RU2316284C1 - Method for removing meningioma ingrowing into the cavity of the upper sagittal sinus in median/posterior third - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: it is necessary to carry out coagulation of tumor tissue being adjacent towards the upper sagittal sinus and ingrowing into it with the ray of Nd-Yag-laser at power ranged 30-35 W for about 5-6 min till the appearance of carbonized tissue in the area of the impact described. Then comes the ablation of this part of tumor at power ranged 15-20 W for about 3-5 min till the appearance of minimal venous hemorrhage out of the sinus. The innovation provides bloodless operation and total removal of tumor at keeping the lumen of the upper sagittal sinus.

EFFECT: higher efficiency.

1 ex

Description

The invention relates to medicine, namely to neurosurgery and can be used to improve the clinical results of the treatment of patients with parasagittal meningiomas that grow into the upper sagittal sinus (BCC) in the middle / posterior third and do not completely plug it (with preserved blood flow).

There is a surgical method for the removal and prevention of recurrence of parasagittal meningioma with a partial ingrowth of meningioma into the lumen of the BCC in the middle / posterior third of it, in the region of one of the sinus angles, which consists in edge resection of the area of the infiltrated dura mater in the region of the BCC angle within the macroscopically unchanged TMT after application bent vascular clamp or clip and dopplerographic control with subsequent suturing of the BCC edge with a continuous atraumatic suture with 5 / 0-7 / 0 thread (G.A. Gabibov, A.V. Koz s Principles of Surgery parasagittal meningiomas:. state of the art // Questions of Neurosurgery 1994. №1, S.3-7).. A significant disadvantage of this method is that, firstly, the removal of the tumor is possible only if the clearance of the SCD is narrowed by no more than 50% and is often accompanied by massive blood loss during resection of the infiltrated SCD wall. Secondly, when the intra-sinus part of the tumor is removed, the percentage of recurrence of parasagittal tumors does not decrease and remains at the same level.

There is a method of surgical removal of meningioma growing in the BCC in the middle / posterior third of it, which consists in removing the intra-sinus part of the tumor and suturing the infiltrated wall of the BCC, carefully coagulating it and putting a hemostatic sponge on the outside (G.A. Gabibov, A.V. Kozlov. Principles surgery of parasagittal meningiomas: the current state of the problem // Questions of Neurosurgery. 1994. No. 1. P.3-7).

The disadvantage of this method, as noted by the authors themselves, is the high invasiveness of the operation. At the time of removal of the tumor from the sagittal sinus, massive bleeding can occur, which greatly complicates the total removal of the tumor node from the SCD. Removing the intra-sinus part of the tumor in this way does not lead to a mathematically significant decrease in the likelihood of continued growth of meningiomas.

Closest to the claimed is a surgical method for removing meningioma growing into the cavity of the BCC in the middle / posterior third of it (G.A. Gabibov A.V. Kozlov. Principles of surgery for parasagittal meningiomas: current state of the problem // Problems of Neurosurgery. 1994. No. 1. S.3-7). This method consists in the removal of the bulk of the tumor by traditional methods and the rejection of marginal sinus resection, if there is a danger of narrowing its lumen by more than 50% or a sharp decrease in blood flow according to Dopplerography when applying a clamp or temporary clip. The part of the tumor that grows into the lumen of the superior sagittal sinus is left undeleted, subjecting it only to monopolar electrocoagulation.

The disadvantage of this method is that the part of the tumor that grows in the SCD remains undeleted, since electrocoagulation affects only its surface layers. This will cause a continued growth of meningioma, and the patient will inevitably undergo repeated surgery. Electrocoagulation of a tumor node growing in the SCD does not affect the incidence of relapse of parasagittal meningiomas.

Objective: to propose a method for atraumatic total removal of the tumor, preventing the occurrence of relapse.

The solution of this problem allows you to get a positive therapeutic effect - to reduce brain injury during surgical removal of the tumor, reduce intraoperative blood loss and surgery time, prevent relapse and improve postoperative treatment results for this group of patients. An economic effect is also achieved - the time spent by the patient in the bed is reduced, the cost of rehabilitation therapy is reduced.

The technical result is achieved through the use of an Nd-YAG laser, which is able to coagulate the tumor to a depth of 0.5-0.7 cm, which allows you to completely remove it. In this case, the tumor dehydrates, decreases in volume and opens up the lumen of the superior sagittal sinus. Bleeding when exposed to a laser on the intra-sinus part of the tumor is minimal.

