本文關(guān)鍵詞： 前庭神經(jīng)鞘瘤 彌散張量示蹤圖 面神經(jīng) 蝸神經(jīng) 三叉神經(jīng)鞘瘤彌散張量追蹤圖像 面聽神經(jīng) 三叉神經(jīng) 外展神經(jīng)　出處：《首都醫(yī)科大學(xué)》2015年博士論文　論文類型：學(xué)位論文

【摘要】：背景前庭神經(jīng)鞘瘤（Vestibular schwannoma, VS）手術(shù)的目的就是在消滅腫瘤的同時(shí)，保護(hù)好患者的面、聽神經(jīng)功能。在大聽神經(jīng)瘤中，由于神經(jīng)位置、走行的不確定性，以及神經(jīng)在形態(tài)學(xué)上較正常神經(jīng)常發(fā)生較大的偏差，使在術(shù)中達(dá)到這一目標(biāo)挑戰(zhàn)重重。在之前的研究中，有人在術(shù)前用面神經(jīng)的彌散張量示蹤圖像（Diffusion tensor tractography, DTT）來預(yù)測(cè)面神經(jīng)的位置。本研究將在這一技術(shù)的基礎(chǔ)上，引入“超選”這一概念，來研究DTT用于術(shù)前判斷面神經(jīng)，蝸神經(jīng)和三叉神經(jīng)的有效性。 方法本研究共納入2013年11月至2014年5月間就診于首都醫(yī)科大學(xué)宣武醫(yī)院的23位患者，腫瘤大小從漢諾威分級(jí)T3b到T4b不等。在3.0T的MRI上，采集受試者的彌散張量成像（Diffusion tensor image, DTI）以及增強(qiáng)的穩(wěn)態(tài)構(gòu)成干擾序列（Contrasted constructive interference in steady state, CISS+C），將其導(dǎo)入Brainlab iPlan3.03導(dǎo)航工作站，在術(shù)前對(duì)患者的顱神經(jīng)進(jìn)行DTT重建，預(yù)測(cè)其相對(duì)于腫瘤的位置，然后在術(shù)中對(duì)這一結(jié)果進(jìn)行驗(yàn)證。 結(jié)果在21位患者（91.30%）中，DTT描述的面神經(jīng)位置同術(shù)中情況吻合。這其中包括2例面神經(jīng)從腫瘤與囊變之間穿過的病例以及3例發(fā)生面神經(jīng)膜變的病例。此外，在4位有術(shù)前有效聽力的患者中，DTT技術(shù)在術(shù)前成功辨認(rèn)出了腫瘤周圍除面神經(jīng)和三叉神經(jīng)以外的神經(jīng)，其中，2例明確為蝸神經(jīng)，另外2例無法判定具體的神經(jīng)功能。在1位患者中，DTT在術(shù)前識(shí)別出了從腫瘤中間穿過的神經(jīng)纖維，而該纖維的存在在術(shù)中得到了驗(yàn)證。 結(jié)論超選DTT可以有效預(yù)測(cè)復(fù)雜情況下的面神經(jīng)，包括膜變的面神經(jīng)、從囊變與瘤實(shí)質(zhì)之間穿過的面神經(jīng)；還可以有效識(shí)別蝸神經(jīng)以及被腫瘤包繞的神經(jīng)纖維結(jié)構(gòu)，有助于提升聽神經(jīng)瘤手術(shù)的安全性。 背景三叉神經(jīng)鞘瘤（Trigeminal schwannoma）為第二大顱內(nèi)神經(jīng)鞘瘤，，手術(shù)相關(guān)的顱神經(jīng)功能缺損在三叉神經(jīng)鞘瘤手術(shù)中是普遍存在的現(xiàn)象。由于腫瘤可以起源于三叉神經(jīng)節(jié)及節(jié)前和節(jié)后的鞘膜，導(dǎo)致瘤周顱神經(jīng)位置差別較大。而較低的發(fā)病率使既往研究難以通過大宗病例來揭示顱神經(jīng)的排列，手術(shù)醫(yī)師在術(shù)前對(duì)神經(jīng)位置的預(yù)判難以充分。近年來，DTT被用來在術(shù)前尋找聽神經(jīng)瘤周圍的面聽神經(jīng)，但未見DTT用于三叉神經(jīng)鞘瘤的相關(guān)報(bào)道。 方法本研究共納入2014年1月至2014年11間就診于首都醫(yī)科大學(xué)宣武醫(yī)院的3位患者，腫瘤均主要位于CPA區(qū)。在3.0T的MRI上，采集受試者的彌散張量成像（Diffusion tensor image, DTI）以及增強(qiáng)的穩(wěn)態(tài)構(gòu)成干擾序列（Contrastedconstructive interference in steady state, CISS+C），將其導(dǎo)入Brainlab iPlan3.03導(dǎo)航工作站，在術(shù)前對(duì)患者的顱神經(jīng)進(jìn)行DTT重建，預(yù)測(cè)其相對(duì)于腫瘤的位置，然后在術(shù)中對(duì)這一結(jié)果進(jìn)行驗(yàn)證。 結(jié)果在術(shù)中，3位患者的V-VIII對(duì)顱神經(jīng)在三叉神經(jīng)鞘瘤周圍排列差異較大。而在3位患者V-VIII對(duì)顱神經(jīng)的DTT結(jié)果中，除病例3的展神經(jīng)外，其余神經(jīng)的排列同術(shù)中情況完全吻合，各種變異均被DTT準(zhǔn)確描述。 結(jié)論超選DTT可以通過對(duì)V-VIII對(duì)顱神經(jīng)的重建，有效預(yù)測(cè)三叉神經(jīng)鞘瘤周圍多變的顱神經(jīng)排列方式，為術(shù)者在術(shù)前提供一個(gè)神經(jīng)排列的可靠印象，從而有助于三叉神經(jīng)鞘瘤周圍顱神經(jīng)的保留。
[Abstract]:Background : The purpose of the surgery is to protect the patient ' s face and listen to the neurological function while the tumor is eliminated . In the large acoustic neuroma , the position of the facial nerve is predicted due to the nerve position , the uncertainty of walking , and the more normal nerve in morphology . In the previous study , the concept of " hyperselective " was introduced to study the effectiveness of DTT for the determination of facial nerve , cochlear nerve and trigeminal nerve before operation . Methods This study was included in 23 patients at the Xuanwu Hospital of Capital Medical University between November 2013 and May 2014 . The size of tumor ranged from Han ' s to T4b . On MRI of 3.0 T , diffusion tensor imaging ( DTI ) and enhanced steady state constitutive interference sequence ( CISS + C ) were collected , which was introduced into Brainlab iPlan3 . 