神经内镜下和传统分流术治疗脑积水的疗效评价

目的 评价神经内镜下第三脑室底造瘘术(ETV)或联合神经内镜引导下脑室腹腔分流术(EVPS)与传统分流术治疗脑积水的临床效果和并发症.方法 深圳大学第一附属医院神经外科自2002年6月至2009年6月共手术治疗299例脑积水患者,其中神经内镜组(98例)患者行神经内镜下ETV或联合EVPS(20例梗阻性脑积水患者仅行ETV,78例行ETV联合EVPS),传统分流组(201例)患者行传统分流术(196例行脑室腹腔分流术,5例行脑室心房分流术),分析2组患者的临床资料并比较其临床疗效和并发症的发生率.结果 与传统分流组比较,神经内镜组远期疗效好、堵管发生率低、置管位置准确率高、置管次数少,差异均有统计学意义(P<0.05).结论 应用神经内镜治疗不同原因脑积水是有益的手术方法,具有远期疗效好、堵管发生率低、置管位置准确等优势.     

神经内镜治疗脑积水

目的：探讨神经内镜在脑积水治疗中的作用。方法：采用神经内镜单独或辅助手术的方法,对111例患者行126次治疗。结果：随访3－34个月。第三脑室底脚间池造瘘术的54例导水管狭窄性脑积水45例（83％）有效。脉络丛凝固术的26例交通性脑积水20例（77％）有效。透明隔穿通术的6例单侧脑室积水均有效。内镜引导置管的40例次脑积水,分流管颅内端均通畅。并发症：术后体温发烧1－4天11例,颅内感染2例,硬膜下出血及积液2例。结论：神经内镜用于脑积水的治疗,明显改善手术疗效、降低并发症,可使部分患者免除体内置管之苦,应作为导水管狭窄性脑积水、进展缓慢的交通性脑积水及单侧脑室积水的首选治疗方法。对分隔型及其他类型脑积水,内镜应作为术中重要辅助工具。     

第三脑室底造瘘术治疗梗阻性脑积水与分流术的疗效比较

目的 比较梗阻性脑积水的两种手术方法的疗效及并发症。方法 采用经神经内镜第三脑室底造瘘术治疗梗阻性脑积水35例，脑室腹腔分流术治疗梗5且性脑积水63例。结果 造瘘组：平均用时35min，症状缓解34例(97.1％)，复发1例(2．9％)，并发症3例(8.6％)，为非感染性发热；分流组：平均用时78min，症状缓解63例(100％)，复发16例(25．4％)，并发症18例(28．6％)，为分流管堵塞、感染、颅内血肿及分流管外露等。两组均无死亡。结论 经神经内镜第三脑室底造瘘术治疗梗5且性脑积水较脑室腹腔分流术的疗效相当，并发症及复发率明显降低，手术时间缩短，应作为梗阻性脑积水的首选治疗方法。     

神经内镜辅助分流管脑室端放置在脑积水中的应用

目的 总结脑室-腹腔分流术(V-P分流术)中采用神经内镜辅助分流管脑室端固定的疗效.方法 回顾性分析13例脑积水病人的临床资料,均行V-P分流术,术中行侧脑室额角或枕角穿刺,并在神经内镜监视下固定分流管脑室端于透明隔,同时行透明隔造瘘4例,术后随访并复查头部CT.结果 术后无明显头痛、发热及颅内出血者.术后平均随访14个月,复查头部CT显示:所有病人分流管脑室端均固定于透明隔,无移位、分流管堵塞等严重并发症;脑室较术前明显缩小4例(31％),稍缩小6例(46％),无明显变化3例(23％).结论 神经内镜辅助分流管脑室端固定,可在一定程度减少分流管堵塞的发生,为防治此类并发症提供新思路.     

