RU2764831C1 - Method for cerebral meningioma removal - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery. Internal decompression of the tumor is performed. Then the tumor capsule is strengthened by bipolar coagulation. Surgical coagulator Erbe VIO 200 S with a current of 20-25 W is used over the entire visible area of ​​the tumor until the color of the capsule changes from pink to gray. The section of the tumor opened after strengthening the capsule is separated from the brain tissue by traction for the strengthened capsule. Then, the next section of the capsule, exposed after traction of the previously fortified section, is strengthened. Strengthening of the capsule and separation of the tumor from the brain tissue by traction of the capsule are carried out sequentially until the tumor is separated from the brain.

EFFECT: method allows to remove cerebral meningioma, to reduce the likelihood of trauma and edema of brain tissue, avoiding the development of circulatory disorders and focal neurological symptoms.

1 cl, 1 ex

Description

The invention relates to medicine, namely to neurosurgery, and can be used in the removal of cerebral meningiomas with a thin capsule.

The problem of surgical treatment of patients with cerebral meningiomas is currently an urgent task. Despite the fact that the surgical technique for resection of these neoplasms has been developed, serious technical difficulties often arise during its removal. To remove a cerebral meningioma after its internal decompression, the tumor is sequentially separated from the brain tissue by pulling (traction) by the existing capsule. But due to the weakly expressed thin capsule of the tumor, which is often damaged when it is stretched, additional undesirable traumatization of the brain occurs, leading to the development of focal neurological symptoms in the postoperative period when it is removed.

A known method of removing cerebral meningioma (RF Patent No. 2211058, publ. 27.08.2003, bull. No. 24), which consists in the fact that the tumor matrix and the tumor are treated with a Nd-YAG laser with circular movements of the defocused beam through the dura mater from the periphery to the center , initially coagulating the feeding and draining vessels of the tumor, then "boil" the stroma of the tumor, dissect the dura mater along the perimeter and simultaneously remove the tumor from the brain.

The use of a neodymium laser can lead to excessive deep coagulation and damage to the capsule.

Closest to the claimed is a method for removing cerebral meningioma, described by Tigliev G.S., Olyushin V.E., Kondratiev A.N. in the monograph "Intracranial meningiomas" on page 269. To remove a meningioma, the authors recommend at the first stage to reduce its volume (internal decompression of the tumor) using an ultrasonic aspirator, bipolar coagulation, and a vacuum aspirator. And then, using the resulting reserve space, carry out traction of the tumor capsule and separate it from the surrounding medulla.

The main disadvantage of the method is the limited scope of its application. Not infrequently, the tumor capsule is thin, weakly expressed, and when it is held and pulled at the moment of separation from the brain (traction), it is often damaged, which leads to repeated capture, holding it with tweezers and additional trauma to the brain. Therefore, the removal of meningioma in the future occurs using metal spatulas. They allow the brain to be pushed away from the tumor, and not vice versa, to separate the tumor from the brain tissue by safely pulling (traction) by its capsule. These manipulations also lead to additional traumatization of the surrounding brain. This technique of meningioma removal in the postoperative period leads to the development of excessive cerebral tissue edema in the patient, circulatory disorders and the development of undesirable focal neurological symptoms in the form of paresis and even paralysis in the extremities.

The objective (technical result) of the present invention is to create a method for removing cerebral meningioma, free from the disadvantages described above.

The problem is solved by the fact that in the method of removing cerebral meningioma by internal decompression of the tumor, traction of the tumor capsule and separating it from the surrounding medulla, after internal decompression of the tumor, the tumor capsule is strengthened by bipolar coagulation using a surgical coagulator Erbe VIO 200 S with a current power of 20-25 W over its entire visible area until the color of the capsule changes from pink to gray, the area of the tumor that has opened after the strengthening of the capsule is separated from the brain tissue by traction on the strengthened capsule, then the next part of the capsule, exposed after traction of the previously strengthened area, is strengthened, the capsule is strengthened and the tumor is separated from the brain tissue by traction, the capsules are carried out sequentially until the tumor is separated from the brain.

A change in the color of the capsule from pink to gray indicates a change in its structure. In this case, the capsule shrinks, becomes denser, and pulling it does not lead to its mechanical damage, which makes it easy and atraumatic to separate the meningioma from the brain tissue.

