of thermal damage to the brain stem and internal carotid artery was excluded, since the tumor reliably covered them itself.

In the future, when the medial and posterior parts of the tumor are removed due to the high probability of thermal damage to the brain stem, main arterial vessels (internal carotid arteries, anterior cerebral arteries) and hypothalamic departments and a high likelihood of gross neurological deficiency and death, we delimited these formations with padded 4 mm thick soaked in the patient’s blood. This was done so that this high-intensity laser radiation with a power of 55 W was completely absorbed by the patient’s blood located on the quilted jackets and did not penetrate these important formations and did not lead to their thermal destruction. Further laser removal of the tumor was carried out by the same method.

The volume of the tumor was so large that, after its total removal, the optic nerves, chiasm, internal carotid arteries, anterior cerebral arteries, and anterior connective artery and brain stem became clearly visible. After removing the entire volume of the tumor, the brain sank, its ripple appeared.

The operation on this was completed. The dura mater is sutured tightly. Bone flaps laid in place. Soft tissue sutured in layers.

The histological diagnosis is a typical psamomatous meningioma.

In the postoperative period, the patient's condition was satisfactory. He was conscious, adequate. Headaches hardly bothered.

Neurological symptoms did not increase.

Control MR imaging of the brain, performed on the 3rd day after the operation, confirmed the absence of a tumor. Cerebral edema persisted at the preoperative level. The patient was activated a week after the operation. He independently moved around the department. Discharged from the clinic after two weeks in satisfactory condition.

Currently, his condition is satisfactory. Focal symptoms, disorders of higher nervous activity were not detected. Disabled person 3 groups.

Thus, the use of the Nd-YAG laser during removal of the posterior and medial sections of the giant basal meningioma of the brain (9 × 9 × 9 cm) with the protection of important anatomical brain formations according to the technology developed by us allowed us not to additionally injure the brain (this is indicated by the absence of increase in neurological symptoms in the postoperative period and the previous degree of cerebral edema in the area of surgical intervention according to the control of MRI), to conduct total removal of the tumor, to save the patient’s life u and get an excellent clinical result.

Claims (2)

1. A method of protecting important anatomical formations of the brain during laser removal of extracerebral tumors by laying a quilted jacket on them, characterized in that quilted jackets 3-4 mm thick soak the patient’s blood and delimit the anatomical brain formations. 2. The method according to claim 1, characterized in that the radiation of the Nd-YAG laser with a power of 55-60 watts is absorbed by the blood.