脑室镜第三脑室底造瘘治疗非交通性脑积水54例分析

目的探讨脑室镜第三脑室造瘘(ETV)治疗非交通性脑积水的疗效。方法回顾性分析54例非交通性脑积水病人的临床资料,均行ETV治疗,根据随访结果对ETV疗效进行客观的临床评估。结果成功实施ETV52例,造瘘失败2例。对成功实施ETV的病例随访3～39个月,有效44例;无效8例,均改行脑室-腹腔分流术。术后未见严重并发症和死亡病例。结论ETV治疗非交通性脑积水具有微创、疗效好、手术时间短、并发症少及康复快等优点,可作为首选治疗。     

神经内窥镜治疗脑积水

目的：探讨神经内窥镜在脑积水治疗中的作用。方法：应用神经内窥镜单独或辅助手术。对123例脑积水患者根据其类型不同采用不同的手术方式；对58例导水管狭窄性脑积水行内窥镜下第三脑室底脚间池造瘘术；28交通性脑积水行脉络丛凝固术；8例单侧脑室积水行透明隔穿通术；14例丘脑肿瘤合并双侧室间孔堵塞性脑积水行透明隔穿通，肿瘤活检并内窥镜引导下放置V-P分流管；15例，进展迅速的交通性脑积水行内窥镜引导放置V-P分流管的颅内端。结果：随访3-36个月。123例中108例（88%）有效，无严重并发症。结论：神经内窥镜用于脑积水的治疗，明显改善手术疗效，降低并发症，可使部分患者免除体内置管，对分隔型及其他类型脑积水，内窥镜应作为术中重要辅助工具。     

神经内镜下第三脑室底造瘘术在梗阻性脑积水中的应用

目的探讨神经内镜下第三脑室底造瘘术(endoscopic third ventriculostomy,ETV)治疗梗阻性脑积水的手术适应证、术中注意事项、术后疗效及并发症的预防。方法分析23例梗阻性脑积水行ETV治疗患者的临床表现、影像资料、术中所见和治疗效果。结果 23例患者中,21例患者手术取得良好的效果;1例原发性中脑导水管狭窄患者初次行ETV后无效,后又行脑室-腹腔分流术,效果良好;另1例脑出血导致的梗阻性脑积水患者无效。术后,出现发热患者4例、颅内积气2例、癫痫发作1例、硬膜下积液1例。结论 ETV治疗梗阻性脑积水,具有手术疗效好、并发症少等优点,值得在临床推广、应用。     

神经内镜对第三脑室后部肿瘤的诊疗价值

目的分析神经内镜对第三脑室后部区域肿瘤的诊断和治疗价值。方法回顾性分析110例第三脑室后部区域肿瘤的病例资料。术前病人均继发非交通性脑积水,均行神经内镜手术治疗。结果神经内镜下取得组织标本99例(99/110,90%),最终获得明确病理结果 89例(89/110,80.9%)。行第三脑室底造瘘术(ETV) 106例(106/110,96.4%),其中术后脑积水缓解100例(100/106,94.3%),无效需改行外引流或脑室-腹腔分流术6例(6/106,5.7%)。内镜下全切肿瘤2例(2/110,1.8%),术后脑积水均缓解。术中出血改行脑室外引流2例(2/110,1.8%)。术后出现并发症12例(12/110,10.9%),经处理后好转,无手术相关死亡。术后随访1年或以上,接受ETV的病例,术后远期需进一步行脑室-腹腔分流术或其他分流手术25例。结论对第三脑室后部区域肿瘤,神经内镜可通过活检或切除肿瘤组织来明确诊断,以便于指导下一步治疗。神经内镜还可安全、有效治疗肿瘤相关的非交通性脑积水,具有重要临床价值。     

