Tratamiento neuroendoscópico de quistes aracnoideos en edad pediátrica. Resultados de una serie de 20 pacientes

IntroductionNeuroendoscopy has become an effective and safe treatment for arachnoid cysts in the paediatric population. We review the paediatric patients with arachnoid cysts treated by neuroendoscopy in our hospital and analyse the results.Material and methodsA retrospective analysis of 20 patients operated on from 2005 to 2018. The variables assessed are: gender, age, clinical presentation, cyst site, presence of hydrocephalus and/or extra-axial collections, endoscopic procedures and complications. Procedure success is defined as an improvement in symptoms and reduction in cyst size until end of follow-up.ResultsOur series comprised 13 males and 7 females (mean age: 64.6 months, range: 4–172 months). The most frequent site was suprasellar-prepontine (7), followed by intraventricular (6), quadrigeminal (3), interhemispheric (2) and Sylvian (2).A total of 70% (14/20) of patients had hydrocephalus at diagnosis, which increased to 85% in suprasellar-prepontine cysts and 100% in quadrigeminal cysts. Only 4/14 patients with required a ventriculoperitoneal shunt (median age at diagnosis: 12.5 months). Of these 4 patients, 3 developed severe shunt overdrainage.The procedure was successful in 60% (12/20) of the patients in the series. Success by location was 57% (4/7) in suprasellar cysts, 33% (1/3) in quadrigeminal cysts, 66% (4/6) in intraventricular cysts, 100% (2/2) in interhemispheric cysts and 50% (1/2) in Sylvian cysts. Treatment thus failed in 8 cases, with a mean time to failure of 12.12 months (range: 0-45 months). A new neuroendoscopic procedure was performed in 4 of these 8 cases (success in 2/4), a ventriculoperitoneal shunt was placed in 2 cases, a cystoperitoneal shunt was placed in 1 case and the remaining case was managed conservatively. Mean follow-up time was 52.45 months (range: 3-129 months).ConclusionsNeuroendoscopy is an effective and safe treatment for arachnoid cysts in paediatric patients that also enables managing associated hydrocephalus in most cases. The choice of neuroendoscopic procedure and success rate depend on cyst location. Younger patients have been found to have a higher shunt dependency rate. In these cases, measures to prevent shunt overdrainage are recommended.     

Endoscopic assisted craniotomy for resection of fourth ventricular lesions and confirmation of aqueductal patency via a suboccipital median aperture approach

Adequate exposure to fourth ventricular (4V) lesions located adjacent to the cerebral aqueduct and superior medullary velum often mandates extensive telovelar dissection. We assessed the utility of endoscopic assistance via a median aperture approach during suboccipital resection of 4V lesions. We retrospectively reviewed a series of nine patients who underwent suboccipital resection of a 4V lesion via an endoscopic-assisted median aperture approach from 2011 to 2018. Our series included the following pathology: ependymoma (2), rosette-forming glioneuronal tumors (2), pilocytic astrocytoma (1), metastatic melanoma (1), epidermoid cyst (1), organized hematoma (1), and neurocysticercosis (1). Preoperative symptoms included headache (n = 8, 88.9%), nausea (n = 5, 55.6%), vomiting, dizziness, and gait disturbance (n = 4 each, 44.5%). In four cases, the endoscope was used for the majority of the resection or to resect additional tumor located rostrally in the 4V following maximal microscopic resection. In five patients, it was used to confirm extent of resection and patency of the cerebral aqueduct. Gross total resection was achieved in five patients (55.6%). No postoperative complications were attributed to use of the endoscope for additional resection. No patients required immediate CSF diversion, and one patient underwent ventriculoperitoneal (VP) shunt insertion over one year after initial biopsy/fenestration due to tumor progression. Our series is the first to demonstrate the utility of angled endoscopic assistance via a median aperture approach during microsurgical approaches for a variety of 4V lesions. Confirmation of patency of the cerebral aqueduct may help avoid requirements for CSF diversion.     

