脑脊液引流试验对原发性正常压力性脑积水分流手术效果的预测

目的应用脑脊液引流试验(Tap试验)对原发性正常压力性脑积水(iNPH)病人进行术前评估,预测分流手术的有效性。方法前瞻性研究50例iNPH病人,先行Tap试验,5 d后行脑室-腹腔分流术(V-P分流术)。Tap试验前1 h、Tap试验后24 h及分流术后7 d分别对病人的神经功能进行评估。通过筛检试验统计分析评估Tap试验并预测iNPH病人分流手术的有效性。结果 Tap试验阳性31例,其中V-P分流术临床症状改善30例,未改善1例;Tap试验阴性19例,其中V-P分流术后症状改善6例,未改善13例。结果提示Tap试验对iNPH分流手术的灵敏度为83.3%,特异度92.9%,阳性预测率96.8%,阴性预测率68.4%。结论 Tap试验是理想的iNPH分流手术疗效的阳性预测指标。     

影响正常压力性脑积水分流术的预后因素

目的 探讨影响正常压力脑积水行脑脊液分流手术预后的因素.方法 从27例正常压力脑积水病人临床症状、病程、腰穿放液和引流试验等因素分析手术效果.结果 术后随访3个月～3年,依照疗效判定标准,显效7例(25.9％);有效15例(55.6％);无效4例(14.8％).其中以步态不稳改善最明显,以痴呆、尿失禁为主要症状者疗效较差.腰穿测CSF平均压力≥140 mmH2O者优于压力＜140 mmH2O的患者;腰穿压力＜ 140 mmH2O,且24 h CSF总引流量＜250 ml、夜间12 h CSF引流量＜150 mL的患者疗效最差.结论 对正常压力性脑积水,根据临床表现及脑脊液动力学的变化可以预测NPH分流手术的有效性.     

经Ommaya囊放液试验在正常压力性脑积水术前评估中的应用

目的 探讨经Ommaya囊放液试验在正常压力性脑积水术前评估中的应用价值。方法 选择2013年1月至2018年1月收治的56例正常压力性脑积水。至少2次及以上Tap试验结果阴性，进一步行侧脑室Ommaya囊置入，并经Ommaya囊脑脊液放液试验或持续引流试验，根据评估结果制定相应治疗方案。结果 9例单次放液试验后症状改善（20~30 ml/次），19例2~3次放液试验后症状改善（20~30ml/次），26例持续引流试验后症状改善（3~7 d，150~200 ml/d）。48例行分流术，术后恢复良好；4例定期经Ommaya囊抽液治疗；2例首次放液试验后症状明显好转，未进一步处理，随访2~4年，以较高生活质量生存。2例评估阴性，未进一步处理。结论 经Ommaya囊放液试验在正常压力性脑积水术前评估中具有较高灵敏度，可作为初步评估困难后的一种进一步评估、治疗方案。     

经腰大池与经侧脑室Ommaya囊行持续放液试验在常压性脑积水患者术前评估中的应用区别

目的分析研究经腰大池置管与经侧脑室Ommaya囊行持续放液试验在常压性脑积水患者术前评估中的应用区别。方法选择2012年1月至2018年1月间我院收治的76例正常压力性脑积水患者,均至少两次或两次以上腰穿Tap试验结果为阴性。按照患者住院号末位数字奇、偶数分组,奇数组的39例患者给予腰大池置管,偶数组的37例患者给予侧脑室前角Ommaya囊置入,之后行持续放液试验,根据评估结果给予进一步的治疗,并将两组患者的评估情况、并发症、治疗效果等作一比较。结果 Ommaya囊组在评估阳性率及脱管、梗阻、神经根刺激等并发症的预防上均优于腰大池组,差异具有统计学意义;两组患者在分流术后1年内症状改善率及感染、癫痫等并发症的控制方面差异不具有统计学意义。结论两种方法行持续放液试验在正常压力性脑积水患者术前评估中均具有较高的应用价值,其中经Ommaya囊引流组在评估效果及并发症的预防上较经腰大池引流组体现出了一定的优势。     

