RU2322213C1 - Method for resecting the part of the superior sagittal sinus being completely occupied with tumor in its middle/posterior third - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: acutely one should dissect the part of tumor-occupied sinus being 0.5 cm against anatomically intact sinus at the front and from behind. It is necessary to coagulate anterior, not dissected tumor-occupied part of the superior sagittal sinus (SSS) with radiation of Nd-Yag laser at power being 20-25 W for 2-3 min till the appearance of carbonized tissue in area of the impact suggested. Then comes the ablation of this part of sinus with radiation at power being 10-15 W for about 5-7 min till the onset of minimal venous hemorrhage out of the intact part of sinus, then it is important to carry out analogous treatment of posterior, not dissected part of SSS. The innovation enables to keep venous collectors inflowing into the intact SSS, avoid additional cerebral traumatism and practically bloodlessly remove the tumor totally.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to neurosurgery, and can be used to improve the clinical results of treatment of patients with parasagittal meningiomas that grow into the upper sagittal sinus (SCD) in the middle / posterior third and completely plug it.

A surgical method is known for removing and preventing the recurrence of parasagittal meningiomas with complete germination of the SCD lumen in the middle / posterior third. With complete BCC occlusion at the end of the operation, the obliterated area is resected with the mandatory preservation of compensatory veins flowing into the sinus anterior and posterior to the occlusion site (G.A. Gabibov, A.V. Kozlov. Principles of surgery for parasagittal meningiomas: current state of the problem // Questions of Neurosurgery. 1994. No. 1. P.3-7).

A significant disadvantage of this method is the high probability of massive blood loss during resection of the infiltrated SCD wall. In addition, with this removal of the intrasinus part of the tumor, the percentage of relapse of parasagittal tumors does not decrease and remains at the same level.

Closest to the claimed is a surgical method for the removal of meningioma, growing and completely plugging SCD in the middle / posterior third (N. N. Schmidek, W. H. Sweet. Operative Neurosurgical Techniques: Indications, Methods, and Results. 2nd ed. Orlando, 1988). The method consists in determining the boundaries of the sinus region that has sprouted by the tumor, excising it, and then using the autovenous graft from the saphenous vein of the thigh for plasty of the sinus defect. The transplant must be placed in the external framework (either from a T-shaped temporary vascular shunt or from a reinforced arterial prosthesis) to give it the necessary stiffness, and also correctly oriented to the blood flow. To prevent thrombosis, a prerequisite is irrigation of the wound with a heparin solution and its introduction into the BCC lumen, the establishment of isolated platinum microelectrodes in the suture area and at the center of the graft for 5-7 days, which must then be removed.

To replace relatively small defects in one or two walls of the SCD, local tissues (TMT, aponeurosis, or muscle-aponeurotic flap) can be used. A temporary stop of bleeding from the BCC is provided by the occlusion of its cylinders (it is possible to install a temporary bypass shunt with inflated cuffs to maintain blood flow during the plastic phase of the operation) or by pressing a finger on the inner surface of the bones of the skull at the front and rear edges of the bone defect.

The obvious disadvantages of this method are the extremely complex and laborious for the neurosurgeon plastic microsurgical manipulations, accompanied by massive blood loss and significantly lengthening the surgical intervention. They can be performed only by high-class neurosurgeons and reproduced in isolated cases. In simple neurosurgical clinics, their replication is impossible. In addition, it is necessary to first investigate the patency of the deep veins of the lower leg and subsequently replace the v.saphena magna defect with a synthetic venous prosthesis.

The objective of the proposed method is the total atraumatic removal of parasagittal meningiomas, completely plugging SCD in the middle / back of its third.

The solution of this problem allows you to radically remove the tumor, reduce brain injury, reduce intraoperative blood loss, significantly improve the postoperative results of treatment of this group of patients, reduce the patient’s stay in bed.

The technical result is achieved through the use of an ND-YAG laser to remove parasagittal meningiomas that completely plug in BCC in its middle / posterior third.