It has been experimentally established that the change in the structure of the capsule occurs in the power range of 20-25 W. At a current power of less than 20 W, the capsule retains its structure, which makes it impossible to separate the tumor from the surrounding brain tissue without using additional tools that injure the brain. With a current power of more than 25 W, the capsule changes color from pink to black, a pronounced coagulating effect occurs. At the same time, the capsule is burned, its structure becomes even weaker, and when trying to separate the tumor from the brain tissue, the capsule breaks.

The proposed method is carried out as follows.

After gaining access to the tumor, the tumor is isolated and mobilized with its internal decompression step by step using microsurgical technique, instrumentation, an ultrasound aspirator under a microscope magnification up to ×20. If, after internal decompression of the tumor, it is found that the capsule is weakly expressed and when you try to separate it from the brain by traction, it is torn, the capsule is strengthened outside the tumor by bipolar coagulation using an Erbe VIO 200 S surgical coagulator with a current power of 20-25 W over its entire visible area until the color of the capsule changes from pink to gray. As a rule, the change in color and, accordingly, the structure of the capsule occurs within 1-1.5 minutes. After that, the area of the tumor that opened after the strengthening of the capsule is separated from the brain tissue by traction by the strengthened capsule. Then, the next section of the capsule, exposed after traction of the previously strengthened section, is strengthened. Strengthening of the capsule and separation of the tumor from the brain tissue by traction of the capsule is carried out sequentially until the tumor is separated from the brain.

Industrial applicability of the proposed method is confirmed by clinical examples.

Clinical example 1

Patient A., 55 years old, was admitted to the clinic in July 2020.

Anamnesis of the disease: noted a decrease in memory, began to forget names, dates. He independently underwent an MRI examination of the head with contrast dated July 22, 2020, where an extracerebral formation of the left frontal region (meningioma) was detected. Education dimensions 74×56×64 mm. Consulted by a neurosurgeon NNIIT them. Ya.L. Tsivyan, surgical treatment is recommended. The patient was hospitalized for elective surgery.

Complaints at admission: headaches, dizziness, memory loss. Anamnesis of life: not burdened. The condition is satisfactory.

Neurological status: Consciousness is clear. Behavior is appropriate. The position is active. Oriented in place, time, self. The addressed speech is understood in full. Distinguishes smells when the tongue protrudes in the midline. Strength in all muscle groups of the limbs 5 points. Muscle tone in the limbs is normal, symmetrical. Deep reflexes are symmetrical, medium liveliness. There are no pathological signs. Convincing violations of sensitivity are not present. Shell characters are not defined. Stable in the Romberg position. Performs coordinating tests confidently.

Brain MPT data with contrast from July 22, 2020: Extracerebral space-occupying lesion in the left frontal area (meningioma). Dimensions education 74 X 56 X 64 mm.

Diagnosis at admission:

Primary: Extracerebral space-occupying formation (meningioma) in the left frontotemporal region involving the sphenoparietal sinus.

Concomitant: Hypertension, stage 2, stage 2, risk 3. Paroxysmal atrial fibrillation, tachysystolic variant, paroxysm dated 08/07/2020. CHA2DS2-VASc 1 point, rhythm restored. CHF1. Obesity 2 st (BMI 383.74). fatty hepatosis. Chr. gastritis, remission.

The patient was shown surgical treatment aimed at removing the tumor.

Surgery protocol dated August 19, 2020 Name of surgery: Cranioectomy of the left frontotemporal region. Microsurgical removal of an extracerebral mass in the left frontal region involving the sphenoparietal sinus under neuronavigation control. Plastics of the dura mater (dura mater).