腰大池-腹腔分流术治疗正常压力脑积水的临床分析

目的总结腰大池-腹腔分流(LPS)术治疗特发性正常压力脑积水(iNPH)的疗效及优点。方法回顾性分析采用可调压分流管行LPS术治疗33例特发性正常压力脑积水(iNPH)病人的临床资料,主要临床表现有步态障碍、认知障碍和尿失禁,并分别采用5 m折返行走试验、简易智能精神状态检查(MMSE)和问卷调查方法对其进行评估。脑脊液放液试验阳性者作为手术治疗的必备条件,Evan’s指数评估手术前后脑室系统变化。结果本组脑脊液放液试验24 h内5 m折返行走试验阳性21例,24~72 h内阳性12例。术后随访6~24个月,多数病人临床症状不同程度好转。术前平均MMSE评分(24.8±2.8)分,术后6个月(26.2±2.5)分,两者差异显著(P0.05);平均Evan’s指数术前为0.39±0.04,术后6个月为0.38±0.04,两者无显著差异(P=0.3137)。本组无死亡、术后感染和分流管堵塞等并发症。结论 LPS是治疗iNPH的有效方法,具有创伤小、恢复快、并发症少等优点。     

脑室-腹腔分流术治疗外伤性正常压力性脑积水的疗效

目的探讨脑室-腹腔分流术(V-P分流术)治疗外伤性正常压力性脑积水的效果。方法回顾性分析48例外伤性正常压力性脑积水病人的临床资料,根据术前临床症状分为典型症状组和不典型症状组,均行V-P分流术,其中行去骨瓣减压术22例。并评估分流术后病情及预后情况。结果随访12个月,根据GOS评分,术后恢复良好12例,轻度残疾23例,重度残疾8例,植物生存3例,死亡2例。根据电话及门诊随访,病情改善41例(85.4%),病情无明显好转甚至恶化7例;其中典型症状组病情改善率100%,不典型症状组病情改善率72%。影像学检查提示:分流术后所有病人脑室均有不同程度缩小。22例行去骨瓣减压术的病人,分流术后6个月内均顺利行颅骨修补术,术后病情均明显改善。结论对外伤性正常压力性脑积水病人,把握好手术适应证,即使无典型临床症状,行V-P分流术后,大部分病人预后可获得改善。     

侧脑室-矢状窦分流在复杂性脑积水治疗中的应用及效果

目的探讨侧脑室-矢状窦分流在复杂性脑积水治疗中的应用及效果。方法回顾性分析采用侧脑室-矢状窦分流术治疗的10例复杂性脑积水患者的临床资料;根据患者术前评估及术中情况采取低压泵连接或直接连接两种手术方式。结果术后1个月,10例患者临床症状改善明显; 3个月后6例患者可自行行走,3例患者因原发病仍卧床,腰穿脑脊液压力及常规、生化检查均正常; 1例患者术后症状部分缓解,仍有高颅压症状,腰穿脑脊液压力偏高,术后3个月脑脊液检查完全正常后,再行脑室-腹腔分流术,术后症状消失。结论侧脑室-矢状窦分流对脑脊液检查异常的复杂性脑积水的治疗,在恰当的病例选择下,有一定的临床效果。     

43例脑积水脑室-腹腔分流术后并发症分析

脑积水是神经外科常见的一种病症,侧脑室-腹腔分流手术(V-P分流术)是治疗脑积水的有效方法,虽然手术本身并不复杂,但是分流术是神经外科手术中并发症最高的手术,术后容易出现堵管、感染、脑脊液的过度分流或分流不足等并发症发生[1].我院自2005年5月～2010年10月为43例脑积水患者实施V-P分流手术,现总结资料,报告如下. 1资料与方法 1.1一般资料43例患者中,男30例,女13例.年龄3月～69岁,平均39岁.发病原因:外伤性脑积水24例,高血压脑室内出血后脑积水7例,自发性9例,肿瘤致梗阻性脑积水3例.43例中脑积水合并颅骨缺损7例,其中儿童4例.表现为头痛、头晕,恶心、呕吐36例,嗜睡、反应迟钝3例,痴呆2例,步态不稳3例,尿失禁2例,所有患者均经CT或MRI检查,证实脑室系统不同程度扩大.本组患者术前均行腰穿检查,脑脊液压力在100～180mmH2O7例(正常压力脑积水),脑脊液压力＞ 180mmH2O36例(高压性脑积水).术前脑脊液常规检查排除颅内感染和脑脊液蛋白含量高于0.6g/L者.     