神经内镜在治疗脑积水中的应用

目的 探讨神经内镜在脑积水诊断治疗中的应用方法及价值。方法 1998年10月－2000年1月我院应用神经内镜治疗99例各类脑积水病人，采用4种手术方法（包括三脑室底造瘘，透明隔造瘘术，囊肿脑室造瘘术，脑室－腹腔分流术），对手术适应症，并发症及预后等做了初步探讨。结果 98例效果满意，临床症状消失或明显缓解，影像学脑室变小，分流管位置满意；1例临床症状、影像学均无变化。并发症：2例三室底造瘘病人术后短期出现发热、头痛加重；1例分流管调整拔管时脑室内出血；无感染、分流管梗阻、致残及死亡。结论 神经内镜在脑积水的诊断和治疗中可以发挥重要作用，利于明确诊断，选择适宜的手术方案。同时在直视下准确操作，具有微创，高效，并发症少的优势。     

神经内镜脑室应用解剖学研究与临床应用

目的研究脑室的神经内镜解剖学特点,探讨其临床应用价值.方法在15例尸颅标本及20例脑积水患者术中用神经内镜观察侧脑室、第三脑室的解剖结构.采用神经内镜治疗脑积水20例,其中行ETV 16例,1例行透明隔造瘘术,3例行脑室-腹腔分流术,并分析其临床和影像学结果.结果脉络丛、室间孔、乳头体及导水管开口等是内镜经额角人路观察侧脑室和第三脑室的重要＂路标＂.20例脑积水患者治疗后,19例症状好转,影像学复查脑室缩小的14例;1例脑转移瘤引起的脑积水患者,术后3月死亡.并发脑膜炎1例,发热2例,1例切口愈合不良,4例ETV术后并发头皮下少量积聚液,出血2例.结论经额角入路观察范围最大,是脑室内神经内镜手术的最常用入路.对于多种原因引起的梗阻性脑积水患者ETV有很好的效果.慎重选择造瘘部位和器械对于避免出血等严重并发症有重要意义.     

神经内镜在丘脑出血破入脑室手术中的应用

目的 探讨神经内镜下早期脑室内血肿清除联合第三脑室底造瘘术（ETV）治疗丘脑出血破入脑室的疗效。方法 回顾性分析2011年7月至2015年7月收治的68例丘脑出血破入脑室的临床资料。36例（观察组）行神经内镜血肿清除术联合ETV,术后留置脑室外引流管;32例（对照组）行脑室外引流术（EVD）并联合尿激酶血肿腔注入。术后随访12~26个月,平均（23±2.1）个月。结果 观察组有效率（86.1%,31/36）明显高于对照组（62.5%,20/32;P<0.05）。观察组留置脑室外引流管时间[（1.8±1.1） d]较对照组[（4.8±1.8） d]明显缩短（P<0.05）。观察组术后脑积水发生率（12.9%,5/36）明显低于对照组（37.5%,12/32;P<0.05）。观察组术后颅内感染发生率（0%）与对照组（6.3%）无统计学差异（P>0.05）。两组均未发生过度引流、脑疝、再次出血。结论 神经内镜下早期血肿清除联合ETV治疗丘脑出血破入脑室安全有效,可明显降低术后分流依赖性脑积水发生率,显著改善病人预后。     

How should primary aqueductal stenosis in adults be treated? – A review

In 10% of adult patients with hydrocephalus, the cause is because of aqueductal stenosis (AS), causing enlargement of the lateral and third ventricles. There are currently two alternate forms of surgical treatment for AS; shunt surgery and ventriculostomy. Shunt surgery is associated with high complication rates and many patients need revisions, but the effectiveness is high. Endoscopic third ventriculostomy (ETV), re-establishing a physiological route of CSF dynamics, has become the treatment of choice for AS in most neurosurgical centers. ETV has fewer complications and revisions are rare, but some patients need shunt surgery to improve despite a patent ventriculostomy. There are today no common criteria for patient selection to either ETV or ventriculo-peritoneal shunt surgery.     