神经内镜治疗自发性脑室出血的疗效分析

目的探讨神经内镜对自发性脑室出血手术治疗的疗效分析。方法收集2009年6月至2013年12月我院经CTA筛查的119例自发性脑室出血患者,分为2组:神经内镜手术组(NEG)48例、脑室外引流组(EVDG)71例,手术治疗均在48小时内进行;比较二组不同术式术后6小时颅脑cT,血肿清除率、术后并发症及术后6个月对患者进行ADIL预后分级等治疗效果评估。结果①血肿清除率:NEG明显优于EVDG(p0.01)。②术后片发症:发生率分别为1 2.5%、40.6%。NEG明显低于EVDG(p=0.048)。③术后6月ADI分级:NEG和EVDG术后6个月ADL预后评分恢复良好(ADL.Ⅰ~Ⅲ级)比例分别为:79.17%(38/48)、46.48%(33/71)。NEG术后6月ADL评分明显优于EVDG(p=0.001)。结论神经内镜组手术血肿清除率高、并发症少、预后好,优于脑室外引流手术组。     

经冠状缝-额中回入路神经内镜手术治疗高血压性基底节区出血的标准化流程分析

目的 总结一种简单实施、有效的、标准的经冠状缝-额中回入路神经内镜手术治疗高血压性基底节区出血的标准化流程。方法 回顾性分析2019年4月至2021年4月按统一标准实施的经冠状缝-额中回入路神经内镜手术治疗的48例高血压性基底节区出血的临床资料。术中未使用神经导航及3D-slicer等软件辅助定位。结果 术后24 h内复查头CT显示残余血肿量中位数为2.4（1.1~3.9）ml;血肿清除率中位数为94.0%（90.0%~98.0%）。无术后再出血。出院时GCS评分中位数为13（11~14）分。术后随访6~30个月（中位数15个月）,mRS评分0~2分35例,3~4分10例,5~6分3例。结论 神经内镜下经冠状缝-额中回入路手术治疗高血压性基底节区出血是一种简单易行的手术方式,无需神经导航及3D-slicer等软件辅助定位,可以取得良好的手术效果。     

经鼻蝶神经内镜和显微镜垂体瘤切除术的疗效对比分析

目的对比神经内镜下经鼻蝶切除术和显微镜切除术对垂体瘤的临床疗效差异。方法选取本院2016年8月～2018年4月期间71例垂体瘤患者为研究对象,其中40例患者行经鼻蝶神经内镜垂体瘤切除术,31例行显微镜垂体瘤切除术。患者术后通过影像学和内分泌检查评价手术切除率,观察术后患者激素水平变化和视觉恢复情况,统计两组术式术后并发症情况。结果内镜手术组中38例(95%)患者肿瘤被完全切除,2例(5%)患者肿瘤次全切除,显微镜组中23 (74. 19%)例患者肿瘤完全切除,8例(25. 81%)患者肿瘤次全切除,内镜组肿瘤全切率相比于显微镜组较高,差别有统计学意义(P 0. 05)。术后患者泌乳素(PRL)和促肾上腺皮质激素(ACTH)水平内镜组相较于显微镜组降低显著,差别有统计学意义(P 0. 05),生长激素(GH)水平两组无统计学差异(P 0. 05)。术后1周患者加权视野指数(VFI)较术前升高,视野平均缺损(MD)、模式标准差(PSD)降低,内镜组视觉改善效果优于显微镜组,差别有统计学意义(P 0. 05)。内镜组术后并发症发生率相比于显微镜组较低,差别有统计学意义(P 0. 05)。结论相比于传统显微镜切除术,经鼻蝶神经内镜垂体瘤切除术能够达到较高全切率,在改善多项激素水平和视觉障碍方面有明显优势,同时术后并发症发生率较低,安全性高,值得作为主流手术方式推广应用。     

Idiopathic bilateral occlusion of the foramen of Monro: An unusual entity with varied clinical presentations

We review our experience with four patients who presented to our Medical Center from 2005–2015 with adult idiopathic occlusion of the foramen of Monro (FM). All patients underwent CT scanning and MRI. Standard MRI was performed in each patient to rule out a secondary cause of obstruction (T1-weighted without- and with gadolinium, T2-weighted, fluid-attenuated inversion recovery [FLAIR] and diffusion-weighted imaging [DWI] protocols). When occlusion of the FM appeared to be idiopathic, further high-resolution MRI with multiplanar reconstructions for evaluation of stenosis or an occluding membrane at the level of the FM was performed (T1-weighted without- and with gadolinium, T2-weighted 3D turbo spin-echo). Occlusion of the FM was due to unilateral stenosis and septum pellucidum deviation in two patients, to an occluding membrane in one, and to bilateral stenosis in one patient. Urgent surgical intervention is mandatory when there are signs of increased intracranial pressure while asymptomatic patients may be managed conservatively. In this patient series, truly bilateral stenotic obstruction of the FM was best managed with ventriculoperitoneal shunt and patients with membranous obstruction or unilateral stenosis with septum deviation were treated endoscopically.     