动脉瘤性蛛网膜下腔出血后正常颅压脑积水15例临床分析

目的探讨动脉瘤性蛛网膜下腔出血(aSAH)后正常颅压脑积水(NPH)临床表现与处理。方法分析aSAH后NPH手术治疗的15例患者病历资料,男性6例,女9例,平均年龄(57.00±8.25)岁,aSAH发病时Hunt-Hess分级II级6例,III级6例,IV级3例,动脉瘤均行开颅手术夹闭,出现脑积水症状的时间分别为术后1个月4例,2个月9例,3个月2例。再次入院后均行腰穿放脑脊液试验(Tap试验),腰穿测压在70~180mmH_2O(1mmH_2O=0.0098kPa),Tap试验阳性13例,阴性2例,均应用可调压分流系统行脑室-腹腔分流术。结果术后随访1年,临床症状治愈12例,好转1例,无效2例。结论关注aSAH后正常颅压脑积水发生的高危因素,一旦确诊脑积水,应及时采取可调压分流系统行脑室-腹腔分流术,一般可获得满意的临床效果。     

正常压力脑积水腰穿放液试验及脑室腹腔分流术疗效的初步临床分析

目的探讨正常压力脑积水(Normal Pressure Hydrocephalus,NPH)患者行腰穿放液试验(The Cerebrospinal Fluid Tap Test,CSFTT)及脑室腹腔分流术后步态障碍、认知障碍及影像学改善情况和变化特点。方法回顾性分析2017年12月～2018年9月就诊于中国医科大学神经内科的5例经CSFTT及脑室腹腔分流术证实的NPH患者的临床资料及影像学资料,并进行对比分析。结果 5例患者CSFTT结果均阳性,其中最长为发病3 y后行CSFTT。5例患者步态障碍、简易精神状态检查(Mini-mental State Examination,MMSE)及蒙特利尔认知评估量表(Montreal Cognitive Assessment,MoCA量表)评分在CSFTT后8 h及24 h改善最显著(最多达85%),Rey听觉词语学习测验(Rey auditory verbal learning test,RAVLT)及日常生活能力量表(Activity of daily living,ADL)评分在CSFTT后无明显变化,在脑室腹腔分流术后逐渐改善;连线测验、排尿功能及影像学在CSFTT及脑室腹腔分流术后均无明显变化。结论正常压力脑积水患者在发病后3 y行CSFTT及脑室腹腔分流术仍有效; MMSE、Mo CA可作为正常压力脑积水患者CSFTT后首选的认知功能改善评价指标,RAVLT及ADL评分可有效用于脑室腹腔分流术的疗效评估。     

The value of temporary external lumbar CSF drainage in predicting the outcome of shunting on normal pressure hydrocephalus

OBJECTIVE: It has been reported that temporary external lumbar CSF drainage (ELD) is a very accurate test for predicting the outcome after ventricular shunting in patients with normal pressure hydrocephalus (NPH). However, only a limited number of patients have been studied for assessing the predictive accuracy of ELD. Therefore, the value of ELD in predicting the outcome after a ventriculoperitoneal shunt in patients with presumed NPH was assessed. METHODS: All patients with presumed NPH were invited to participate in this study. Clinical assessment, MRI, and neuropsychological evaluation were followed by a lumbar CSF tap test consisting of removing 40 ml CSF. When this test resulted in marked clinical improvement of gait impairment, mental disturbances, or both, the patient was shunted without further tests. In patients with either questionable or no improvement after the CSF tap test, ELD was carried out. The value of ELD for predicting the outcome after shunting was calculated by correlating the results of ELD with that of ventriculoperitoneal shunting. RESULTS: Between January 1994 and December 2000, 49 presumed NPH patients from three institutes were included. Forty three had idiopathic, and the remaining six had secondary NPH. Forty eight patients were shunted; 39 had an ELD of whom 38 completed the test. After 2 months 35 of the 48 (73%) shunted patients had improved. The predictive value of a positive ELD was 87% (95% confidence interval (95% CI) 62-98) and that of a negative ELD 36% (95% CI 17-59). In two patients serious test related complications (meningitis) occurred without residual deficit. CONCLUSION: The study suggests that although the predictive value of a positive ELD is high, that of a negative ELD is deceptively low because of the high rate of false negative results. The costs and invasiveness of the test and the possibility of serious test related complications further limits its usefulness in managing patients with presumed NPH.     

