摘要：这项综合性研究深入探讨了脑膜瘤的诊断与治疗，尤其聚焦于巨大顶叶脑膜瘤和囊性脑膜瘤。通过细致分析临床数据、影像学特征、手术技术、围手术期管理以及预后因素，旨在详细了解当前的知识状况并确定有待改进的领域。研究结果强调了准确诊断、精准手术干预以及有效的围手术期护理在

摘要：这项综合性研究深入探讨了脑膜瘤的诊断与治疗，尤其聚焦于巨大顶叶脑膜瘤和囊性脑膜瘤。通过细致分析临床数据、影像学特征、手术技术、围手术期管理以及预后因素，旨在详细了解当前的知识状况并确定有待改进的领域。研究结果强调了准确诊断、精准手术干预以及有效的围手术期护理在改善患者预后方面的重要性。此外，对不同类型脑膜瘤进行比较，揭示了神经外科肿瘤学领域所面临的共同挑战与机遇。

关键词：巨大顶叶脑膜瘤；囊性脑膜瘤；诊断；治疗；预后

脑膜瘤主要起源于蛛网膜帽状细胞，是颅内肿瘤的重要组成部分，且大多数为良性。然而，它们的位置和特征给神经外科医生带来了巨大挑战。顶叶作为关键神经功能的中枢，当受到大型脑膜瘤侵袭时，就变成了复杂的手术区域。与此同时，囊性脑膜瘤由于其囊性和实性成分的外观多变，带来了一系列独特的诊断与管理难题。近年来，技术进步革新了对这些肿瘤的治疗手段，但仍需深入探索以优化患者护理。

患有巨大顶叶脑膜瘤的患者通常会表现出各种各样的症状。对总共 [X] 例患者的研究显示，其年龄跨度从 [最小年龄] 至 [最大年龄]，平均年龄为（[平均年龄数值] ± [标准差数值]）岁，他们出现的症状包括头痛（[X3] 例）、呕吐（[X4] 例）、肢体无力（[X5] 例）、感觉异常（[X6] 例）以及癫痫发作（[X7] 例）。这些表现不仅扰乱了日常生活，还对手术决策过程起到了指导作用。

患者的长期预后与肿瘤切除程度密切相关。根据辛普森切除分级系统，[X8] 例患者达到 Ⅰ 级切除（完全切除肿瘤，包括受累的硬脑膜和颅骨），[X9] 例患者为 Ⅱ 级切除（完全切除肿瘤并电凝附着的硬脑膜），[X10] 例患者为 Ⅲ 级切除（完全切除肿瘤，但硬脑膜未处理或部分处理），[X11] 例患者为 Ⅳ 级切除（仅部分切除肿瘤）。总体切除率（Ⅰ - Ⅲ 级切除率之和）为 [总体切除率数值]%。随访时间为 3 个月至 3 年，平均为（[平均随访时间数值] ± [标准差数值]）年，包括定期门诊就诊和电话咨询。在此期间，许多患者的症状有所改善，[X17] 例患者报告头痛和呕吐症状缓解，[X18] 例患者肢体功能和感觉恢复增强，[X19] 例患者癫痫发作得到更好控制。然而，[X20] 例患者出现肿瘤复发，复发时间范围为 [复发时间范围]。复发病例通过再次手术（[X201] 例）或放疗等保守治疗（[X202] 例）进行管理。

囊性脑膜瘤虽然不太常见，但存在独特的诊断困难。其影像学表现，尤其是在 CT 扫描上，可能具有误导性。例如，一位 80 岁左撇子男性患者，出现反复局灶性运动性癫痫发作并继发全身性发作，头颅对比增强 CT 显示左侧顶枕叶有一个大的囊性肿块。最初，其外观提示可能为恶性肿瘤，凸显了误诊的可能性。然而，进一步的钆增强 MRI 检查提供了更准确的图像，精确地勾勒出了肿瘤的实性和囊性成分。这个病例说明了多模态成像在得出正确的初步诊断方面的重要性。

MRI 凭借其卓越的软组织对比度，是囊性脑膜瘤诊断的基石。它能够区分肿瘤的囊性和实性部分，从而更准确地评估肿瘤的大小、位置及其与周围结构的关系。这些详细的影像学信息不仅对诊断至关重要，对于手术规划也同样关键，因为它有助于外科医生预估切除手术的复杂性。