Operation description: In the position of the patient on the operating table on the back, with the head turned to the right, with the head fixed in the Mayfield bracket, after the stage of navigation markup, a horseshoe-shaped incision of the soft tissues was made in the left frontotemporal region. The skin-aponeurotic flap is folded back to the base. Further, the left temporal muscle was separated and folded back to the base. From the 1st burr hole, with the help of a trephine and a spherical bur, resection trepanation was performed in the left frontotemporal region, the size of the trepanation window was 10 by 10 cm. In the center of the trepanation window, the DM is sealed - a tumor node under the DM. The DM was opened with a horseshoe-shaped incision along the perimeter of the localized tumor, within the unchanged DM. A pink extracerebral tumor with well-defined borders with the brain (meningioma) was found. Gradually, with the use of microsurgical techniques, instruments, ultrasound aspirator under a microscope magnification up to ×20, tumor isolation with its internal decompression was started. After internal decompression of the tumor, it was found that the capsule was weakly expressed and, when trying to separate it from the brain (traction), it was torn, which made it difficult to separate the meningioma from normal brain tissue. To strengthen the existing capsule outside the tumor, it was treated with bipolar coagulation using a surgical coagulator Erbe VIO 200 S with a current power of 20 W over its entire visible area. After 1 minute, the capsule changed color from pink to gray, wrinkled and thickened. Capsule processing was stopped. After that, the tumor was separated from the brain tissue by safe pulling (traction) by the reinforced capsule. Using the methods described above, the meningioma was removed completely. When the tumor is removed, he pays attention that it grows into the wall of the hypertrophied sphenoparietal sinus, from where the bleeding was obtained, which was stopped with the help of Tachocomb. The tumor matrix is localized in the area of the sphenoparietal sinus. It is treated with electrocoagulation. After removal of the tumor, a cavity of 7×7×6 cm was formed in the brain, and its good pulsation appeared. Hemostasis with Wylocell and EVESIL glue. TMO Neuro-Patch plastic, Tachocomb and EVESIL glue were additionally laid on top. Layer-by-layer stitches on the wound. The muscle is sutured. Two semi-tubes were installed epidurally. Metal braces on the skin. Aseptic bandage.

The postoperative period proceeded without complication and increase in focal neurological symptoms.

Control MRI of the brain from 24.07. 2020 - total removal of the tumor. The wound healed by first intention.

Histological conclusion: The mythological structure of the tumor corresponds to meningioma, Grade I, ICD-O code 9531/0.

The patient was discharged from the department on the 15th day after the operation.

Thus, the removal of a tumor that has a thin, unexpressed, easily torn capsule, which was strengthened by the method proposed by us, did not lead to additional brain injury and did not contribute to the development of new neurological symptoms.

Clinical example 2.

Patient B., 47 years old, was admitted to the clinic in September 2020.

Medical history: In the middle of 2020, headaches appeared and began to increase. Once developed a general epileptic seizure. He underwent an MRI of the brain with contrast, which revealed an extracerebral formation of the right frontal region (meningioma), measuring 70 X 50 X 60 mm. Consulted by a neurosurgeon NNIIT them. Ya.L. Tsivyan, surgical treatment is recommended. Hospitalized for elective surgery.

Complaints at admission: Headaches, epilepsy. Anamnesis of life: not burdened. Condition: Satisfactory.

Neurological status: Consciousness is clear. Behavior is appropriate. Oriented in place, time, self. The addressed speech is understood in full. Distinguishes smells. Strength of the limbs 5 points. Deep reflexes are symmetrical, medium liveliness. There are no pathological signs. Convincing violations of sensitivity are not present. Shell characters are not defined. She is stable in the Romberg position.

Brain MRI data with contrast from August 24, 2020: An extracerebral space-occupying formation in the right frontal region (meningioma), causing compression of the anterior horn of the right lateral ventricle, 70 X 60 X 60 mm in size.

Diagnosis at admission: Main: Spacious extracerebral mass (meningioma) in the right frontotemporal region with involvement of the sphenoparietal sinus. The patient was shown surgical treatment aimed at removing the tumor.

Surgery protocol dated September 11, 2020. Name of the operation: Cranioectomy of the right frontotemporal region. Microsurgical removal of an extracerebral space-occupying formation in the right frontal region involving the sphenoparietal sinus under neuronavigation control. TMO plastic.

