RU2211058C2 - Method for removing cerebral meningioma - Google Patents

Abstract

FIELD: medicine, neurosurgery. SUBSTANCE: the suggested method deals with treating patients with convex cerebral meningiomas at extensive vascularization. Tumor matrix and tumor should be treated with circular movements of defocused beam through dura mater from periphery to the center by coagulating initially supplying and draining tumor vessels. Then one should treat tumor stroma, dissect dura mater along its perimeter and simultaneously take tumor out of brain. Tumor matrix should be treated with laser beam at diameter of not more than 4 mm, 45-60 W power for 12- 15 min. The method enables to decrease cerebral traumaticity degree at removing the tumor and decrease intraoperational blood loss. EFFECT: higher efficiency. 1 cl, 3 dwg, 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 convexital brain meningiomas with abundant vascularization.

 Known surgical method for the treatment of extracerebral meningovascular brain tumors, which consists in the use of microsurgical techniques, optics, bipolar coagulation, vacuum aspirator, ultrasonic resonator at the stage of microsurgical tumor removal (G.S. Tigliyev // On principles of surgery for extracerebral tumors / Surgery of intracranial extracerebral tumors. Under the editorship of G.S. Tigliev, V.E. Olyushin, St. Petersburg, 1977, S. 10-16). The sequential or combined use of this arsenal of tools allows the method of biting to remove brain meningiomas.

 A significant disadvantage of this method is that this method of removing the tumor is traumatic and is often accompanied by massive blood loss. This is primarily due to the fact that in order to start manipulating tumors, it is necessary to carry out brain retraction and expose the tumor area, which always leads to additional and sometimes unjustified traumatization of the brain and aggravation of its edema. Secondly, when removing dense brain tumors, it is not always possible to use an ultrasonic resector, since its power does not allow to destroy and aspirate such meningiomas. All this leads, as a rule, to significant intraoperative blood loss, additional brain trauma and complicates the total removal of the tumor.

A known method of surgical removal of extracerebral tumors, which consists in the use of a carbon dioxide laser with a wavelength of 10.6 μm (Bryk V.E., Malyshev BN, Prozorov VN // Method for removing the tumor. Copyright certificate N 555570, 1976) . To remove a meningioma, the author with a focused beam of a CO ₂ laser first removed the central part of the tumor node, and then the peripheral sections of the tumor with thin layers of a successively defocused laser beam.

 The author used a carbon dioxide laser with a wavelength of 10.6 μm to remove convexital meningiomas. The use of this laser does not lead to complete hemostasis, since the laser beam is absorbed by water in the surface of the tumor (up to 300 microns). It does not coagulate large arterial and venous vessels with a diameter of up to 1 mm. The use of this type of laser, according to published data, does not shorten, but greatly delay the operation.

 Closest to the claimed is a surgical method for removing cerebral meningiomas described by Juji Takeuchi et al., 1982 (Juji Takeuchi et al. // The Nd-YAG Laser in Neurological Surgery / Surg. Neurol, 185: 140-142, 1982).

 The authors use it to remove convexital meningioma according to the following method: they coagulate the surface of the tumor with a Nd-YAG laser with a power of 40-50 W and at the same time produce its vacuum aspiration. Long-term use of vacuum metal suction by constant pressure on the tumor during a large discharge causes a constant significant fluctuation of the tumor and the underlying brain, which leads to additional trauma to the brain and the great vessels supplying the tumor. This in turn causes gross angiospasm, progressive peritumor edema, which can lead to death.

 The objective of the proposed method is the total removal of convexital extracerebral tumors having abundant vascularization, reducing brain trauma during surgical removal, a significant reduction in the time of surgery and intraoperative blood loss.

 The solution of the problem allows to achieve a positive therapeutic effect, which consists in the radical removal of the tumor, which has abundant vascularization; reduce intraoperative blood loss, reduce brain trauma during tumor removal, and reduce the time of surgery. When using the method, there is an economic effect: reducing the patient's stay in bed, reducing blood flow and blood substitutes; social effect - improving the quality of life of patients.

 The technical result was achieved due to the original technology of tumor removal: processing of the matrix and tumor through the dura mater from the periphery to the center provides coagulation of the supply (arterial) and drainage (venous) vessels of the tumor, which reduces blood loss. The simultaneous removal of the "boiled" tumor without aspiration allows you not to injure the brain.

 The problem is solved due to the fact that the tumor matrix and the tumor are treated with circular movements of the defocused beam through the dura mater from the periphery to the center, coagulating the tumor’s nourishing and draining vessels, then “boil” the stroma of the tumor, dissect the dura mater along the perimeter, and simultaneously remove tumor from the brain. The matrix of the tumor is treated with a laser beam with a diameter of not more than 4 mm, with a power of 45-60 W for 12-15 minutes.

 The method was carried out as follows. Clinical tomography examination and intraoperative confirmation of a patient with convexital cerebral meningioma involves surgery using an Nd-YAG laser. To do this, osteoplastic trepanation of the skull is performed over the site of the tumor and the dura mater is exposed. Convexital meningioma always has a matrix - a section of the dura mater of various sizes in size, from which it grows.

 When the above point of growth, the matrix of the tumor, is found on the dura mater, its surface treatment begins with a defocused beam of an Nd-YAG laser with a power of 45-60 W and a diameter of not more than 4 mm Processing of the matrix and the underlying tumor always began with its peripheral areas. This was necessary in order to first coagulate the tumor (arterial) and drainage (venous) vessels of the tumor, passing from the brain to the tumor. This effect led initially, as was said first, to coagulation of the vessels of the tumor, and then to “boiling” of the dense stroma of the tumor tissue. After coagulation of the peripheral sections of the matrix and the tumor with circular motions of the laser beam, the middle and then the central sections of the matrix and tumor were gradually processed.