囊性脑膜瘤的手术方法与巨大顶叶脑膜瘤的手术方法有相似之处。在保留神经功能的同时精确切除肿瘤仍然是首要目标。然而，囊肿的存在增加了额外的复杂性。外科医生必须小心处理囊液，防止其溢出，因为这可能导致术后化学性脑膜炎等并发症。此外，根据囊肿壁的组织学性质，可能需要部分或全部切除囊肿壁，以确保肿瘤完全切除。

术后组织病理学检查是必不可少的。在上述病例中，肿瘤最终被确诊为良性的世界卫生组织（WHO）Ⅰ 级纤维母细胞型脑膜瘤。这一确诊结果不仅验证了诊断，还为未来的管理决策提供了指导，包括是否需要进一步监测或辅助治疗。

巨大顶叶脑膜瘤和囊性脑膜瘤都在很大程度上依赖 CT 和 MRI 的组合来实现准确诊断。识别脑膜瘤的特征性迹象（如 “脑膜尾征”）以及精确勾勒囊性脑膜瘤的囊性成分的重要性怎么强调都不为过。这些影像学特征构成了制定适当手术策略的基础。

在手术技术方面，尽量减少组织损伤、精确控制血管以及进行术中监测的原则是通用的。无论是处理顶叶的大型实性肿瘤还是复杂的囊性脑膜瘤，目标都是在保护神经功能的同时实现完全切除。这需要高超的手术专业技能以及先进技术的运用。

术前优化患者状况、术后密切监测以及积极管理并发症对于这两种肿瘤类型都是至关重要的。早期识别和治疗癫痫、感染及其他并发症对患者获得良好预后起着关键作用。此外，康复在促进神经功能恢复方面的作用在两种情况下同样重要。

总之，脑膜瘤（特别是巨大顶叶和囊性脑膜瘤）的诊断与治疗需要多学科协作。准确的影像学检查、精确的手术技术以及全面的围手术期护理是成功管理患者的支柱。虽然已经取得了显著进展，但挑战依然存在，尤其是在肿瘤解剖结构复杂和病理亚型具有侵袭性的情况下。未来的研究应聚焦于利用人工智能等新兴技术实现更准确的诊断，以及采用微创外科技术改善患者预后。通过了解不同脑膜瘤类型之间的异同，神经外科肿瘤学领域能够不断进步，为患者带来更好的希望和生活质量。

Abstract: This comprehensive study delves into the diagnosis and treatment of meningiomas, with a particular focus on giant parietal lobe meningiomas and cystic meningiomas. By meticulously analyzing clinical data, imaging characteristics, surgical techniques, perioperative management, and prognostic factors, it aims to provide a detailed understanding of the current state of knowledge and identify areas for improvement. The results highlight the importance of accurate diagnosis, precise surgical intervention, and effective perioperative care in enhancing patient outcomes. Additionally, a comparison between different types of meningiomas reveals common challenges and opportunities for advancing the field of neurosurgical oncology.

Keywords: Giant parietal lobe meningioma; Cystic meningioma; Diagnosis; Treatment; Prognosis

Meningiomas, predominantly originating from arachnoid cap cells, constitute a significant portion of intracranial tumors, with the majority being benign. However, their location and characteristics can pose formidable challenges to neurosurgeons. The parietal lobe, a hub of crucial neurological functions, becomes a complex surgical terrain when afflicted by large meningiomas. Simultaneously, cystic meningiomas present their own set of diagnostic and management dilemmas due to the variable appearance of their cystic and solid components. In recent years, technological advancements have revolutionized the approach to these tumors, yet there remains a need for in-depth exploration to optimize patient care.

Patients with giant parietal lobe meningiomas often exhibit a diverse array of symptoms. A total of [X] patients studied, with ages spanning from [Minimum Age] to [Maximum Age] and an average age of ([Average Age Value] ± [Standard Deviation Value]) years, presented with symptoms such as headache ([X3] cases), vomiting ([X4] cases), limb weakness ([X5] cases), sensory abnormalities ([X6] cases), and epileptic seizures ([X7] cases). These manifestations not only disrupt daily life but also guide the surgical decision-making process.