Description of the operation: In the position of the patient on the operating table on the back, with the head turned to the left, with the head fixed in the Mayfield bracket, after the stage of navigation markup, a horseshoe-shaped incision of the soft tissues was made in the right frontotemporal region. The skin-aponeurotic flap is folded back to the base. The left temporal muscle was separated and folded back to the base with the help of a Fishhook. From the 1st burr hole, with the help of a trephine and a spherical bur, resection trepanation was performed in the left frontotemporal region, the size of the trepanation window was 12 by 11 cm. The DM moderately transmit brain pulsation. In the center of the trepanation window, the DM is sealed - a tumor node under the DM. The latter was opened with a fringing incision along the perimeter of the localized tumor, within the unchanged DM. A pink extracerebral tumor with well-defined borders with the brain, resembling a meningioma, was found. Gradually, with the use of microsurgical technique, instrumentation, ultrasound aspirator under a microscope magnification up to ×16, tumor isolation and mobilization with its internal decompression were started. After internal decompression of the tumor, it was found that the capsule was weakly expressed and torn during traction and an attempt to separate it from the brain. To strengthen the existing capsule outside the tumor, it was treated with bipolar coagulation using a surgical coagulator Erbe VIO 200 S with a current power of 20 W in mode 2 over its entire visible area for 0.5 minutes. In this case, the change in the color and structure of the capsule did not occur, therefore, the processing of the capsule was continued for 1 minute, gradually increasing the current power. At a current power of 24 W, the structure and color of the capsule changed. After that, the tumor was separated from the brain tissue by safe pulling (traction) by a reinforced gray capsule. Using the methods described above, the meningioma was removed completely. The tumor matrix is localized in the area of the sphenoparietal sinus. It is treated with electrocoagulation. After removal of the tumor, a 6×6×6 cm cavity was formed in the brain, and its good pulsation appeared. Hemostasis with Wylocell and EVESIL glue. Plastic TMO Neuro-Patch. Layer-by-layer seams on the wound. The muscle is sutured. Two semi-tubes were installed epidurally. Metal braces on the skin. Ac. Bandage.

The postoperative period was uneventful. There was no increase in focal neurological symptoms.

Control MRI of the brain dated September 13, 2020 - total removal of the tumor. The wound healed by first intention.

Histological conclusion: The mythological structure of the tumor corresponds to meningioma, Grade I, ICD-O code 9531/0.

The patient was discharged from the department on the 13th day after the operation.

Thus, the removal of a tumor with a thin, unexpressed, easily torn capsule, which was strengthened by our proposed method, did not lead to additional brain injury and did not contribute to the development of new neurological symptoms.

Clinical example 3.

Patient S., 43 years old. Was admitted with a diagnosis of parasagittal meningioma of the right occipital region, involving the superior sagittal sinus in the posterior third.

Anamnesis of the disease: He has been ill for several years, the last year there were epileptic seizures of a general type, in October 2020 a series of general epileptic seizures arose, the ICD No. 1 was delivered by the ambulance team. An MRI of the brain was performed, and an extracerebral mass in the right occipital region was revealed. She was consulted by a neurosurgeon and surgical treatment was recommended. In October 2020, she was hospitalized in the neurosurgical department No. 1 of NIIITO for surgical treatment.

The condition is satisfactory.

Complaints: General weakness, headaches, epileptic seizures of a general type.

MRI of the brain with contrast: Extracerebral volumetric formation in the occipital region, parasagittally on the right, measuring 5X6X5 cm.

Taking into account the history of the disease, neurological symptoms and MRI data, the patient was diagnosed with Parasagittal meningioma of the right occipital region, with involvement of the SCD in its posterior third. The patient was shown an operation aimed at removing the tumor.

Operation: October 30, 2020. Craniotomy in the occipital-parietal region on the right. Microsurgical removal of a parasagittal meningioma in the posterior third of the superior sagittal sinus on the right under conditions of neurophysiological monitoring. TMO plastic.

