立体定向术治疗多发性脑脓肿(附11例临床分析)

目的通过对立体定向术治疗多发性脑脓肿的回顾性分析,总结手术经验。方法应用Leksell-G型定向仪,行MRI引导下立体定向穿刺 术中抗生素冲洗术,设计最佳手术入路,行多发脓肿穿刺,术后常规应用抗生素治疗2周。结果11例多发脑脓肿患者,共30个脓肿,均一次穿刺成功,经抽吸冲洗后复查脓腔消失。抗生素治疗2周后,经随访全部病例治愈。结论立体定向术具有定位准确、安全、创伤小等优点,适用于多发性脑脓肿及脓肿部位较深或位于语言、运动中枢等主要功能部位,或由于年老体弱或其他严重疾病不能耐受开颅手术者。     

立体定向穿刺引流治疗深部多发性脑脓肿

目的采用采用立体定向穿刺引流治疗探部及多发性脑脓肿.方法使用颅表定位器,对31例深行部及多发性脑脓肿立体定向穿刺引流术,术后持续冲洗引流3～14天,常规应用敏感肮生素.结果本组31例,共38个脓肿,均一次穿刺成功,经冲洗引流后,2例因脓肿腔不闭合而行手术治疗.余经CT复查证明脓腔消失,随访至今未见脓腔复发.结论多发性脑脓肿及小型的深部脑脓肿,直接手术有一定的困难,尤其是脓肿位于脑重要的功能区,手术风险更大.CT引导下立体定向穿刺引流治疗脑脓肿,以其操作方便,定位准确,损伤小,疗效可靠而显示其明显的优越性,特别是对儿童及年老体弱者     

脑脓肿立体定向外科治疗

目的进一步评价立体定向外科手术在脑脓肿治疗中的作用并探讨脑脓肿的最有效治疗方法。方法自1999年1月至2005年3月共外科手术治疗脑脓肿患者24例，其中男19，女5例，年龄7～76岁（平均44．5岁）。单发脓肿21例；多发脓肿3例。共行立体定向引导脓肿穿刺及引流手术20例：脓肿穿刺14例，穿刺置管引流6例；开颅手术切除脓肿4例。结果全部手术均获得成功，一例患者2W后复发施行了第二次定向手术，另一例于立体定向手术结束时出现癫痫大发作。出院时所有患者临床症状全部消失或明显改善，头颅CT或MRI复查显示脓肿腔消失。22例患者接受了4个月至3年的随访（平均14个月），均未见脓肿复发。结论立体定向脑脓肿穿刺抽吸和引流手术应为脑脓肿的首选治疗。     

脑脓肿7例手术治疗体会

目的 探讨脑脓肿的治疗方法和疗效.方法 脓肿穿刺冲洗引流术4例,脓肿切除术3例.结果 6例痊愈,1例复发,二次手术后痊愈.结论 脑脓肿不宜早期手术,应先抗生素治疗2～4周,待脓肿壁形成后再手术. 摘要： 1 资料与方法 1.1 一般资料 男4例,女3例;年龄24～59岁;血源性1例,外伤性2例,上感3例,耳源性1例;顶叶3例,基底节1例,颞枕部2例,额叶1例.7例均行头颅CT及增强CT扫描,2例行MRI扫描. 1.2 治疗方法 全身应用抗生素治疗2～4周后,3例行脓肿切除术,4例应用YL-1型颅脑穿刺针行立体定向脓肿穿刺冲洗引流术.术后继续全身应用抗生素2～4周,抗癫治疗1.5～2 a.     

立体定向穿刺引流术治疗脑深部脓肿临床分析

目的 探讨立体定向穿刺引流术治疗脑深部脓肿的效果。方法 回顾性分析2012年1月至2019年12月立体定向穿刺引流术治疗的7例脑深部脓肿的临床资料。结果 6例为单发脓肿,1例为多房性脓肿;脓肿位于中脑1例,丘脑1例,基底节区1例,颞叶深部2例,额顶叶深部2例。术后5例脓肿消失,意识恢复清醒;1例虽意识恢复清醒,但最终因延髓炎症造成呼吸、心跳骤停死亡;1例颞部深部脓肿为多房性脓肿,单次穿刺引流不全后进一步开颅手术,最终治愈。结论 立体定向穿刺引流术定位准确、安全、创伤小,是一种治疗脑深部脓肿有效方法,尤其单个脑深部脓肿。     

