第十七届赛克勒中国医师年度奖——精彩答辩选登
答辩人：张玉琪
Question： According to your paper, the pediatric craniopharyngiomas can be divided into six typies. Can you tell us the difference between your calssfication and Dr.Yasargil's ?
问：你将儿童颅咽管瘤分为6种类型，与Yasargil教授的分类有什么不同？
Answer ：Craniopharyngiomas were classificated into six typies by Dr.Yasargil and three typies by Dr.Hoffman. At their times,CT scan and MR imaging had not been used. Dr.Yasargil's classification depended on the operative observation during the surgery and Dr.Hoffman's classification depended on the pre-operative angiography. My classification depended on the pre-operative MR imaging and the operative observation,therefore may be more comprehensive.
, 百拇医药
答：Yasargil教授依据手术中的发现来将颅咽管瘤分为6类，Hoffman教授依据脑血管造影将颅咽管瘤分为3类，他们的共同点是没有考虑到术前MRI影像学提供的情况。因为，在他们的时代，头颅CT和MRI没有得到普及应用。所以，他们的分类具有一定的局限性。我的分类是依据术前MRI和术中发现，更具有全面性和时代性。
Question：You used the transcallosal-interseptal-interforniceal approach to remove the third ventricle tumor. If the tumor extended into the lateral ventricle, what did you do?
问：你做经胼胝体-透明隔间隙-穹隆间入路切除第三脑室内的肿瘤，如肿瘤长入侧脑室，你如何处理？
Answer：With the transcallosal-interseptal-interforniceal approach,I separated the septum and fornix,entered the third ventricle. When the tumor grew into the lateral ventricle, the septum could be open to expose the lateral ventricle. The lateral ventricle tumor can be removed directly. The fornix is preserved so that the child has no memory loss.
, 百拇医药
答：我选择经胼胝体-透明隔间隙-穹隆间入路切除第三脑室内的肿瘤，如肿瘤长入侧脑室，可切开透明隔即可进入侧脑室，从而切除肿瘤。此方法可保护穹隆，如穹隆损伤，可导致病儿术后记忆障碍。
答辩人：钟春龙
Question: What's the difference between parapetrosal approach and transpetrosal approach for the petroclival tumors?
问：对于岩斜肿瘤，请说出经岩周入路和经岩骨入路的区别。
Answer: In 1993, Fukashima modified the classical presigmoid approach and established a novel parapetrosal approach with minimal drilling of a small portion of the posterior petrous bone limited to exposing a 4mm×10 mm area of the presigmoid dura. All semicircular and the endolymphatic duct must be preserved to maintain normal 8th nerve functions postoperatively. It is not necessary to perform a mastoidectomy or extensive drilling. As a result, the parapetrosal approach is much simpler, safer and less time- consuming compared to other extensive transpetrosal procedures.
, http://www.100md.com
答：1993年Fukushima提出的经岩周入路，只需磨除少量的岩周后部骨质，显露乙状窦前方4mm×10mm的硬膜区。注意保留所有半规管及内淋巴管的完整性。无需乳突切除及扩大岩骨磨除范围。硬膜切开后平行岩嵴切开小脑幕至游离缘即可直达岩斜区。与其他扩大经岩骨入路比较，岩周乙状窦前入路更简单、安全、省时。
答辩人：于新
Questions: What are the indications for the combined treatment for craniopharyngiomas and how to prevent the irradiation injury to the hypothalamus?
问：这种联合治疗的适应证是什么？在治疗中如何预防丘脑下部的放射性损伤？
, 百拇医药 Answer: We think that the indications of the combined treatment for craniopharyngiomas are as follows: (1)The solid part is small, lower, and not close to the optic nerve. (2)The cyst is single, and volume is 3 to 40 ml.(3)All the lesion can be covered by effective irradiation dose. (4)Especially for the remaining or recurrent tumor after craniotomy.In the combined treatment of the craniopharyngiomas, it is very important to prevent the irradiation injury of the surrounding structures such as the optic nerve, chiasm, hypothalamus and vascular structures. In those structures, the optic nerve and chiasm are the most sensitive ones to the irradiation, and their ability to bear the irradiation is about 9 to 12 Gy. So if the irradiation dose is lower than 9Gy, the treatment will be safe. We have not found any report about the bearability and side effect of the hypothalamus related to the gamma knife radiosurgery. And in this group we did not find this kind of complications.