The patient is in a supine position with a fixed head in a Mayfield brace. After the stage of navigation markup, a horseshoe-shaped incision of soft tissues was made in the parieto-occipital region on the right. Skin-aponeurotic flap thrown to the base on the handles. Skeletonized occipital bone. From the 1st burr hole using a pneumotrepan, a craniotomy was performed in the occipital region on the right. The bone flap has been removed. The DM is thinned, it is dissected by a horseshoe-shaped incision along the tumor node with its base to the superior sagittal sinus (ASS). A volumetric formation is visualized parasagittally. The tumor is gray-cherry in color, denser in consistency, with clear contours, tightly soldered to the arachnoid membrane, visually resembles a meningioma. Using microsurgical instruments, a microscope under a magnification of 12×-14× under conditions of continuous neurophysiological monitoring, electrocoagulation separated the tumor from arachnoid adhesions, dissected its capsule, and performed its internal decompression using vacuum and ultrasonic aspirators. At the same time, a reserve space was formed in the tumor itself. Attempts to separate the tumor from the brain tissue by traction by the capsule, using the reserve space in the tumor, were unsuccessful, since the capsule was thin and easily torn. To strengthen the existing capsule on the outside of the tumor, its single treatment with bipolar coagulation was started using a surgical coagulator Erbe VIO 200 S with a current power of 26 W over its entire visible area for 1 minute. Coagulation with such power led to a pronounced coagulating effect, the visible part of the tumor capsule became black, burned and torn. Therefore, it was decided to reduce the current strength to 25 during coagulation of subsequent sections of the capsule, while a good coagulating effect and a change in its color from pink to gray were noted. At the same time, after 0.5 minutes, the capsule changed its structure, wrinkled, thickened, and traction did not lead to its mechanical damage, which made it possible to easily and atraumatically separate the meningioma from the brain tissue. Using the above methods sequentially, the meningioma was removed completely. The tumor invaded the dura mater and the lateral wall of the SCC, the wall of the latter was treated by electrocoagulation. After removal, the brain straightened out, its distinct pulsation appeared. Hemostasis with H2O2 tapes and electrocoagulation + Surgicell fibrillar. Control of hemostasis, the wound is dry. Plastic defect of the dura mater with its own aponeurosis and periosteum. The bone flap was put in place, the latter was fixed with 4 craniofixes. Layer-by-layer stitches on the wound. On the skin, the seams are metal brackets. Aseptic bandage.

In the neurological status one day after the operation: Consciousness is clear. The position is active. Oriented to place, time and self. Neurological status at the preoperative level.

Histological conclusion: The mythological structure of the tumor corresponds to meningioma (meningothelial variant of the structure), Grade I, ICD-O code 9531/0.

Postoperative course without complications. The wound healed by first intention.

Control MRI of the brain 3 days after the operation - total removal of the tumor.

The patient was discharged from the department on the 15th day after surgery.

Thus, the removal of a tumor that has a thin, unexpressed, easily torn capsule, which was strengthened by the method proposed by us, did not lead to additional brain injury and did not contribute to the development of new neurological symptoms.

Clinical example 4.

Patient E., 54 years old. She was admitted with the main diagnosis: parasagittal meningioma of the right frontal region, involving the superior sagittal sinus in the anterior third.

Concomitant diagnosis: Hypertension 2 tbsp, 2 tbsp, risk 4. Paroxysmal form of atrial fibrillation, out of paroxysm. CHS1. Autoimmune thyroiditis, diffuse nodular form. Primary hypothyroidism, drug subcompensation. Chr. gastritis, remission. Varicose veins of the lower extremities. HVN1. Erythrocytosis, unspecified, possibly secondary. Hepatitis, minimally active, unspecified.

Anamnesis of the disease: Sick for several years, there were seizures with loss of consciousness, associated these conditions with fatigue, did not seek help. In September 2019, an attack occurred

generalized convulsions, ICD No. 11 was delivered by the SMP team. An MRI of the brain was performed, and an extracerebral mass (meningioma) was detected in the right frontal region. She was consulted by a neurosurgeon and surgical treatment was recommended. In January 2020, she was hospitalized in the neurosurgical department No. 1 for surgical treatment aimed at removing the formation.

The condition is satisfactory.

Complaints: General weakness, headaches, dizziness, periodic bouts of loss of consciousness.

MRI of the brain with contrast: Extracerebral mass formation in the frontal region parasagittally on the right, 4X5X5 cm in size.

Taking into account the history of the disease, neurological symptoms and MRI data, the patient was diagnosed with the following diagnosis: Parasagittal meningioma of the right frontal region, involving the superior sagittal sinus in its anterior third. The patient was shown an operation aimed at removing the tumor.