The problem is solved due to the fact that the section of the sinus germinated by the tumor is excised in an acute way, departing 0.5 cm from the anatomically unchanged sinus in the front and back, the anterior not excised part of the superior sagittal sinus is grown, the tumor has grown, by radiation from an Nd-Yag laser with a power of 20-25 W for 2-3 minutes, before the occurrence of carbonized tissue in the area of exposure, this section of the sinus is ablated by radiation with a power of 10-15 W for 5-7 minutes, until the appearance of minimal venous bleeding from unchanged the second part of the sine, then the back non-excised part of the BCC is processed by radiation of an Nd-Yag laser of the same power and duration to obtain a similar result.

The method is as follows.

With clinical and tomographic detection of parasagittal meningioma of BCC, which completely germinates in the middle / posterior third, surgery is performed using an Nd-YAG laser.

After trepanation and dissection of the dura mater, microsurgical removal of meningioma is performed with the exception of the part of the tumor that germinates SCD in its middle / posterior third. A section of the BCC that is completely overgrown with meningioma is palpated.

The procedure for excising the part of the SCD that has sprouted by the tumor should be carried out very carefully, preserving every millimeter of the anatomically preserved sinus. Therefore, the section of the sinus is excised from the side where it sprouted with a tumor. The intersection of the sinus directly along the border with the tumor will lead to massive venous bleeding from it, and after it stops, to an additional shortening of the unchanged part of the sinus, which will undoubtedly affect the violation of the venous outflow along it. In addition, hasty and gross manipulations in the field of the air force can lead to the separation of large venous collectors that flow into the sinus and the appearance of “venous” cerebral infarctions.

To exclude the above-described complications from the sprouted part of the BCC, the section is excised in an acute way, departing 0.5 cm from the anatomically unchanged sinus in front and behind. Then, the first step is the coagulation of the anterior, non-excised part of the BCC of a 0.5 cm long sinus section of the tumor that has sprouted with a tumor by radiation of an Nd-Yag laser with a power of 20-25 W for 2-3 minutes, before the appearance of carbonized tissue in the zone of exposure. Then, layer-by-layer ablation of this part of the sinus with the tumor is carried out by radiation of an Nd-Yag laser with a power of 10-15 W for 5-7 minutes, until minimal venous bleeding from the unchanged part of the sinus appears. The appearance of venous bleeding from the sinus indicates complete removal of the tumor.

The second step is the coagulation of the posterior non-excised part of the BCC by radiation of an Nd-YAG laser with a power of 20-25 W for 2-3 minutes, before the appearance of carbonized tissue in the area of exposure and ablation of this sinus with a power of 10-15 W for 5-7 minutes , until the appearance of minimal venous bleeding from the unchanged part of the sinus.

Laser resection of this part of the sinus occurs atraumatically without contact with the sinus and tumor and does not cause any additional trauma and rough manipulations with it. In addition, all this happens absolutely bloodless.

Concrete example

Patient O., 52 years old, I / B No. 4297/05 was admitted to the Neurosurgery Clinic of NIITO with DZ: Giant parasagittal meningioma in the parietal region on the right with full germination of the upper sagittal sinus in the middle / posterior third.

From the anamnesis - 4 years ago I began to notice headaches in the frontoparietal region from two sides. Headaches gradually increased, and a decrease in memory and vision appeared (“fog before the eyes”). Two years after the onset of headaches, a generalized epipressure developed. After that, the frequency of seizures was 2 times a year. For 6 months before admission, weakness in the left arm and leg appeared and began to progress.

A brain MRI scan revealed giant parasagittal meningioma in the right parietal region. Hospitalized at the Clinic of Neurosurgery NIITO for surgical treatment.

In neurological status upon admission, the patient has central moderate left-sided hemiparesis. No other focal symptoms were detected.

On the survey R-grams of the skull in 2 projections, a significant increase in finger impressions in the frontal region is revealed.

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

Eye examination: Vis D = 0.8

Vis S = 0.7.

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 parasagittal meningioma in the middle-posterior SCD 10 × 9 × 10 cm in size, causing compression of the body and horn horns of the lateral ventricles and deformation of the corpus callosum. The tumor invades the SCD cavity in the mid-posterior regions and causes its complete obstruction for 3.0 cm. There is no sinus flow in this zone. In the place of localization of the tumor, pronounced edema of the brain substance is determined.

