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　　蝶骨嵴外側(cè)腦膜瘤

 

　　A 51-year-old man had previously undergone surgery for a sphenoid wing meningioma of the left skull base. Six years later he complained of a dull headache. CT disclosed an extensive, predominantly lateral sphenoid wing meningioma on the right side with infiltration of the temporal muscle.  This was presumed to represent an extracranial extension from a primary intracranial tumor.

 

　　Tumor Infiltration of the temporal muscle and infratemporal fossa was already evident when the right frontotemporal skin flap was raised. After removal of the extracranial part of the tumor, a frontotemporal craniotomy was performed, exposing the extra-dural portion of the large intracranial meningioma. Two measures were taken to minimize tension and pressure on the frontal and temporal lobes during further dissection:

 

　　1) The lesser sphenoid wing was removed with the diamond burr.

 

　　2) The Sylvian fissure was opened micro-surgtcally after incising the    dura a safe distance from the area of tumor infiltration.

 

　　The tumor was then debulked from its center using an ultrasonic aspirator (CUSA). As the tumor capsule became lax, the branches of the middle cerebral artery could be identified, and dissection of the capsule proceeded along the middle cerebral artery branches to the internal carotid artery. At that point it was possible to remove the tumor completely,including its dural attachment, without danger to nei**oring'structures. The dura was patched with stored dura, the bony defect was repaired with a methylmethacrylate implant, and the soft tissues were closed in layers.The postoperative course was uncomplicated.

 

　　Case 14: Medial sphenoid wing meningioma

 

　　蝶骨嵴內(nèi)側(cè)腦膜瘤

 

　　A 64-year-old woman had suffered left-sided headache for 3 years.Shortly before hospitalization she experienced transient y spells with loss of consciousness. Two years earlier she had had an episode of speech impairment and paralysis of the right arm that resoved in a few minutes. Results of neurological examination were positive only for slight paresis of the right arm.CT scan showed a mass lesion that appeared to arise from the left medial sphenoid wing? extending into the anterior and middle cranial fossa.The cerebral angiogram displayed upward deviation of the middle cerebral artery with displacemant of the anterior cerebral artery and vascular pattern typical of meningloma.

 

　　The tumor was exposed through a left frontotemporal crani-otomy with a wide opening of the Sylvian fissure. The meningio-ma was reduced in size with the ultrasonic aspirator? and the heavily enmeshed middle cerebral artery was microsurgically freed of tumor.Additional tumor was removed along the courses of the middle cerebral artery, and the internal carotid artery, also enveloped by tumor, was isolated.   It was then possible to completely remove the neoplasm along with its dural attachment on the inner sphenoid wing.  The anterior cerebral artery and the slightly displaced left optic nerve were  anatomically and functionally preserved. The wound was closed in standard fashion.  The patient left the hospital 18 days after the surgery, neurologically intact. Postoperative CT scan showed total tumor removal.

 

　　The major problem with a medial sphenoid wing meningioma of this type is its close proximity to important structures,such as the internal carotid artery and its branches, the optic nerve, the oculomotor nerve, and possibly the other motor nerves of the eye.  By following the surgical strategy described above, we were able to safely isolate the internal carotid artery, which was completely encased in tumor, along with functionally important adjacent structures.

 

　　Case 15: Sphenocavernous meningioma

 

　　蝶骨嵴海綿竇腦膜瘤

 

　　A 57-year-old man who was already blind in the left eye as a result of a war injury developed sensory disturbance in the territory of distribution of  the right trigeminal nerve.  This was accompanied by functional disturbance of the abducens and trochle-ar nerves. CT scans showed a medially situated mass lesion in the middle cranial fossa with infiltration of the cavernous sinus, penetration of the right sphenoid sinus, and slight extension into the posterior cranial fossa. Vision in the right eye was intact. The mild nature of the clinical symptoms and the preexisting blindness in the left eye complicated the decision whether to operate. After thorough consultation, the patient insisted that we attempt to remove as much of the tumor as possible without compromising the vision that remained.  This meant preserving the function of both the optic nerve and the oculomotor nerve, which was certainly enveloped by tumor. Because of the existing left-sided amaurosis, functional preservation of the trochlear and abducens nerves was of minor importance, since diplopia was not a primary concern.

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