, 百拇医药
答：我们认为这种治疗的适应证包括：(1)实体性肿瘤部分体积较小，位置较低，与视神经间应有一定的距离；(2)囊性部分应为单发，体积在340 ml为最佳；(3)在治疗中所有的病变应能被有效的放射剂量所覆盖；(4)特别适合于手术后残留或复发的病变。在治疗过程中，预防病变周围的重要结构如视神经，视交叉，丘脑下部和血管结构的放射性副损伤是非常重要的，在这些重要结构中，视神经和视交叉对放射线最为敏感，其耐受能力约为9 ～ 12 Gy，因此如果对这些结构的放射剂量在9Gy以下，治疗将是安全的，目前尚无有关丘脑下部的耐受剂量和放射性损伤的文献报道。在本组病人中也没有发现这种并发症的发生。
答辩人：余新光
Question ：In your patients with petroclival meningiomas, what's the most serious complication after the tumor was totally removed? And what's the lesson?
, 百拇医药
问：在你的岩斜脑膜瘤病人中，肿瘤全切后最严重的并发症是什么？有什么经验教训？
Answer：Two patients developed Weber's syndrome.In these 2 cases,the tumors had invaded the midbrain and there were perforating arteries passing through the tumor.I was unable to preserve the vessels while I did radical resection of the tumors.We should remember that “What we want is not the tumor,but a viable patient”.
答：有两个病人发生了Weber's 综合征(同侧动眼神经瘫伴对侧肢体瘫)。原因是肿瘤侵犯到中脑，且有小动脉穿过肿瘤供应中脑，为求肿瘤全切除，未能保全这些穿通血管。我们应该记住“手术的战利品不是切下来的肿瘤，而是良好生存的病人”这句话。
, http://www.100md.com
答辩人：张赛
Question：1.What do you think is the best indication for mild hypothermia for brain trauma?
问：你认为颅脑创伤亚低温治疗的最好指征是什么
Answer：The indication of hypothermia is an important problem. In general, most investigators thought that all patients with severe brain trauma are indicatied for mild or moderate hypothermic therapy except for patients associated with low blood pressure, hypoxia, low body temperature. But about the best indication for brain hypothermia, we think that the patients who have GCS 6-8 score、 admitted 3 hours after trauma with located area of cerebral contusion、ICP value is less than 40 mmHg, are the most appropriate cases for hypothermic therapy. Patients who have GCS score 3-5 , admitted over 3 to 24 hours after trauma, diffuse cerebral injury, ICP value is over 40 mmHg, may be adaptive cases, but the effecti of hypothermia is limited. If the ICP value is over 40 mmHg and the patient is admitted over 24 hours after trauma, the patient is not indicated for mild or moderate hypothermic therapy, we should keep a controlled normothermia (36.5℃-37.5℃), in order to prevent secondary brain damage.
答：亚低温治疗的指征是一个很重要的问题。一般认为，在所有重型颅脑创伤病人中除了伴有低血压、低氧血症、低体温者外，都是亚低温治疗的指征.但是,关于亚低温治疗的最佳指征,我们认为,颅脑创伤后3小时内入院、GCS 6～8分、局限性脑挫裂伤、颅内压值在40mmHg以内者是亚低温治疗的最佳指征。颅脑创伤后超过3小时而在24小时内入院、GCS 3～5分、弥漫性脑损伤、颅内压值超过40mmHg者也是亚低温治疗的指征，但亚低温治疗的效果有限。如果，颅内压值超过40mmHg，而且颅脑创伤后超过24小时入院者，不适合进行亚低温治疗。但应当对这类病人给予控制性正常温度范围(36.5℃～37.5℃)的治疗，以防止和减轻继发性脑损害。, 百拇医药
Question： According to your paper, the pediatric craniopharyngiomas can be divided into six typies. Can you tell us the difference between your calssfication and Dr.Yasargil's ?
