RESUMO
OBJECTIVE: To learn about the effects of cranial base surgery. DESIGN: Cohort study with a mean follow-up of 30 months. SETTING: Population-based. PATIENTS: A consecutive sample of 183 patients who underwent cranial base surgery; 118 patients had malignant skull base tumors, the majority of which were previously treated; 50 had benign tumors; 9 had congenital malformations of the skull base; 3 had inflammatory lesions, and 3 had traumatic defects of the skull base. MAIN OUTCOME MEASURES: Disease-free interval, overall survival, and rate of complications and functional status. INTERVENTION: Cranial base surgery was followed by radiotherapy (in previously untreated patients). RESULTS: After completion of follow-up (mean, 30 months), 30 (25.4%) patients had died of their malignant tumors and 8 (6.8%) had died of other causes. One patient (0.84%) was lost to follow-up. The overall cancer survival rate without regard to histologic type was 67% (63% with no evidence of disease). Among the patients who were treated for benign neoplasm, 72% had no evidence of disease at a mean follow-up of 39 months. The group of patients with congenital malformations and inflammatory and traumatic lesions demonstrated successful correction of their presurgical problem with skull base surgery. One patient (who had invasive aspergillosis) died of disease. The overall surgical-medical mortality rate was 2%; the complication rate was 33%, and the Karnofsky performance score was improved or unchanged after surgery in 83% of patients. The average duration of surgery, number of blood transfusions used, and length of the hospital stay were 10 hours, 3 units, and 15 days, respectively. CONCLUSIONS: Cranial base surgery is a valid surgical technique for treatment of cranial base afflictions. In this study it was found to be beneficial in controlling benign and malignant disease and to be the treatment of choice for selected congenital malformations, trauma, and inflammatory lesions.
Assuntos
Neoplasias Cranianas/cirurgia , Crânio/cirurgia , Adolescente , Adulto , Criança , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Crânio/anormalidades , Neoplasias Cranianas/mortalidade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
This study reviewed 124 patients who required facial nerve manipulation during cranial base surgery. Most of them underwent only nerve displacement or selective transection for improved surgical access to the cranial base (70 and 34, respectively). Fourteen patients had the facial nerve resected for oncologic reasons and repaired with primary nerve grafting. Most patients regained quite satisfactory facial function with quality correlating with the degree of nerve injury. Six patients had facial nerve resected as part of oncologic palliation and had the facial deficit rehabilitated with regional tissue. A correlation between preoperative facial nerve weakness and the quality of nerve graft function was not found. An oncologic correlation, however, is suggested (patients with preoperative weakness had less favorable prognosis). Overall, patients who require facial nerve resection for oncologic reasons do not do as well as those with normal preoperative function.
Assuntos
Nervo Facial/anatomia & histologia , Nervo Facial/cirurgia , Crânio/cirurgia , Estimulação Elétrica , Expressão Facial , Músculos Faciais/inervação , Músculos Faciais/fisiopatologia , Nervo Facial/fisiopatologia , Feminino , Seguimentos , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Contração Muscular/fisiologia , Regeneração Nervosa , Transferência de Nervo , Crânio/inervação , Neoplasias Cranianas/patologia , Neoplasias Cranianas/cirurgia , Nervo Sural/transplante , Osso Temporal/inervação , Osso Temporal/cirurgiaRESUMO
The computed tomography scans and magnetic resonance imaging films of 57 patients who underwent anterior or anterolateral cranial base surgery from January 1987 to August 1989 were retrospectively reviewed to ascertain the significance of early and late postoperative intracranial imaging changes. Extra-axial changes (air, blood, cerebrospinal fluid collection) were found in 96% of patients; axial changes (brain edema, contusion) were seen in 30% of patients in the first postoperative period (72 hours). Subsequently, extra-axial changes began to resolve but axial changes became more prevalent. After 6 months, only axial changes persisted (encephalomalacia). It was encouraging to find a low correlation of imaging abnormalities with clinically significant findings.
Assuntos
Imageamento por Ressonância Magnética , Crânio/cirurgia , Tomografia Computadorizada por Raios X , Encefalomalacia/diagnóstico por imagem , Encefalomalacia/etiologia , Humanos , Projetos Piloto , Complicações Pós-Operatórias , Período Pós-Operatório , Estudos Retrospectivos , Crânio/diagnóstico por imagem , Crânio/patologia , Fatores de TempoRESUMO
Facial translocation is a new approach which has been developed for surgical management of extensive lesions of the anterolateral cranial base, including the nasopharynx, sphenoid sinus, clivus, infratemporal fossa, superior orbital fissure, and cavernous sinus. Temporary displacement of the craniofacial skeleton allows direct, wide access to this complex anatomic area, while giving the surgeon a high degree of control over critical neural and vascular structures.
Assuntos
Rinorreia de Líquido Cefalorraquidiano/cirurgia , Craniotomia/métodos , Histiocitoma Fibroso Benigno/cirurgia , Neoplasias Nasofaríngeas/cirurgia , Neoplasias dos Seios Paranasais/cirurgia , Seio Esfenoidal/cirurgia , Adolescente , Idoso , Rinorreia de Líquido Cefalorraquidiano/diagnóstico , Histiocitoma Fibroso Benigno/diagnóstico , Humanos , Imageamento por Ressonância Magnética , Masculino , Microcirurgia/métodos , Neoplasias Nasofaríngeas/diagnóstico , Neoplasias dos Seios Paranasais/diagnóstico , Seio Esfenoidal/patologia , Tomografia Computadorizada por Raios XRESUMO
A patent internal carotid artery (ICA) is essential in most patients. Management of skull base lesions often requires translocation, balloon embolization, or resection of this vessel. Preoperative tests to assess the availability of collateral flow have not been uniformly accurate. A new test that significantly increases the safety of surgical removal of the ICA is described. One hundred thirty-six patients were studied with temporary balloon occlusion (TBO) of the ICA and determination of stable xenon-enhanced computed tomography cerebral blood flow (Xe/CT CBF) measurements. Eleven patients failed TBO and were determined to be at very high risk of stroke with loss of the ICA. Ninety-six of the patients were predicted to be at minimal risk with permanent loss of the ICA by Xe/CT CBF studies. Twenty-one patients in this group had either permanent balloon occlusion (PBO) or surgical resection of the ICA with no permanent neurologic sequelae. Our studies show that the combination of preoperative TBO and Xe/CT CBF studies significantly increases the safety of ICA resection.
Assuntos
Artéria Carótida Interna/cirurgia , Cateterismo , Infarto Cerebral/prevenção & controle , Circulação Cerebrovascular , Neoplasias de Cabeça e Pescoço/cirurgia , Cuidados Pré-Operatórios , Adolescente , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Pressão Sanguínea , Artéria Carótida Interna/diagnóstico por imagem , Cateterismo/normas , Criança , Pré-Escolar , Circulação Colateral , Neoplasias de Cabeça e Pescoço/terapia , Humanos , Lactente , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Risco , Fatores de Risco , Tomografia Computadorizada por Raios X , XenônioRESUMO
Curability of skull base tumors is related to the ability to achieve a complete resection. Resection of the internal carotid artery with the tumor puts the patient at risk for catastrophic cerebral injury. Autogenous vein grafting is not always technically or physiologically possible. We present eight patients with tumors eroding the cranial base who underwent safe resection or occlusion of the internal carotid artery as predicted by three tests: 1. carotid arteriography, 2. temporary balloon occlusion of the internal carotid artery, and 3. xenon computerized tomography cerebral blood flow mapping. No patient suffered permanent central nervous system injury.