Head CT examinations play a pivotal role in the initial evaluation. They excel in detecting tumor calcifications, providing valuable insights into the bony anatomy and potential challenges during surgery. For instance, the visualization of calcified regions can influence the choice of surgical approach, as it may indicate areas of increased tumor adherence or altered tissue density.

MRI, with its multi-sequence capabilities, offers a more comprehensive view. In the T1WI sequence, the tumor typically appears iso- or slightly hypointense, while in T2WI, it shows iso- or slightly hyperintense characteristics. After contrast administration, the characteristic "dural tail sign" is often observed, along with homogeneous enhancement of the tumor mass. This detailed anatomical information is indispensable for precise surgical planning, allowing surgeons to anticipate the tumor's relationship with surrounding brain structures and blood vessels.

The choice of patient position, whether supine or lateral, is meticulously determined based on the tumor's location. Head fixation with a head frame ensures stability and optimal exposure of the surgical field. Incisions, such as the commonly employed horseshoe-shaped or question mark-shaped designs, are strategically placed to minimize damage to functional areas and provide the shortest access route to the tumor. During scalp flap elevation, meticulous attention is paid to preserving the blood supply to ensure the viability of the tissue throughout the procedure.

A milling cutter is utilized to create a bone flap of appropriate size. This demands a delicate balance, as the window must be large enough to fully expose the tumor border, yet small enough to avoid inadvertent damage to critical structures like the dura mater and the sagittal sinus. In cases where the tumor abuts the sagittal sinus, microscopic dissection is employed to carefully separate the tumor from the sinus wall. Temporary control of the sinus blood flow may be necessary in some instances, but strict time limits are adhered to in order to prevent venous congestion and its associated complications.

Under the microscope, surgeons employ a combination of sharp and blunt dissection techniques to separate the tumor from the surrounding normal brain tissue. Identifying the correct plane of dissection, often along the arachnoid space, is crucial to prevent excessive tissue damage. Feeding arteries, which are typically derived from branches of the internal carotid artery and middle cerebral artery, are identified and coagulated early in the procedure to minimize intraoperative bleeding. When faced with a firm tumor texture, an ultrasonic aspirator (CUSA) can be employed to perform piecemeal resection, reducing the need for excessive traction on the brain. Throughout the resection, neuronavigation is used to continuously verify the surgical position, and intraoperative electrophysiological monitoring safeguards the integrity of functional area cortices and conduction tracts. Any abnormal changes in the monitored signals prompt immediate surgical adjustments.

Following tumor removal, the dura mater is meticulously sutured. In cases of significant dural defects, artificial dura mater or autologous fascia grafts are used to prevent cerebrospinal fluid leakage. The bone flap is then repositioned and fixed. If part of the skull has been removed due to tumor invasion or surgical necessity, a subsequent skull reconstruction procedure is scheduled to restore the cranial integrity, which is not only aesthetically important but also crucial for protecting the brain.

A comprehensive preoperative workup includes a battery of tests to evaluate the patient's overall health, including cardiac, pulmonary, hepatic, and renal functions. Any existing water and electrolyte imbalances are corrected to optimize the patient's physiological state for surgery. For patients with a history of epileptic seizures, appropriate anti-epileptic medications are initiated preoperatively to reduce the risk of seizure activity during and after the procedure. Additionally, detailed discussions with the patient and their family regarding the surgical risks, expected outcomes, and potential complications are essential to obtain informed consent and psychological preparedness.

Immediate transfer to the neurosurgical intensive care unit (NICU) is standard practice. Here, continuous monitoring of vital signs, including heart rate, blood pressure, respiration, and oxygen saturation, is complemented by close observation of the patient's consciousness and pupil responses. These measures are crucial for the early detection of life-threatening complications such as intracranial hemorrhage and brain herniation. Intracranial pressure monitoring is also implemented, and when necessary, dehydration and intracranial pressure-lowering therapies are promptly initiated.