The problem is solved due to the fact that they produce coagulation of the tumor tissue directly adjacent to the BCC and growing into it with a Nd-Yag laser with a power of 30-35 BT for 5-6 minutes before the appearance of carbonized tissue in the zone of exposure, and then ablation of this area of the tumor with a power of 15-20 W for 3-5 minutes until the appearance of minimal venous bleeding from the sinus.

The method was carried out as follows.

Clinical tomography examination and intraoperative confirmation in a patient with parasagittal meningioma of the middle / posterior third of the BCC that grows into it and does not impair blood flow in it results in surgery using an Nd-YAG laser.

After trepanation and dissection of the dura mater, microsurgical removal of the main mass of meningioma is performed with the exception of the part of the tumor adjacent directly to the BCC. Then carry out the coagulation of tumor tissue directly adjacent to the BCC and growing into it with a beam of an Nd-Yag laser with a power of 30-35 BT for 5-6 minutes before the appearance of carbonized tissue in the area of exposure. This effect initially leads to coagulation of the vessels of the tumor and dehydration of the tumor tissue to a depth of 0.5-0.7 cm. It is significantly reduced in size, “pulled” outward from the BCC and opens its lumen. To completely remove the coagulated part of the tumor, which is still in the SCD cavity, ablation (evaporation) of this part of the tumor with a power of 15-20 W is performed for 3-5 minutes until minimal venous bleeding from the sinus appears. The appearance of venous bleeding from SCD is a pathognomonic sign of total removal of the tumor from the SCD cavity.

Concrete example

Patient K., born in 1950, I / B, 1351/99, was admitted to the Neurosurgery Clinic of NIIITO with a diagnosis of Relapse of giant bilateral parasagittal meningioma of the posterior third of the superior sagittal sinus and falx that grows in the BCC cavity and does not completely obturate it.

From the anamnesis: Operated in a clinic of the Novosibirsk NIIIT in 1990 for a large parasagittal meningioma of the middle third of the sagittal sinus on the left with growth in the BCC cavity. Osteoplastic trepanation was performed in the parietal region on the left, total removal of parasagittal meningioma growing from the falcon sinus angle on the left. The tumor matrix and its part, growing in the SCD cavity, are coagulated by monopolar coagulation.

5 years after the operation, he began to notice headaches in the parietal-temporal region on the left. Headaches gradually increased, and a decrease in memory and vision appeared ("fog before the eyes"). Six months after the onset of headaches, a generalized epipressure developed. After this, epipressions began to be repeated once every 5-6 months. Clinical data indicated a recurrence of meningioma of the same localization, but the patient was not examined (MRI of the brain was not performed).

Over time, headaches and the frequency of seizures increased, in connection with this, in 1999, an MRI of the brain was performed on an outpatient basis, revealing a giant bilateral parasagittal meningioma in the posterior third of the BCC. He was hospitalized at the Neurosurgery Clinic of NIIITO for repeated surgical treatment.

In the neurological status upon receipt of the patient focal neurological symptoms were not detected. The patient was inadequate, uncritical of his condition.

The 2-projection R-grams of the skull revealed a significant increase in finger impressions in the frontal region and the presence of a bone defect with a bone graft located in it in the parietal region on the left.

EEG is a rough focal symptomatology in the form of a focus of slow activity in the parietal lobes on both sides.

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

Eye examination: Vis D = 0.7,

Vis S = 0.6.

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

Brain MRI: a giant bilateral parasagittal meningioma in the posterior SCD 10 × 9 × 10 cm in size, causing compression of the body and the posterior horns of the lateral ventricles and deformation of the corpus callosum. Most of the tumor 6 × 5 × 7 cm in size is located on the left, the smaller - on the right. The tumor on the left invades the SCD cavity in the posterior regions, but does not cause its complete obstruction. Sinus blood flow saved. The size of the intra-sinus part of the tumor is 0.5 × 2 × 0.5 cm. In the place of localization of the tumor, pronounced edema of the brain substance is determined.

On the basis of clinical and tomographic studies, the patient was diagnosed with giant bilateral parasagittal meningioma in the posterior SCD with germination in his cavity on the left, but not causing his obstruction.