立体定向穿刺引流术或开颅切除术治疗脑脓肿

目的 探讨立体定向穿刺引流术或开颅切除术治疗脑脓肿的效果。方法 回顾性分析2011年1月至2019年4月收治的36例脑脓肿的临床资料，其中13例采用CT/MRI定位立体定向穿刺+抗生素冲洗术（穿刺组），23例采用开颅脓肿切除术（开颅组）。结果 36例病灶深度（23.9±10.6）mm，其中穿刺组（32.5±11.2）mm，开颅组（19.0±6.3）mm。36例病灶最大截面积平均（13.6±23.3）cm2，其中穿刺组（8.7±6.5）cm2，开颅组平均（16.6±28.9）cm2。36例中，11例培养阳性，阳性率为30.56%。术后随访共32例，随访率为91.43%，其中穿刺组12例，开颅组20例；平均随访（24.1±22.4）个月，其中穿刺组平均随访（34.4±29.0）个月，开颅组平均随访（18.6±15.7）个月。穿刺组未见复发及死亡病例；开颅组1例术后3个月复发，6例死亡。出院时，36例GOS评分（3.9±1.0）分，其中穿刺组（4.2±0.7）分，开颅组（3.8±1.2）分；末次随访时，36例GOS评分（3.97±1.53）分，其中穿刺组（4.8±0.4）分，开颅组（3.5±1.7）分。结论 位于深部的脑脓肿，立体定向穿刺引流术具有微创、精准等独特优势；而对脑水肿较重、有脑疝的病人，宜采用开颅手术，必要时需去除骨瓣     

9例脑脓肿的手术治疗体会

目的 总结脑脓肿手术治疗的经验。方法 回顾性分析2004年4月至2017年11月收治的9例脑脓肿的临床资料。2例行脓肿切除术；7例行脓肿穿刺引流术，术后脓腔注射抗生素。根据脓液培养结果或经验抗炎治疗。结果 9例均恢复良好；复查CT至脑水肿明显消退后出院。1例出院即失访，余8例均随访3个月；脓肿无复发，CT示局部无水肿或轻度脑水肿。结论 脑脓肿经切除或穿刺引流均可获得良好疗效。     

脑脓肿的MRI诊断和立体定向手术治疗

目的 探讨核磁共振(MRI)弥散加权成像(DWI)与表观弥散系数(ADC)值在脑炎病理变化全过程中的诊断价值,进一步评价立体定向脓液抽吸及引流术在脑脓肿治疗中的作用.方法 利用脑炎在核磁共振DWI及ADC值上的表现,对14例23个脓肿灶的磁共振表现进行分析.共行立体定向引导脓肿穿刺及引流手术20例:脓肿穿刺14例,脓肿腔穿刺引流6例.结果 脑脓肿不同期的MRI DWI表现和ADC值有明显不同.20例手术均获得成功,术后头颅CT或MRI复查显示脓肿腔消失.所有病人在随访期内(4个月至3年,平均14个月)未见脓肿复发.结论 脑炎各个时期有其不同的MRI表现,DWI及ADC值已成为脑炎各期诊断的一个重要诊断依据.立体定向脑脓肿穿刺抽吸和引流手术应为脑脓肿的首选外科手段.     

包膜期脑脓肿的MRI特征及临床意义

目的 总结包膜期脑脓肿的MRI特征及临床意义。方法 分析18例行手术治疗的包膜期脑脓肿病人的临床资料，术前均行MR检查，术后均经病理证实。结果 MRI示均呈囊性占位性病变，其脓肿壁上均有一较光滑的低信号“暗带”，脓腔DWI呈高信号。3例行开颅脑脓肿切除术，10例行脑脓肿穿刺引流术，5例行立体定向穿刺引流术，均治愈出院且无明显继发性损害。结论 包膜脑脓肿壁及脓腔的MR特征性表现具有重要的诊断价值和临床意义，对其手术方式的选择具指导作用。     

立体定向手术治疗深部脑脓肿

脑深部多发性脓肿的手术治疗历来是神经外科的一个难题。近年来，国外有较多研究报道，对脑深部病变，立体定向手术显示其优越性。我院1998年9月至2003年6月，采用CT定位立体定向抽吸术治疗深部多发性脑脓肿23例病人，现报告如下。     