问：你将儿童颅咽管瘤分为6种类型，与Yasargil教授的分类有什么不同？
Answer ：Craniopharyngiomas were classificated into six typies by Dr.Yasargil and three typies by Dr.Hoffman. At their times,CT scan and MR imaging had not been used. Dr.Yasargil's classification depended on the operative observation during the surgery and Dr.Hoffman's classification depended on the pre-operative angiography. My classification depended on the pre-operative MR imaging and the operative observation,therefore may be more comprehensive.
, 百拇医药
答：Yasargil教授依据手术中的发现来将颅咽管瘤分为6类，Hoffman教授依据脑血管造影将颅咽管瘤分为3类，他们的共同点是没有考虑到术前MRI影像学提供的情况。因为，在他们的时代，头颅CT和MRI没有得到普及应用。所以，他们的分类具有一定的局限性。我的分类是依据术前MRI和术中发现，更具有全面性和时代性。
Question：You used the transcallosal-interseptal-interforniceal approach to remove the third ventricle tumor. If the tumor extended into the lateral ventricle, what did you do?
问：你做经胼胝体-透明隔间隙-穹隆间入路切除第三脑室内的肿瘤，如肿瘤长入侧脑室，你如何处理？
Answer：With the transcallosal-interseptal-interforniceal approach,I separated the septum and fornix,entered the third ventricle. When the tumor grew into the lateral ventricle, the septum could be open to expose the lateral ventricle. The lateral ventricle tumor can be removed directly. The fornix is preserved so that the child has no memory loss.
, 百拇医药
答：我选择经胼胝体-透明隔间隙-穹隆间入路切除第三脑室内的肿瘤，如肿瘤长入侧脑室，可切开透明隔即可进入侧脑室，从而切除肿瘤。此方法可保护穹隆，如穹隆损伤，可导致病儿术后记忆障碍。
答辩人：钟春龙
Question: What's the difference between parapetrosal approach and transpetrosal approach for the petroclival tumors?
问：对于岩斜肿瘤，请说出经岩周入路和经岩骨入路的区别。
Answer: In 1993, Fukashima modified the classical presigmoid approach and established a novel parapetrosal approach with minimal drilling of a small portion of the posterior petrous bone limited to exposing a 4mm×10 mm area of the presigmoid dura. All semicircular and the endolymphatic duct must be preserved to maintain normal 8th nerve functions postoperatively. It is not necessary to perform a mastoidectomy or extensive drilling. As a result, the parapetrosal approach is much simpler, safer and less time- consuming compared to other extensive transpetrosal procedures.
, http://www.100md.com
答：1993年Fukushima提出的经岩周入路，只需磨除少量的岩周后部骨质，显露乙状窦前方4mm×10mm的硬膜区。注意保留所有半规管及内淋巴管的完整性。无需乳突切除及扩大岩骨磨除范围。硬膜切开后平行岩嵴切开小脑幕至游离缘即可直达岩斜区。与其他扩大经岩骨入路比较，岩周乙状窦前入路更简单、安全、省时。
答辩人：于新
Questions: What are the indications for the combined treatment for craniopharyngiomas and how to prevent the irradiation injury to the hypothalamus?
问：这种联合治疗的适应证是什么？在治疗中如何预防丘脑下部的放射性损伤？
, 百拇医药 Answer: We think that the indications of the combined treatment for craniopharyngiomas are as follows: (1)The solid part is small, lower, and not close to the optic nerve. (2)The cyst is single, and volume is 3 to 40 ml.(3)All the lesion can be covered by effective irradiation dose. (4)Especially for the remaining or recurrent tumor after craniotomy.In the combined treatment of the craniopharyngiomas, it is very important to prevent the irradiation injury of the surrounding structures such as the optic nerve, chiasm, hypothalamus and vascular structures. In those structures, the optic nerve and chiasm are the most sensitive ones to the irradiation, and their ability to bear the irradiation is about 9 to 12 Gy. So if the irradiation dose is lower than 9Gy, the treatment will be safe. We have not found any report about the bearability and side effect of the hypothalamus related to the gamma knife radiosurgery. And in this group we did not find this kind of complications.