 Depending on the area of the matrix and the volume of the tumor, laser treatment was performed for 12-15 minutes. All our manipulations led to coagulation of the stroma of the tumor and a significant reduction in its volume (up to 30-40% of the total volume. The area of the matrix, like the tumor, decreased significantly in volume.

 After treatment of the tumor to carbonization of the matrix, the dura mater was dissected along the perimeter of the tumor over its entire area, and then the tumor nodule was removed bloodlessly and simultaneously from the dura mater without any bleeding. Minimal bleeding in the back of the brain was stopped by a hemostatic sponge.

 The operation was over. Homotransplant defect plasty was performed. A bone flap was placed in place.

Concrete example
Patient B., born in 1938, I / B N 2233/00 g, was admitted to the neurosurgery clinic of NIIIT with a diagnosis of a tumor of the right parietal lobe.

 From the anamnesis: got sick about 3 years ago when she began to notice headaches in the frontotemporal region. Gradually, headaches increased, a decrease in memory appeared. An MRI of the brain was performed on an outpatient basis, revealing a tumor of the right parietal lobe. Hospitalized in a neurosurgery clinic for surgical treatment.

 In the neurological status upon receipt of the patient focal neurological symptoms were not.

 Calculation of R-grams of the skull in 2 projections revealed calcification of uniform density in the right parietal region with clear contours and a size of 33 • 37 • 29 mm.

 EEG - diffuse changes in the bioelectric activity of the brain.

 Ophthalmologist examination: Vis D = 0.9, Vis S = 0.9. The fields of vision for white and red are slightly concentrically narrowed. Retinal angiopathy on the fundus.

 MRI of the brain: a volumetric mass (meningioma) of the right parietal lobe measuring 5 • 4 • 5 cm, causing compression of the body of the right lateral ventricle.

 Based on clinical and tomographic studies, the patient was diagnosed with a convexital extracerebral brain tumor (meningioma) in the right parietal region.

 In the position of the patient on the left side made osteoplastic trepanation in the right parietal region with the flap of the bone on the periosteum. The dura mater (T.M.O.) is sharply tense, almost does not transmit the pulsation of the underlying brain. In the center of the bone defect, a 5 × 5 cm tumor matrix with hypertrophied dura mater vessels was revealed. Under it, a dense mass was palpated - a tumor.

 Subsequently, the matrix and the underlying part of the tumor were treated with a defocused beam of a 50 W Nd-YAG laser with a diameter of not more than 4 mm. Processing of the matrix and the underlying tumor always began with its peripheral areas. This was necessary in order to first coagulate the tumor (arterial) and drainage (venous) vessels of the tumor, passing from the brain to the tumor. This effect led initially, as was said first, to coagulation of the vessels of the tumor, and then to “boiling” of the dense stroma of the tumor tissue. After coagulation of the peripheral sections of the matrix and the tumor with circular motions of the laser beam, the middle and then the central sections of the matrix and tumor were gradually processed (Fig. 1).

 Depending on the area of the matrix and the volume of the tumor, laser treatment was performed for 12-15 minutes. All our manipulations led to coagulation of the tumor stroma and a significant decrease in its volume (up to 30-40% of the total volume). The area of the matrix, like the tumor, was significantly reduced in volume.

 After treatment of the tumor to carbonization of the matrix over its entire area, the dura mater was dissected along the perimeter of the tumor, and then the tumor nodule was removed bloodlessly and simultaneously from the dura mater without any bleeding (Fig. 2). Minimal bleeding in the back of the brain was stopped by a hemostatic sponge.

 The removal of this tumor occurred almost bloodless (intraoperative blood loss was about 50 ml when the tumor was removed). The dura mater is sutured tightly. The bone flap is 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. She was awake. Headaches hardly bothered.

 Neurological symptoms did not increase.

 Control MR imaging of the brain, performed on the 6th day after the operation, confirmed the absence of a tumor (figure 3). Cerebral edema persisted at the preoperative level. There was a cerebrospinal fluid cyst at the site of the removed tumor.

 The patient was activated 10 days after the operation. Discharged from the clinic after two weeks in satisfactory condition.

 At present (after 4 months) his condition is satisfactory. Focal symptoms, disorders of higher nervous activity were not detected.

 Thus, the use of the Nd-YAG laser during the removal of convexital cerebral meningioma (6 • 6 • 5 cm) according to the technology we developed did not additionally injure the brain (this is evidenced by the absence of an increase in neurological symptoms in the postoperative period and the previous degree of cerebral edema brain in the area of surgical intervention according to the control of MRI), perform a very quick and bloodless removal of the tumor, save the patient’s life and get a good clinical result.

Claims (2)

 1. A method for removing brain meningiomas by coagulating a tumor with an Nd-YAG laser, characterized in that the tumor matrix and the tumor are treated with circular movements of the defocused beam through the dura mater from the periphery to the center, coagulating the tumor’s nourishing and draining vessels, then “boil” the stroma of the tumor, the dura mater is cut along the perimeter, and the tumor is immediately removed from the brain.  2. The method according to p. 1, characterized in that the tumor matrix is treated with a laser beam with a diameter of not more than 4 mm, a power of 45-60 W for 12-15 minutes

Images