Stereotactic drainage of brain abscesses

Between 1981 and 1986, 16 patients with brain abscesses underwent computed tomography (CT) guided stereotactic aspiration with (n = 5) or without (n = 11), catheter drainage. Infectious sources were found in 11 patients; 6 patients had concomitant immune suppression. Bacterial or mixed toxoplasmic-fungal or toxoplasmic-viral abscesses were diagnosed in 14 patients. After prolonged antimicrobial treatment, follow-up clinical and radiological evaluations confirmed abscess resolution in 12 patients. The abscess size was smaller in four patients, three of whom died 30-60 days after surgery due to overwhelming systemic opportunistic infections. One patient with a tuberculous brain abscess continued to exhibit gradual abscess regression one year after beginning three-drug antituberculous therapy. No surgical mortality occurred but two patients required evacuation of post-operative intracerebral haematomas that resulted from over-vigorous abscess aspiration. CT stereotactic drainage is a safe and effective technique to diagnose and treat brain abscesses and is mandatory for small or deep-seated lesions. Empirical therapy of suspected brain abscesses is rarely warranted in the era of CT stereotactic surgery.     

Stereotactic drainage of brain abscesses

Between 1981 and 1986, 16 patients with brain abscesses underwent computed tomography (CT) guided stereotactic aspiration with (n = 5) or without (n = 11), catheter drainage. Infectious sources were found in 11 patients; 6 patients had concomitant immune suppression. Bacterial or mixed toxoplasmic-fungal or toxoplasmic-viral abscesses were diagnosed in 14 patients. After prolonged antimicrobial treatment, follow-up clinical and radiological evaluations confirmed abscess resolution in 12 patients. The abscess size was smaller in four patients, three of whom died 30-60 days after surgery due to overwhelming systemic opportunistic infections. One patient with a tuberculous brain abscess continued to exhibit gradual abscess regression one year after beginning three-drug antituberculous therapy. No surgical mortality occurred but two patients required evacuation of post-operative intracerebral haematomas that resulted from over-vigorous abscess aspiration. CT stereotactic drainage is a safe and effective technique to diagnose and treat brain abscesses and is mandatory for small or deep-seated lesions. Empirical therapy of suspected brain abscesses is rarely warranted in the era of CT stereotactic surgery.     

脑脓肿个体化手术治疗

目的总结手术治疗的69例脑脓肿,探讨脑脓肿手术病例的选择和治疗效果。方法分析69例脑脓肿的临床资料,采用立体定向穿刺术16例;开颅脑脓肿切除术25例;小骨窗开颅引流术28例,进行回顾性分析。结果立体定向穿刺术治愈15例,1例复发;开颅脑脓肿切除术治愈20例,好转2例,3例复发。小骨窗开颅引流术治愈25例,好转2例,1例复发。结论脑脓肿的治疗应根据患者年龄、全身状况、有无并发症、脑脓肿大小、部位、形态以及是否多发,采取个体化的治疗方式;个体化治疗有助于提高治疗效果。     

CT／MRI结合立体定向手术临床应用

目的 探讨立体定向手术在颅内病变诊断和治疗中的应用价值.方法 回顾性分析20例立体定向手术,其中脑出血引流8例,脑深部病灶活检5例,脑室穿刺3例,囊性病变抽吸4例.结果 20例立体定向手术均顺利完成,无严重并发症发生.5例活检均证实为胶质瘤,另12例经治疗后症状得到缓解,其余3例继续专科治疗.结论 立体定向手术定位准确,安全可靠,是一种有效的治疗方法.     