The role of computerized rheoencephalography in the assessment of normal pressure hydrocephalus. Preliminary report

BACKGROUND AND PURPOSE: It is generally agreed that the positive result of lumbar cerebrospinal fluid (CSF) withdrawal offers a reliable means for selection of patients likely to respond to shunting in normal pressure hydrocephalus (NPH). However the studies of cerebral hemodynamics in NPH are performed Routinely only in few neurosurgical centers. We therefore studied the effect of CSF withdrawal on cerebrovascular autoregulation (CVA) in this condition by means of computerized rheoencephalography [REG]. MATERIAL AND METHODS: The study group consisted of 27 patients with presumed posttraumatic NPH. In each patient both the tap test and infusion test were performed. Psychometric tests and rheoencephalographic examinations were made twice: before and after CSF withdrawal. The obvious restoration of the functional state of CVA after CSF withdrawal was considered as a positive result of the tap test. RESULTS: Fourteen patients with a positive tap test and/or with resistance to CSF outflow (Rout) of more than 11 mmHg/ml/min were shunted. The improvement was obtained in 10 of them. Only one patient with a positive tap test did not improve. CONCLUSIONS: Our study suggests that restoration of CVA after CSF withdrawal is associated with high likelihood of shunt success, but not vice versa. Evaluation of CVA using REG seems to offer a new diagnostic tool in selecting patients likely to respond to shunting. Further studies are necessary to optimize the amount of CSF withdrawal, the delay between CSF withdrawal and control examinations and methodology of neuropsychological examinations.     

Infusion test in the selection of patients with hydrocephalus for the shunting

The indications for the shunting of the patients with NPH are a matter of discussion. The measurement of the outflow resistance during the infusion test is one of the criteria for shunting. The authors present 38 patients with NPH in whom the lumbar constant-infusion test was carried out. The patients with the outflow resistance more then 13 mmHg/ml/min were selected for shunting. The results at least 4 months after operation are presented.     

Abnormal cerebrospinal fluid-blood flow dynamics. Implications in diagnosis, treatment, and prognosis in normal pressure hydrocephalus.

Increased cerebral blood flow (CBF) has been proposed as responsible for the clinical improvement after cerebrospinal fluid (CSF) shunting in patients with normal pressure hydrocephalus (NPH). In order to determine any abnormal CSF-CBF pressure-flow relationships in NPH, measurements of regional cerebral blood flow (rCBF) and regional cerebral blood volume (rCBV) were made before and after lowering CSF pressure (CSFP) in 15 patients with NPH, and in ten patients with presumed hydrocephalus ex vacuo. Maximal reduction of rCBF and rCBV occurred in the territory of the anterior cerebral artery in NPH but no in dementia due to brain atrophy. Both CBF and rCBV increased after lowering the CSFP by lumbar puncture in patients with NPH. Patients with higher preoperative rCBF and maximal increases in rCBR and rCBV after lowering CSFP showed the most consistent clinical improvement after CSF shunting. Evidence is offered that CBF autoregulation is impaired in NPH. The CBF test assists in both diagnosis and selection of patients for CSF shunting.     

脑脊液释放试验后脑血流变化对正常压力性脑积水患者临床症状改善的预测作用

目的 探讨经颅多普勒超声(Transcranial Doppler,TCD)评价正常压力性脑积水(normal pressure hydrocephalus,NPH)患者脑脊液释放试验对脑血流速度的影响及脑脊液释放试验的效果。方法 收集2015年5月1日-2017年6月1日于上海长征医院神经内科治疗的NPH患者25例,在脑脊液释放试验前及脑脊液释放试验24 h后评估患者NPH分级量表评分、运动功能及应用TCD测试大脑中动脉和大脑前动脉的血流速度; 根据NPH分级量表评分进行分组,降低≥1分者为改善组,否则为未改善组,观察2组动脉血流速度情况。结果 与脑脊液释放试验前比较,改善组患者脑脊液释放试验24 h后行走时间、行走步数均明显减少,TCD示左右两侧大脑中动脉最大流速、平均流速、最小流速均明显降低; 非改善组则无上述改变。结论 脑脊液释放试验NPH分级量表评分的改善可能与大脑中动脉血流速度有关,而TCD可有效地评测NPH患者脑脊液释放试验的效果。     

Shunting normal pressure hydrocephalus: the predictive value of combined clinical and CT data.