第三脑室底造瘘术和脑室腹腔分流术治疗梗阻性脑积水疗效分析

目的探讨神经内镜下第三脑室底造瘘术和传统脑室腹腔分流术治疗梗阻性脑积水的疗效优劣。方法梗阻性脑积水患者60例,随机进行神经内镜下第三脑室底造瘘术或脑室腹腔分流术,对两组患者术后主要并发症、治疗有效率及术后复发率进行对比,并对结果进行统计学分析。结果两组患者术后颅内感染、脑室内出血、气颅、硬膜下积液、慢性硬膜下血肿的发生率分别为0.0%和3.1%、7.1%和3.1%、3.6%和3.1%、0.0%和6.2%、0.0%和6.2%,两者比较无统计学差异。两组患者术后治疗有效率分别为89.3%和84.4%,两者比较无统计学差异。造瘘组患者术后复发率为3.6%,低于分流组的28.1%,两者比较有统计学意义。结论神经内镜下第三脑室底造瘘术治疗梗阻性脑积水术后主要并发症及治疗有效率和传统脑室腹腔分流术无明显差异,但复发率比脑室腹腔分流术低,值得临床推广应用。     

难治性脑积水分流管堵塞伴感染的神经内镜治疗

目的探讨神经内镜三脑室造漏术（NTV）在脑积水分流术后堵管并颅内严重感染病例中的应用。方法回顾性分析了神经内镜下三脑室底造瘘治疗脑积水V-P分流术后堵管并严重颅内感染的患者8例。对治疗时机、手术技巧及术后治疗和近期疗效进行评估。结果8例患者的临床症状及术后影像学检查均有不同程度的好转，无并发症出现。结论神经内镜在治疗脑积水分流术后堵管并颅内严重感染是一种有效的微创手术。     

Initial experience with endoscopic third ventriculostomy in Nigeria, West Africa

Objectives Endoscopic third ventriculostomy (ETV) as an alternative to traditional shunt surgery in the management of hydrocephalus of different etiologies is new in Nigeria and West Africa, with no published data till date. This initial study was done to determine the success rate and complication among our patient population. Materials and methods This series consists of a prospective study of the clinical and radiological features and outcome of the first 25 consecutive patients who underwent ETV. ETV was considered to be successful when there was no event occurring during surgery that resulted in the procedure being aborted, postoperative neurological deficit, or adverse event that resulted in a modification of the normal postoperative care. Patients follow-up was for a minimum of 2 months. Results There were 14 males and 11 females. The median age of the patients was 6 months, ranging from 1 month to 48 years. The study included obstructive hydrocephalus because of aqueductal stenosis, Dandy Walker malformation, and pineal region tumor. ETV was successful in 23 patients. Two patients had cerebrospinal fluid leak and superficial surgical site infection. There was no mortality. Conclusion ETV in this series is safe with comparable surgical outcomes to conventional ventriculoperitoneal shunt surgery, and minimal postoperative morbidity has been observed. A commentary on this paper is available at .     

神经内镜手术后发热反应的临床观察及其意义

目的总结和分析神经内镜术后发热反应的特点。方法回顾性分析88例符合纳入标准的行神经内镜手术治疗病人的临床资料。将病人按手术方式分为5组：外侧裂蛛网膜囊肿造瘘组（SAC）、脑室内蛛网膜囊肿切除组（VAC）、透明膈造瘘组（SPF）、第三脑室底造瘘组（ETV）、脉络丛烧灼术组（CPC），分别总结各组病人的术后发热反应特点。结果术后发热反应以CPC组最重。术后达到最高体温的时间所有病人均不超过术后第3天。ETv组术后最高体温可出现在手术后当El的数小时内．而非ETv组病人无此现象。结论电凝烧灼、坏死组织残留、下丘脑刺激、脑脊液循环能力等多种因素．使神经内镜手术后可出现不同程度的发热反应。     

Long-term outcome and neurologic development after endoscopic third ventriculostomy versus shunting during infancy

