梗阻性脑积水经第三脑室底造瘘术后颅内压变化规律

目的回顾性总结经内镜第三脑室底造瘘术(ETV)治疗梗阻性脑积水的手术技巧、疗效及术后颅内压(ICP)的变化规律及动态ICP监护的价值。方法经内镜行ETV治疗梗阻性脑积水共146例,病因包括导水管狭窄98例、颅内肿瘤48例(第三脑室及松果体区肿瘤)。术后行动态ICP监护53例(导水管狭窄36例、肿瘤17例),平均监护时长96 h。结果随访8个月至6年,术后脑积水明显缓解或消失138例(94.5%),8例脑积水缓解不明显或无效(5.5%),改行脑室腹腔分流术。ICP监护显示:术后6 h内平均ICP明显下降,低于10 mm Hg,此后缓慢轻度上升,96 h稳定于12 mm Hg;单纯导水管狭窄性脑积水平均ICP上升较缓慢、波动较小,最后达到10 mm Hg;而肿瘤性脑积水上升较快、波动较大,最后达到15 mm Hg。并发症28例(19.2%):术后发热22例,双额部硬膜外血肿1例、切口脑脊液漏2例、脑室少量积血2例、硬膜下积液1例。本组无死亡。结论 1第三脑室底造瘘治疗梗阻性脑积水(尤其是导水管狭窄脑积水)安全、有效,应作为其首选治疗手段;2术后行ICP动态监护,不仅可监测颅内压的变化,判断手术是否有效,同时可以观察有无脑室继发性出血等并发症及指导术后用药。

Changes of intracranial pressure in obstructive hydrocephalus after endoscopic third ventriculostomy

Objective The operation skills and curative effect of endoscopic third ventriculostomy（ETV） for treatment of obstructive hydrocephalus,the changes of intracranial pressure（ICP） after operation and the value of ICP monitoring are summarized retrospectively. Methods Endoscopic ETV for treatment of obstructive hydrocephalus were performed in 146 cases,and the etiology of hydrocephalus included aqueduct stenosis（98 cases） and tumors（48 cases,three ventricle and pineal region tumors）. ICP monitoring was perfomed in 53 cases（36 cases of aqueduct stenosis and 17 cases of tumors） with a mean monitoring time of96 h. Results The patients were followed up for 8 months ~ 6 years. Hydrocephalus was relieved noticeably or disappeared in 138 cases（ 94. 5%） and no significant relief or invalid in 8 cases of hydrocephalus（5. 5%）. ICP monitoring showed that average ICP decreased within 6 h after operation（less than 10 mm Hg）,then increased slowly and slightly,and remained at 12 mm Hg at 96 h; mean ICP in herpes aqueduct stenosis hydrocephalus increased slowly and finally reached 10 mm Hg; ICP of tumor hydrocephalus cases rose much faster and finally reached 15 mm Hg. Complications occurred in 28 cases（19. 2%）： postoperative fever in 22 cases,bilateral frontal epidural hematoma in 1 case,cerebrospinal fluid leakage in 2 cases,little bleeding in 2cases,and subdural effusion in 1 case. There was no death case. Conclusion Endoscopic third ventriculostomy for treatment of obstructive hydrocephalus（aqueduct stenosis especially） is safe and effective and should be chose as the preferred treatment. Post-operative ICP dynamic monitoring can detect the changes of intracranial pressure,evaluate the operation efficiency,observe the surgery complications such as bleeding and make a guidance for post-operative medication.