The value of an ordinal global scale derived from combined clinical and CT data (clin/CT scale) to predict the clinical outcome in 112 patients shunted for presumed normal pressure hydrocephalus (NPH) was analysed. The clinical data were retrospectively collected, all CT scans were re-evaluated, and the clin/CT scale was determined blind to the results of further ancillary tests and to the post-surgical outcome. The scale ranked three classes of prediction: on the basis of clinical and CT characteristics, improvement after shunting was probable, possible, or improbable. The predictive value of the clin/CT scale for the subgroup of communicating NPH was established for two different strategies, depending on the strictness of selection criteria for shunting. In the subgroup of patients with presumed communicating NPH, the prevalence of shunt responsiveness was 29%; the best strategy was to shunt only patients with probable shunt-responsive NPH: the sensitivity was 0.54, the specificity 0.84, and the predictive accuracy 0.75, with a limited number of ineffective shunts (11%) and missed improvements (13%). The study illustrates its need to assess the pre-test probability of NPH based on combined clinical and CT data, before establishing the clinical usefulness of an ancillary test.     

Alteration of cerebral perfusion in patients with idiopathic normal pressure hydrocephalus measured by 3D perfusion weighted magnetic resonance imaging

OBJECTIVE: It is controversial whether alteration of cerebral perfusion plays an important role in the pathophysiology of patients with idiopathic normal pressure hydrocephalus (NPH) and can help to predict the outcome after shunt surgery. MATERIALS AND METHODS: 28 patients with suspected NPH were examined clinically (Homburg Hydrocephalus Scale, walking test, incontinence protocol) and by 3D dynamic susceptibility based perfusion weighted magnetic resonance imaging (PWI-MRI) before and after cerebrospinal fluid release (spinal tap test, STT). The perfusion parameters (negative integral (NI), time of arrival (T0), time to peak (TTP), mean transit time, and the difference TTP-T0 were analysed. RESULTS: Three different groups of patients were identified preoperatively: In group 1 seven patients showed an increase in the cerebral perfusion and a clinical improvement after STT. The second group (9 patients) also revealed an increase of the cerebral perfusion, but no significant alteration of the clinical assessment could be found. In the third group neither the cerebral perfusion nor the clinical assessment changed. 14 of the 16 patients (group 1 and 2) were examined three months after shunt placement. 11 patients showed a good or excellent result, 2 patients revealed a fair assessment, and only 1 patient had transiently improved. No patient was downgraded after shunting. In the patient group 1 and 2 the NI increased significantly (effect size: 34%), whereas in group 3 no significant alteration of NI was observed. CONCLUSION: PWI-MRI improves the prediction of outcome after shunt placement in patients with NPH and can offer new insights into the pathophysiology.     

Magnetic resonance spectroscopic determination of a neuronal and axonal marker in white matter predicts reversibility of deficits in secondary normal pressure hydrocephalus

BACKGROUND: Normal pressure hydrocephalus (NPH) is considered to be a treatable form of dementia, because cerebrospinal fluid (CSF) shunting can lessen symptoms. However, neuroimaging has failed to predict when shunting will be effective. OBJECTIVE: To investigate whether 1H (proton) magnetic resonance (MR) spectroscopy could predict functional outcome in patients after shunting. METHODS: Neurological state including Hasegawa's dementia scale, gait, continence, and the modified Rankin scale were evaluated in 21 patients with secondary NPH who underwent ventriculo-peritoneal shunting. Outcomes were measured postoperatively at one and 12 months and were classified as excellent, fair, or poor. MR spectra were obtained from left hemispheric white matter. RESULTS: Significant preoperative differences in N-acetyl aspartate (NAA)/creatine (Cr) and NAA/choline (Cho) were noted between patients with excellent and poor outcome at one month (p = 0.0014 and 0.0036, respectively). Multiple regression analysis linked higher preoperative NAA/Cr ratio, gait score, and modified Rankin scale to better one month outcome. Predictive value, sensitivity, and specificity for excellent outcome following shunting were 95.2%, 100%, and 87.5%. Multiple regression analysis indicated that NAA/Cho had the best predictive value for one year outcome (p = 0.0032); predictive value, sensitivity, and specificity were 89.5%, 90.0%, and 88.9%. CONCLUSIONS: MR spectroscopy predicted long term post-shunting outcomes in patients with secondary NPH, and it would be a useful assessment tool before lumbar drainage.