Based on clinical and tomographic studies, the patient was diagnosed with giant parasagittal meningioma in the middle-posterior sections of the SCD with its full germination over 3 cm.

The patient was operated on December 15, 2005 - bilateral trepanation (more to the right) in the parietooccipital region is parasagittal, total microsurgical removal of the tumor that invades the SCD wall together with the superior sagittal sinus at the border of its middle / posterior third.

For this, after trepanation and dissection of the dura mater, microsurgical removal of a giant parasagittal meningioma was performed using ultrasound with preservation of the BCC and its portion completely grown by the tumor in its middle / posterior third. The size of the removed node was 10 × 9 × 10 cm. The tumor matrix was the right lateral wall of the SCD at the border of its middle / posterior third. A dense section of the SCD was completely palpated here, completely overgrown with meningioma. Its length was 3 cm.

For radical removal of meningiomas, it was decided to excise SCD in the area overgrown with the tumor within healthy tissues. To do this, from the sprouted part of the BCC, the section was excised in an acute way, departing 0.5 cm from the anatomically unchanged sinus in front and then back. The length of the excised section of the sinus was 2 cm. This manipulation was carried out carefully with the help of an electric knife - the section of the sinus germinated by the tumor was excised, 0.5 cm from the border of the anatomically unchanged part. At the same time, the unchanged part of the sinus and veins flowing into it were preserved.

After this, the first step was the coagulation of the anterior, non-excised part of the BCC, which was grown with a tumor 0.5 cm long by radiation from a 25 W Nd-YAG laser for 2.5 minutes before the appearance of carbonized tissue in the area, and then layered ablation of this section of the sinus with radiation power of 15 W for 5 minutes, until the appearance of minimal venous bleeding from the unchanged part of the sinus. The appearance of venous bleeding from the sinus testified to the complete removal of the tumor.

The second step was the coagulation of the posterior non-excised part of the BCC by radiation of an Nd-Yag laser with a power of 25 W for 2.5 minutes, before the appearance of carbonized tissue in the area of exposure, and ablation of this section of the sine by radiation with a power of 15 W for 5 minutes, until a minimal venous bleeding from the unchanged part of the sinus.

Laser resection of this part of the sinus proceeded atraumatically without contact with the sinus and tumor and did not cause any additional trauma and gross manipulations with it. In addition, all this happened absolutely bloodless.

After excision of the part of the BCC sprouted by the tumor, a defect of 3 cm in length was formed. All veins flowing into the unchanged BCC were preserved.

After removing the entire volume of the tumor, the brain sank, its ripple appeared. Dura mater produced. The bone flap is 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. She 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 a week after the operation was activated, independently moved around the department. Discharged from the clinic 12 days after the operation with regressive left-side hemiparesis.

Currently, her condition is satisfactory. Easy left-sided central hemiparesis remains.

Thus, the use of the Nd-YAG laser according to our technology during the removal of cerebral meningioma growing in the SCD cavity and causing its complete obstruction, allowed us to preserve venous collectors flowing into the unchanged SCD and not to additionally injure the brain (this is evidenced 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 MRI), to conduct this stage almost bloodlessly surgery, totally remove the tumor and get a good clinical result.

Claims (1)

The method of resection of the part of the upper sagittal sinus (BCC), which completely germinated the tumor in its middle / posterior third, by determining the front and back borders of the germinated part of the sinus, characterized in that the section of the sinus germinated by the tumor is sharply excised, retreating by 0.5 cm from the anatomically unchanged sinus in the anterior and posterior regions, the anterior, uncircumcised portion of the superior sagittal sinus, which is sprouted by a tumor, is coagulated by radiation of an Nd-Yag laser with a power of 20-25 W for 2-3 min until a carbonized appearance in the affected area tissue ablation is carried out of this area of 10-15 watts sine radiation for 5-7 minutes until the minimum venous bleeding from the unmodified portion of the sine, and then similar processing is carried back, neissechennoy part BCC.