神经内镜术与小骨窗血肿清除术治疗高血压脑出血疗效的Meta分析

目的对比神经内镜术和小骨窗血肿清除术治疗高血压脑出血的临床疗效。方法检索2008年—2018年的万方、维普和PubMed等中英文数据库,找出对比神经内镜术和小骨窗血肿清除术治疗高血压脑出血的文献,利用Rev Man 5.3软件进行Meta分析。结果共纳入4篇随机对照研究和6篇病例对照研究,965例中神经内镜组493例,小骨窗组472例。Meta分析结果示:与小骨窗组相比,内镜组血肿清除率更高(SMD=14.20; 95%CI=[8.48,19.92]),术中出血量更少(SMD=-215.06,95%CI=[-255.41,-174.71]),手术时间更短(SMD=-96.63,95%CI=[-114.24,-79.01]),ICU入住时间缩短(OR=-5.91,95%CI=[-6.26,-5.57]),术后并发症更少(OR=0.28,95%CI=[0.19,0.43]),术后6个月恢复良好率更佳(OR=2.02,95%CI=[1.54,2.66]),病死率更低(OR=0.32,95%CI=[0.16,0.62])。所比较结果均具有统计学意义。结论与小骨窗术相比,神经内镜术治疗高血压脑出血其预后更佳、病死率更低,疗效更好,并且清除率更高,术中出血量减少,手术时间变短,ICU入住天数减少,术后并发症较少,故值得推广。     

神经导航及内镜在慢性硬膜下血肿治疗中应用效果分析

目的探究慢性硬膜下血肿术中采用神经导航和内镜的应用效果。 方法选取深圳市人民医院神经外科自2014年6月至2018年6月收治的硬膜下血肿患者116例，根据患者术中应用设备情况分成常规手术治疗组（64例）与神经导航内镜辅助组（52例）。于术后1周复查，比较2组患者的血肿复发、血肿残留、颅内积气的情况；术后1个月复查，对比2组患者的血肿复发残留情况。 结果患者术后1周进行CT复查，常规手术治疗组部分血肿残留19例、血肿消失45例，神经导航内镜辅助组部分血肿残留7例、血肿消失45例，2组比较差异有统计学意义（P=0.037）。常规手术治疗组硬膜下积液、积气6例，无积液、积气58例；神经导航内镜辅助组硬膜下积液、积气4例，无积液、积气48例；2组比较差异无统计学意义（P=0.748）。患者术后1个月进行CT复查，常规手术治疗组血肿残留或复发11例、血肿消失53例；神经导航内镜辅助组血肿残留或复发3例、血肿消失49例，差异有统计学意义（P=0.038）。 结论应用神经导航及内镜辅助进行慢性硬膜下血肿钻孔引流术，可提高血肿完全清除率，并降低远期血肿复发率，具有一定的应用价值。     

脑积水和蛛网膜囊肿的神经内镜治疗

目的 :探讨神经内镜治疗梗阻性脑积水和蛛网膜囊肿的有效性、安全性和微创性 ,为其进一步临床应用提供参考依据。方法 :采用经内镜神经外科手术和 /或内镜辅助显微神经外科手术治疗梗阻性脑积水 4例和颅内蛛网膜囊肿 3例。结果 :患者术后随访 3～ 6个月。第三脑室底脚间池造瘘治疗 4例 ,梗阻性脑积水 3例显效 ,1例症状缓解 ,含内镜引导分流管置入 1例 ,分流管脑室端通畅。蛛网膜囊肿脑池 /脑室造瘘 囊壁切除术 3例全部有效 ,所有病例均无明显并发症。结论 :神经内镜治疗梗阻性脑积水和蛛网膜囊肿手术创伤小 ,疗效好 ,部分患者可免除体内置管之虞