The long-term outcome of patients is closely related to the extent of tumor resection. According to the Simpson resection grading system, [X8] patients achieved Grade I resection (complete removal of the tumor, including involved dura mater and skull), [X9] had Grade II resection (complete removal with coagulation of the attached dura mater), [X10] had Grade III resection (complete removal, but with untreated or partially treated dura mater), and [X11] had Grade IV resection (partial removal only). The overall resection rate, combining Grades I-III, was [Total Resection Rate Value]%. Follow-up, which spanned from 3 months to 3 years with an average of ([Average Follow-up Time Value] ± [Standard Deviation Value]) years, involved regular outpatient visits and telephone consultations. During this period, symptoms improved in many patients, with [X17] reporting relief from headache and vomiting, [X18] showing enhanced limb function and sensory recovery, and [X19] having better-controlled epileptic seizures. However, [X20] patients experienced tumor recurrence, with the recurrence time ranging from [Recurrence Time Range]. Recurrent cases were managed either with repeat surgery ([X201] cases) or conservative treatments like radiotherapy ([X202] cases).

Cystic meningiomas, though less common, present unique diagnostic difficulties. The radiological appearance, especially on CT scans, can be misleading. As seen in the case of an 80-year-old left-handed man with recurrent focal motor seizures and secondary generalization, a contrast CT of the brain revealed a large left-sided parieto-occipital cystic mass. Initially, the appearance suggested a malignant tumor, highlighting the potential for misdiagnosis. However, further investigation with gadolinium-enhanced MRI provided a more accurate picture, precisely delineating the solid and cystic components. This case exemplifies the importance of multimodal imaging in arriving at a correct provisional diagnosis.

MRI, with its superior soft tissue contrast, is the cornerstone of cystic meningioma diagnosis. It can distinguish between the cystic and solid portions of the tumor, allowing for a more accurate assessment of its size, location, and relationship to surrounding structures. This detailed imaging information is crucial not only for diagnosis but also for surgical planning, as it helps surgeons anticipate the complexity of the resection.

The surgical approach for cystic meningiomas shares similarities with that of giant parietal lobe meningiomas. Precise tumor excision, while preserving neurological function, remains the primary goal. However, the presence of cysts adds an extra layer of complexity. Surgeons must carefully manage the cystic fluid to prevent spillage, which could potentially lead to postoperative complications such as chemical meningitis. Additionally, the cyst wall, depending on its histological nature, may need to be resected in part or in full to ensure complete tumor removal.

Postoperative histopathological examination is non-negotiable. In the aforementioned case, the tumor was ultimately confirmed to be a benign WHO Grade I fibroblastic meningioma. This confirmation not only validates the diagnosis but also guides future management decisions, including the need for further surveillance or adjuvant therapy.

Both giant parietal lobe and cystic meningiomas rely heavily on a combination of CT and MRI for accurate diagnosis. The importance of identifying characteristic signs such as the "dural tail sign" in meningiomas and the precise delineation of cystic components in cystic meningiomas cannot be overstated. These imaging features serve as the foundation for formulating appropriate surgical strategies.

In terms of surgical technique, the principles of minimizing tissue damage, precise vascular control, and intraoperative monitoring are universal. Whether dealing with a large solid tumor in the parietal lobe or a complex cystic meningioma, the goal is to achieve complete resection while safeguarding neurological function. This requires a high level of surgical expertise and the utilization of advanced technologies.

Preoperative optimization of the patient's condition, postoperative vigilant monitoring, and proactive complication management are essential for both tumor types. The early recognition and treatment of epilepsy, infection, and other complications are crucial for a favorable patient outcome. Additionally, the role of rehabilitation in promoting neurological recovery is equally significant in both scenarios.

In conclusion, the diagnosis and treatment of meningiomas, particularly giant parietal lobe and cystic variants, demand a multidisciplinary approach. Accurate imaging, precise surgical techniques, and comprehensive perioperative care are the pillars of successful patient management. While significant progress has been made, challenges remain, especially in cases of complex tumor anatomy and aggressive pathological subtypes. Future research should focus on leveraging emerging technologies such as artificial intelligence for more accurate diagnosis and minimally invasive surgical techniques for improved patient outcomes. By learning from both the similarities and differences between different meningioma types, the field of neurosurgical oncology can continue to advance, offering better hope and quality of life for patients.

来源：医学顾事