丘腦下部膠質(zhì)瘤

 

　　This 16-year-old male presented in 1988 with delayed puber ty, headaches, and progressive visual failure. He was being treated for hypopituitarism at the time of his admission. On examination? he was obese, with short stature and hypogonadism. He had bitemporal hemtanopia with visual acuity 6/24 on the left and hand movements only on the right,  where he had an afferent pupillary defect. Both eyes showed optic atraphy with mild papilledema.

 

　　A skull X-ray showed the pituitary fossa floor and dorsum sellae to be  eroded, and CT scanning showed an intra- and supra-sellar mass lesion with specks of calcification and extensive contrast enhancement causing hydrocephalus. Angtograms of the carotid arteries showed displacements but no pathological circulation. Air encephalogram showed a large suprasellar mass.

 

　　A right frontotemporal cranlotomy revealed an extensive infiltrating low  grade tumor of the base of the diencephalon which was confirmed histologically as a gHoma with uniform cells loosely arranged in a vacuolated background. The cells had oval nuclei and an ill-defined cytoplasm,  with occasional cells showing a bipolar appearance.

 

　　Postoperatively, there was a mild diabetes insipidus and a persistent bitemporal hemianopia. He required a further operation to insert a ventriculoperitoneal shunt for his hydrocephalus. Radiotherapy was given, and for the next few years he required total anterior pituitary replacement, but in 1983 he was readmitted with water intoxication and was found to have a massive central and bilateral tumor recurrence.  He recovered from his water intoxication but still has a marked diencephalic syndrome, bitem-poral hemianopia, and epilepsy.

 

　　Case 10:Chiasmal glioma

 

　　視交叉膠質(zhì)瘤

 

　　This 10-month-old girl was admitted to the Children's Hospital with a 4-day history of bobbing of her right eye. Examination revealed constant 2/sec vertical oscillations of the right eye and occasional head nodding (spasmus nutans). The optic discs and the remainder of her physical examination were normal. Cor-tisol and growth hormone assays were normal.  CT demonstrated a lobular mass in the region of the optic chiasm.

 

　　A right pterional craniotomy was performed with intraopera-ttve monitoring of VEPs.The visual system was stimulated with a strobe light positioned 50 cm from the patient's nasion, flashing at a rate of 1. 08 Hz and an intensity of 16. The amplifier bandpass was 0. 3 to 300 Hz? and 128 responses were averaged.The VEP's were abnormal bilaterally before the tumor resection, both preoperatively and in the operating room. Approximately 60% of the tumor was resected with the CUSA. beginning at the dome of the largest tumor lobule and proceeding down toward the level of the normal chiasm. The VEP's did not change during the resection.The tumor was diagnosed as astrocytoma.

 

　　After surgery,the infant's vision was apparently unchanged. The head-nodding ceased immediately? and the nystagmus ceased 1 month later. The postoperative VEP's were unchanged from the preopratlve ones. The extent of resection was confirmed by CT.

 

　　Case 11: Meningioma of the anterior skull base

 

　　前顱底腦膜瘤

 

　　A 58-year-old man was diagnosed as having a predominantly intracranial meningioma en plaque of the anterior skull base in the midline area? extending from the tuberculum sellae and pla-num sphenoidale to the crista galli.The tumor was exposed in-tradurally through a right frontal craniotomy. The compressed right optic nerve and internal carotid artery were identified and treed from tumor. Then the optic chiasm and left optic nerve? completely encased by tumor? were freed by piecemeal removal of the neoplasm. Residual tumor on the tuberculum sellae and portions of the planum sphenoidale were removed with the diamond burr.  The bone defect was closed in two layers with lyophiHzed dura and a galeal pericranial flap.

 

　　Case 12 : Olfactory groove meningioma

 

　　嗅溝腦膜瘤

 

　　A 59-year-old women presented with a 2-year history of progressive dementia. Clinical examination disclosed bilateral anosmia and a concentric contraction of the left visual field with visualcuity reduced to 20%. Plain radiographs showed erosion of the cribriform plate, and CT scans demonstrated a large mass lesion suspicious for meningioma. The angiogram showed elevation of the anterior cerebral arteries and pathological staining of the tumor vessels supplied via the ophthalmic arteries. The tumor was approached through a bifrontal craniotomy and exposed by gentle retraction of the frontal lobes. Piecemeal removal of the highly vascular tumor was accoplished by bipolar coagulation and resection. Both anterior cerebral arteries, the optic nerves, and the optic chiasm were microsurgically freed of tumor. After removal of the dura bordering on the tumor, the thickened crista galli and cribriform plate were removed with the diamond burr.  The small skull base defect was closed in two layers with a dural graft and a galeal pericranial flap. The postoperative course was uncomplicated, and CT scans confirmed total tumor removal. One year later, the patient was clinically asymptomatic and recurrence-free.

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