, 百拇医药
答：我们认为这种治疗的适应证包括：(1)实体性肿瘤部分体积较小，位置较低，与视神经间应有一定的距离；(2)囊性部分应为单发，体积在340 ml为最佳；(3)在治疗中所有的病变应能被有效的放射剂量所覆盖；(4)特别适合于手术后残留或复发的病变。在治疗过程中，预防病变周围的重要结构如视神经，视交叉，丘脑下部和血管结构的放射性副损伤是非常重要的，在这些重要结构中，视神经和视交叉对放射线最为敏感，其耐受能力约为9 ～ 12 Gy，因此如果对这些结构的放射剂量在9Gy以下，治疗将是安全的，目前尚无有关丘脑下部的耐受剂量和放射性损伤的文献报道。在本组病人中也没有发现这种并发症的发生。
答辩人：余新光
Question ：In your patients with petroclival meningiomas, what's the most serious complication after the tumor was totally removed? And what's the lesson?
, 百拇医药
问：在你的岩斜脑膜瘤病人中，肿瘤全切后最严重的并发症是什么？有什么经验教训？
Answer：Two patients developed Weber's syndrome.In these 2 cases,the tumors had invaded the midbrain and there were perforating arteries passing through the tumor.I was unable to preserve the vessels while I did radical resection of the tumors.We should remember that “What we want is not the tumor,but a viable patient”.
答：有两个病人发生了Weber's 综合征(同侧动眼神经瘫伴对侧肢体瘫)。原因是肿瘤侵犯到中脑，且有小动脉穿过肿瘤供应中脑，为求肿瘤全切除，未能保全这些穿通血管。我们应该记住“手术的战利品不是切下来的肿瘤，而是良好生存的病人”这句话。
, http://www.100md.com
答辩人：张赛
Question：1.What do you think is the best indication for mild hypothermia for brain trauma?
问：你认为颅脑创伤亚低温治疗的最好指征是什么
Answer：The indication of hypothermia is an important problem. In general, most investigators thought that all patients with severe brain trauma are indicatied for mild or moderate hypothermic therapy except for patients associated with low blood pressure, hypoxia, low body temperature. But about the best indication for brain hypothermia, we think that the patients who have GCS 6-8 score、 admitted 3 hours after trauma with located area of cerebral contusion、ICP value is less than 40 mmHg, are the most appropriate cases for hypothermic therapy. Patients who have GCS score 3-5 , admitted over 3 to 24 hours after trauma, diffuse cerebral injury, ICP value is over 40 mmHg, may be adaptive cases, but the effecti of hypothermia is limited. If the ICP value is over 40 mmHg and the patient is admitted over 24 hours after trauma, the patient is not indicated for mild or moderate hypothermic therapy, we should keep a controlled normothermia (36.5℃-37.5℃), in order to prevent secondary brain damage.
答：亚低温治疗的指征是一个很重要的问题。一般认为，在所有重型颅脑创伤病人中除了伴有低血压、低氧血症、低体温者外，都是亚低温治疗的指征.但是,关于亚低温治疗的最佳指征,我们认为,颅脑创伤后3小时内入院、GCS 6～8分、局限性脑挫裂伤、颅内压值在40mmHg以内者是亚低温治疗的最佳指征。颅脑创伤后超过3小时而在24小时内入院、GCS 3～5分、弥漫性脑损伤、颅内压值超过40mmHg者也是亚低温治疗的指征，但亚低温治疗的效果有限。如果，颅内压值超过40mmHg，而且颅脑创伤后超过24小时入院者，不适合进行亚低温治疗。但应当对这类病人给予控制性正常温度范围(36.5℃～37.5℃)的治疗，以防止和减轻继发性脑损害。, 百拇医药