INTRODUCTION: Infants with obstructive hydrocephalus who were under 9 months old were initially treated by neuroendoscopic third ventriculostomy (ETV) after evaluation with magnetic resonance imaging (MRI). The clinical course and long-term outcome of these infants were examined. The outcome was also compared with that of similar infants who received ventriculoperitoneal shunting. METHODS: The patients were divided into three groups based on MRI findings: Group I was made up of six patients in whom mainly the frontal horns of the lateral ventricles were enlarged and the morphology of the cerebral cortex was normal; group II was made up of 13 patients in whom the entire lateral ventricle was enlarged bilaterally and the morphology of the cerebral cortex relatively normal; and group III was made up of six patients in whom the entire lateral ventricle was markedly enlarged bilaterally and there was periventricular leakage of cerebrospinal fluid. RESULTS: In group I, two patients were treated conservatively and four patients were treated with ETV. All of the patients in this group showed virtually normal development at 4 years of age. In group II, development was still delayed in six patients at 1 year after ETV, and two of these patients underwent shunting. All of the patients in this group showed near normal development at 5 to 6 years of age. In group III, all of the patients underwent shunting within 1 year after ETV because there was no appreciable improvement of development at 6 months after the initial procedure. CONCLUSIONS: In infants with obstructive hydrocephalus in whom the cerebral cortex is intact, adequate development can be achieved with ETV alone, although catch-up tends to be slow. In infants in whom cerebral development is inadequate or in whom the cerebrum has already been affected by hydrocephalus, sufficient improvement of development cannot be achieved with ETV alone, even if the intracranial pressure is controlled. It seems that early shunting is more useful for achieving cerebral recovery in this patient group.     

神经内镜第三脑室底造瘘术治疗梗阻性脑积水及其术后颅内压的监测

目的探讨神经内镜第三脑室底造瘘术（ETV）治疗梗阻性脑积水的效果及其术后颅内压（ICP）监测的意义。方法采用ETV治疗梗阻性脑积水36例，其中术后行ICP动态监测9例。结果术后患者症状缓解33例（91．7％），复查头颅CT或MRI示脑室系统较术前缩小；3例（8.3％）肿瘤引起的梗阻性脑积水症状缓解不明显，改行脑室-腹腔分流术。本组无死亡病例。9例术后行ICP监测结果示：①ETV术后18h内平均ICP〈10mmHg，18h后平均ICP轻度上升，稳定于10-12mmHg之间，肿瘤引起的脑积水ICP上升较快；②4例单纯导水管梗阻性脑积水术后使用甘露醇，用药后1-2h ICP下降1-2mmHg，2h后ICP逐渐恢复至用药前水平。结论①ETV后18h内ICP稍低，可能与术中放出脑脊液过多有关，可暂不应用脱水药物；②肿瘤引起的梗阻性脑积水应积极治疗原发病变。     

Assessment of endoscopic treatment for quadrigeminal cistern arachnoid cysts: A 7-year experience with 28 cases

Background

Quadrigeminal cistern arachnoid cysts (QACs) are difficult to treat because of their deep location and the presence of nervous and vascular structures of the pineal–quadrigeminal region. There are several surgical procedures available for QACs, including craniotomy and cyst excision or fenestration, ventriculoperitoneal or cystoperitoneal shunting, and endoscopic fenestration. There is a debate about which method is the best.

Objective

The aim of this study is to evaluate the effectiveness and safety of endoscopic ventriculocystostomy (VC) and third ventriculostomy (ETV) for treatment of arachnoid cysts of the quadrigeminal cistern.

Methods

Twenty-eight patients with QACs who had undergone endoscopic treatment in our department between August 2007 and June 2014 were studied retrospectively. Patient age at the time of endoscopic treatment ranged from 5 months to 42 years, including 25 children (14 males and 11 females) and 3 adults (one male and two females). All patients presented with hydrocephalus and did not undergo shunting prior to neuroendoscopic surgery. The first endoscopic procedures included lateral ventricle cystostomy (LVC) together with ETV in 18 cases, third ventricle cystostomy (3rd VC) together with ETV in 3 cases, and double VC (3rd VC and LVC) together with ETV in 7 cases. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up.