Current concepts in the management of pyogenic brain abscess

Current philosophy of treatment of brain abscess includes aspiration, appropriate antibiotics, treatment of sequelae and eradication of the primary source. Early clinical suspicion and diagnosis with CT is crucial. Small abscesses (<3 cm) in cerebritis or capsular stage located deep in clinically stable, poor surgical risk patients with diagnosis firmly supported by CT, may be treated with medical treatment only. Biweekly CT scan must be done to monitor the treatment response. CT or ultrasound guided aspiration should be performed in the event of clinical deterioration, failure of reduction in size or enlargement of abscesses. Encapsulated abscess (>3 cm), presence of significant neurological deficit or mass effect, doubt in the diagnosis and presumed resistant organisms are best treated with aspiration. Excision is required in large superficial abscesses resistant to multiple aspirations, post-traumatic abscess with a foreign body or fistula and multiloculated abscess of nocardial or actinomycotic aetiology. Results are directly related to the sensorium at the time of presentation. Stereotactic aspiration of all the loculi of multiloculated abscess in single or staged aspiration, and more completed drainage and lavage with endoscopic stereotactic evacuation may cut down indications of excision of brain abscess in future. It is concluded that, with diagnostic and technical advancements, a trend of adequate drainage of brain abscess via minimally invasive surgery is emerging. Confirmation of diagnosis and monitoring of treatment response with magnetic resonance spectroscopy may allow greater number of patients in future to be managed with medical treatment only.     

Endoscopic treatment of brain abscesses

Background Stereotactic aspiration with external drainage has become widely accepted as the standard treatment for intracerebral abscesses. Although neuroendoscopic technique has only been occasionally adopted for this pathology, it introduces some advantages because it presents visual awareness that the pus has been removed.Methods Four patients with cerebral abscess and one with a subdural empyema were operated using a neuroendoscopic technique in our Department between 1996 and 2003. A 4-mm flexible endoscope was introduced into the purulent collection through a burr hole, the pus was meticulously aspirated, and the cavity washed with isovolumetric antibiotic lavages using the working channel for both irrigation and suction.Conclusion Neuroendoscopic treatment of brain abscesses presents some additional advantages as a possible alternative to stereotactic aspiration, which still constitutes the gold standard for this pathology. The adoption of stereotactic or frameless guidance systems can probably be recommended particularly for deep, complex lesions.     

新型颅脑穿刺定位器结合新型头颅CT定位贴片辅助软通道穿刺引流术治疗高血压脑出血

目的探讨新型颅脑穿刺定位器结合新型头颅CT定位贴片辅助软通道穿刺引流术治疗高血压脑出血的应用效果及其临床意义。 方法选取湖州市中心医院神经外科自2014年1月至2015年12月行颅内血肿软通道穿刺引流术的45例高血压脑出血患者作为对照组,应用普通心电电极片CT定位法辅助穿刺;选取2016年1月至2018年7月行颅内血肿软通道穿刺引流术的48例高血压脑出血患者作为观察组,应用新型颅脑穿刺定位器结合新型头颅CT定位贴片辅助穿刺。对比2组患者的手术治疗效果和临床预后,并对新型颅脑穿刺定位器结合新型头颅CT定位贴片辅助定位法的经济性和实用性进行分析。 结果与对照组比较,观察组术中出血量更少,血肿清除率更高,且差异均具有统计学意（P<0.05）;2组患者的手术时间比较,差异无统计学意义（P>0.05）;观察组住院时间少于对照组,且术后3个月的预后优于对照组,差异具有统计学意义（P<0.05）。 结论新型颅脑穿刺定位器结合新型头颅CT定位贴片辅助软通道穿刺引流术治疗高血压脑出血可以提高穿刺定位准确性及颅内血肿清除率,减少术中出血量,从而改善患者预后,提高生存质量,适宜在广大基层医院开展。     

Drastic Therapy for Listerial Brain Abscess Involving Combined Hyperbaric Oxygen Therapy and Antimicrobial Agents

Background

Listeria monocytogenes (L. monocytogenes) is a rare causative pathogen of brain abscess that is often found in immunocompromised patients. Although patients with supratentorial listerial abscesses showed a longer survival with surgical drainage, the standard therapy for patients with subtentorial lesions has not been established.

Case Report

We report herein a patient with supra- and subtentorial brain abscesses caused by L. monocytogenes infection. These abscesses did not respond to antibiotics, and his symptoms gradually worsened. Drainage was not indicated for subtentorial lesions, and the patient was additionally treated with hyperbaric oxygen therapy, which dramatically reduced the volume of abscesses and improved the symptoms.

Conclusions

This is the first report of drastic therapy for a patient with listerial brain abscesses involving combined antibiotics and hyperbaric oxygen therapy. The findings suggest that hyperbaric oxygen therapy is a good option for treating patients with deep-seated listerial abscesses and for who surgical drainage is not indicated.