03 navigation workstation . After operation , the cranial nerves of the patients were reconstructed to predict their position relative to the tumor , and then the results were validated during the procedure . Results In 21 patients ( 91.30 % ) , the position of facial nerve described by DTT was consistent with that in the operation . This included 2 cases of facial nerve passing between tumor and capsule and 3 cases of facial nerve film change . In addition , DTT technique successfully identified the nerves except facial nerve and trigeminal nerve in 4 patients with preoperative effective hearing . In one patient , DTT identified nerve fibers passing through the middle of the tumor before operation , and the presence of the fiber was verified during operation . Conclusion The super - selected DTT can effectively predict the facial nerve in complex cases , including facial nerve of the membrane , the facial nerve passing between the cystic degeneration and the tumor parenchyma , and can effectively identify the cochlear nerve and the nerve fiber structure surrounded by the tumor . It can help to improve the safety of the acoustic neuroma . BACKGROUND To the present study , it is difficult to reveal cranial nerves in patients with trigeminal neurilemmoma due to the fact that tumor can originate from trigeminal ganglion and preganglionic and ganglionic sheath , and the lower incidence makes it difficult to reveal cranial nerve arrangement through large cases . In recent years , DTT has been used to find the acoustic nerve around the acoustic neuroma before surgery , but no DTT is used in the related report of trigeminal neurilemmoma . Methods This study was included in three patients from January 2014 to November 2014 at the Xuanwu Hospital of Capital Medical University . The tumor was mainly located in CPA area . On MRI of 3.0 T , the diffusion tensor imaging ( DTI ) and enhanced steady state constitutive interference sequence ( CISS + C ) were collected , which was introduced into Brainlab iPlan3 . 03 navigation workstation . After operation , the cranial nerves of the patients were reconstructed to predict their position relative to the tumor , and then the results were verified during operation . Results Among the 3 patients , V - VIII was significantly different around the trigeminal neurilemmoma . In the 3 patients with V - VIII , except for the abducens of the case 3 , the arrangement of the remaining nerves was completely consistent with that in the operation . All the variations were accurately described by DTT . Conclusion The super - selective DTT can be used to reconstruct the cranial nerves around the trigeminal neurilemmoma by the reconstruction of V - VIII to the cranial nerves , and provide a reliable impression of the nerve arrangement before the operation , thus contributing to the retention of the cranial nerves around the trigeminal neurilemmoma .

【學(xué)位授予單位】：首都醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R739.4

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本文編號(hào)：1453995