Results

Complete success was achieved in 25 (89.3 %) of 28 cases. During the follow-up period, one case underwent endoscopic reoperation with success. Shunts were implanted in 2 patients due to progression of symptoms and increase in hydrocephalus after the first endoscopic operation. Shunt independency was achieved in 26 (92.9 %) of 28 cases. The cyst was reduced in size in 22 cases (78.6 %). Postoperative images showed a reduction in the size of the ventricles in 23 cases (82.1 %). There was no surgical mortality. Subdural collection developed in 4 cases (14.3 %) and required a transient subduroperitoneal shunt in 2 cases, whereas the other 2 patients were asymptomatic and did not require any surgical treatment.

Conclusions

VC together with ETV through precoronal approach is an effective treatment for symptomatic QACs and should be the initial surgical procedure. The surgical indications should include signs of elevated ICP (including increased head circumference), Parinaud syndrome, gait ataxia, and nystagmus. Also, surgery is indicated by progressive enlargement of the cyst and young children with large cysts even if the patients are asymptomatic. Contraindications to surgery include the absence of symptoms (older children and adult) and isolated developmental delay. The main criterion for successful surgery should be improvement of clinical symptoms instead of reduced cyst volume and/or ventricular size. Repeated endoscopic procedures may be considered only for the patients whose symptoms improved after first endoscopic operation.

     

A comparison of neuro-endoscopic techniques with other surgical procedures in the treatment of arachnoid cysts in children

The aim of the study was to evaluate the use of neuroendoscopic techniques (in comparison with other surgical procedures) in the treatment for arachnoid cysts in children. The analysis was performed on results of treatment 22 children with arachnoid cysts submitted to neuroendoscopic procedures. The group consisted of 6 girls and 16 boys, aged from 1 day to 18 years (mean age 5.3 years, SD +/- 5.6). The control group treated with other, non-endoscopic surgical procedures consisted of 61 patients (20 girls and 41 boys aged from 10 days to 17 years, mean age 7 years, SD +/- 6). Criteria of success varied according to the type of surgical treatment. In the case of procedures other than shunt implantation, the treatment was regarded as effective, if there was no need to change the surgical method, while shunt implantation was considered effective, if shunt revision was not necessary. The operative treatment outcome was assessed using the Glasgow Outcome Scale. Post-treatment changes in the clinical state were graded as improvement, no change, or deterioration. In terms of the assumed criteria of success in the treatment for arachnoid cysts, neuroendoscopic procedures and microsurgical cyst excisions were among the most effective methods. As many as 90.9% of neuroendoscopically treated children needed no other operation, in comparison with 92.6% of patients submitted to microsurgical procedures, who needed no change in the operative treatment. In the group of neuroendoscopically treated patients the effectiveness of neuroendoscopic operations varied according to the type of procedure used. Cystocysternostomies or cystoventriculostomies were successful in 100%. The analysis of clinical outcome has shown that deterioration was observed only in 13% of the patients with shunt implantation. Analyzing each type of arachnoid cyst separately, a statistically significant relationship was found between improvement of the clinical state and the use of craniotomy in the surgical treatment for cysts localized in the posterior fossa. Improvement in the case of neuroendoscopically treated children was related to a larger reduction in the cyst size after surgery and to a lower intensity of intraoperative bleeding. Neuroendoscopic techniques allowed to reduce the average period of hospitalization. Neuroendoscopic cystocysternostomy and cystoventriculostomy were the most effective techniques, besides microsurgical excision of arachnoid cysts. Neuroendoscopic treatment efficacy depends on the type of procedure used. The application of neuroendoscopic techniques allows to reduce the period of hospitalization.