Surgery: January 30, 2020. Craniotomy in the right fronto-parietal region. Microsurgical removal of parasagittal meningioma of the anterior third of the superior sagittal sinus on the right under conditions of neurophysiological monitoring. TMO plastic.

The patient is in a supine position with a fixed head in a Mayfield brace. After the stage of navigation markup, a horseshoe-shaped incision of soft tissues was made in the frontal region on the right, about 15 cm. Skeletonized frontal bone. From 4 burr holes with the help of a pneumotrepan, a craniotomy was performed in the frontal region on the right. The bone flap was raised on an elevator and removed. At the same time, there is (in the center of the bone flap, the inner plate) an area of bone hyperostosis, pronounced tuberosity on its inner part, ~ 15 X 20 mm in size. The dura mater itself (dura mater) is thinned, at the site of hyperostosis it is tightly attached to the bone, and therefore the integrity of the latter was violated. The DM is dissected with a horseshoe-shaped incision along the tumor node with its base towards the superior sagittal sinus. Parasagittally in the region of the anterior third of the sagittal sinus, a volumetric formation is visualized. The tumor is gray-cherry in color, denser in consistency, with clear contours, tightly soldered to the arachnoid membrane, visually resembles a meningioma. Using microsurgical instruments, a microscope under 8x-12x magnification under conditions of continuous neurophysiological monitoring, electrocoagulation separated the tumor from arachnoid adhesions, dissected its capsule, and using vacuum and ultrasonic aspirators, its internal decompression was performed. At the same time, a reserve space was formed in the tumor itself. An attempt to separate the tumor from the brain tissue by traction by the capsule was unsuccessful, since it was thin and easily torn. Therefore, using a spatula, the brain tissue began to be separated from the tumor capsule, protecting the brain with padded jackets. Thus, by separating the tumor from the surrounding brain, the tumor was removed completely. The tumor invaded the dura mater and the lateral wall of the superior sagittal sinus. The sinus wall was treated with electrocoagulation. After removal, the brain began to swell and straighten out, its distinct pulsation appeared. Hemostasis with H202 tapes and electrocoagulation + Surgicell fibrillar. Control of hemostasis in the wound is dry. Plastic defect of the dura mater with its own aponeurosis and periosteum. A plate "Takhokomba" + "Spongostan" was laid on top of the TMF. The hyperostotic component on the bone flap was processed with an electric drill to healthy tissue (fragments of hyperostosis were also sent for histological examination), the bone flap was put in place, the latter was fixed with 3 craniofixes. Layer-by-layer stitches on the wound. On the skin, the seams are metal brackets. Ac. alcohol bandage.

In the neurological status one day after the operation:

Consciousness is clear (15 GCS points). Behavior is appropriate. The position is active. Oriented to place, time and self. There is a moderately pronounced left-sided hemiparesis, more in the leg of the central type.

Locally, the postoperative scar is rich, without signs of inflammation.

Histological conclusion: The mythological structure of the tumor corresponds to meningioma (meningothelial variant of the structure), Grade I, ICD-O code 9531/0.

Postoperative course, with the exception of moderately severe right-sided hemiparesis, without complications. The wound healed by first intention.

Control MRI of the brain 2 days after the operation - the residual part of the tumor is not defined.

The patient was discharged from the department on the 14th day after surgery.

Thus, the removal of the tumor, in connection with a thin, unexpressed, easily torn capsule, was carried out not by traction by the capsule, but by separating it from the brain with metal spatulas and padded jackets, which led to additional brain injury, edema, impaired local cerebral circulation and development focal neurological symptoms in the form of a moderate central type of left-sided hemiparesis.

Claims (1)

A method for removing cerebral meningioma by internal decompression of the tumor, traction of the tumor capsule and separating it from the surrounding medulla, characterized in that after internal decompression of the tumor, the tumor capsule is strengthened by bipolar coagulation using a surgical coagulator Erbe VIO 200 S with a current power of 20-25 W throughout its visible area until the color of the capsule changes from pink to gray, the tumor area opened after the strengthening of the capsule is separated from the brain tissue by traction on the strengthened capsule, then the next part of the capsule, exposed after traction of the previously strengthened area, is strengthened, the capsule is strengthened and the tumor is separated from the brain tissue by traction, the capsules are carried out sequentially until the tumor is separated from the brain.