07/15/99, an operation in the occipital region: Bone-plastic surgery in the left parietal-occipital region, resection trepanation in the right parietal-occipital region, total removal of the parasagittal giant meningioma with the removal of part of the tumor growing in the BCC.

In the “sitting” position of the patient, osteoplastic trepanation was made in the parietal-occipital region on the left with additional bone resection in the parietal-occipital region on the right measuring 6 × 7 cm. The dura mater (TMT) is sharply tense, almost does not transmit the pulsation of the underlying brain. It is opened by a horseshoe-shaped cut from two sides, the base of the BCC. The parietal and occipital lobes are edematous, prolapse into the defect of the TMT. Parasagittally from two sides on the surface of the brain on an area of 3 × 4 cm, a cherry-colored tumor of dense consistency with a well-defined capsule resembling meningioma is determined. Under an increase of 4.4, coagulation of vessels passing from the brain to the tumor along the border of the tumor was made first on the left and then on the right. Then, using an ultrasound scan, an internal intracapsular tumor decompression (removal of its parenchyma) was performed, first on the side of the larger node (left) and then on the right. After removal of approximately 80% of the tumor mass, it began to separate from the adjacent brain in the depths of the parietal and occipital lobes. The tumor spread in depth, reaching the corpus callosum, so it was necessary to separate it from the pericallous arteries. The tumor matrix is the falx-sinus angle on the left in the posterior third of the BCC and the large sickle process. The part of the large crescent process germinated by the tumor is resected. After removal of the bulk of the tumor, its portion remained immediately adjacent to and growing in the SCD cavity in its posterior third on the left, on an area of 2 × 1 cm. This dense SCD site was palpated well, which was sprouted by meningioma by MRI.

To remove this part of the tumor and prevent its continued growth, coagulation of the tumor tissue directly adjacent to and growing into BCC was performed using a 35 W Nd-Yag laser beam for 5 minutes before the appearance of carbonized tissue in the zone of exposure. The tumor growth site was represented by a dark, dense, structureless dehydrated tissue. This effect initially led to coagulation of the vessels of the tumor and dehydration of the tumor tissue to a depth of 0.5 cm. However, it significantly decreased in volume and opened the lumen of the SCD. To completely remove the coagulated part of the tumor, which is still in the SCD cavity, ablation (evaporation) of this part of the tumor with a power of 15 W was performed for 3 minutes before the appearance of a drop of blood from the SCD. The appearance of venous bleeding from SCD was a confirmation that the tumor was completely removed from it.

After removing the entire volume of the tumor, the brain sank, its ripple appeared. Dura mater produced. The bone flap on the left is laid in place. Soft tissue sutured in layers.

The histological diagnosis is a typical psammomatous meningioma.

In the postoperative period, the patient's condition was satisfactory. He was awake. 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. The degree of cerebral edema in the area of the removed tumor remained unchanged. The patient was activated a week after the operation, independently moving around the department.

Discharged from the clinic after two weeks in satisfactory condition.

At present (7 years after surgery) his condition is satisfactory. Focal symptoms, disorders of higher nervous activity were not detected. The frequency of seizures during anticonvulsant therapy 1 time in 7 months. Brain MRI data from 2006 indicate no recurrence of the disease.

Thus, the use of the Nd-YAG laser according to the technology developed by us allowed us not to additionally injure the brain. This is evidenced by the absence of an increase in neurological symptoms in the postoperative period and cerebral edema in the area of surgical intervention. The developed technology also allowed this stage of the operation to be carried out almost bloodlessly, to completely remove the tumor, while preserving the SCD lumen and to obtain a good long-term clinical result. Analyzing the clinical data of the course of the disease in this patient after the first operation according to standard technologies for removing the tumor from the SCD by coagulation, it can be stated that he recurred the tumor 5 years later. Removal of the tumor during the second operation according to the laser technology developed by us guaranteed in this patient the prevention of recurrence of meningioma for already 7 years.

Claims (1)

A method for removing meningioma growing into the superior sagittal sinus (SCD) in the middle / posterior third by removing a tumor from the sinus cavity, characterized in that the tumor tissue is coagulated directly adjacent to and growing into the SCB with an Nd-Yag laser beam of power 30-35 W for 5-6 minutes before the appearance of carbonized tissue in the area of exposure, and then ablation of this area of the tumor with a power of 15-20 W for 3-5 minutes until the appearance of minimal venous bleeding from the sinus.