儿童后颅窝肿瘤术前梗阻性脑积水的治疗

目的观察内镜第三脑室造瘘术(ETV)和脑室腹腔分流术(VPS)治疗后颅窝肿瘤梗阻性脑积水患儿的临床效果。方法选择我院2006—2012年80例脑积水中线后颅窝肿瘤(42髓母细胞瘤和室管膜瘤38)患儿,分为2组,A组(42例)行ETV,平均随访27.4个月,B组(38例)行VPS,平均随访25个月。结果 A组术中大出血发生2例(6.2%)和脑脊液漏1例(3.1%)。B组分流感染发生3例(9.4%),2例患者术后4.5个月脑室死亡。硬膜下积液发生3例(9.4%),硬膜外血肿1例(4.7%),1例(4.7%)上升脑疝。相比脑室腹腔分流术,由于手术时间短(15min vs.35min),并发症发病率较低(9.3%vs.38%),无死亡病例(0vs.4.7%),手术失败发生率较低(6.2%vs.38%)。结论 ETV可作为后颅窝肿瘤儿童患者伴明显梗阻性脑积水的治疗首选。     

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。     

脑室-腹腔分流术后分流不畅的原因分析及处理

目的 总结脑室-腹腔分流术后发生分流不畅的治疗经验。方法 2010年1月至2014年1月采用脑室-腹腔分流术治疗脑积水患者87例。结果 术后出现分流不畅共6例,占6.90%（6/87）。梗阻性脑积水患者3例,远端和近端梗阻各1例,行神经内镜下第三脑室底造瘘术;远端堵塞1例,行脑室-心房分流术后好转。交通性脑积水患者3例,1例远端堵塞,行左侧脑室-腹腔分流术后好转;2例分流系统通畅但症状进行性加重,更换更低压力分流泵后好转。结论 严格把握脑室-腹腔分流术指征,选择合适分流系统和手术方式,规范精细的手术操作有助于预防术后分流不畅的发生;脑室-心房分流术、第三脑室底造瘘术对分流不畅的治疗有较好作用。     

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.     

第三脑室底造瘘术和脑室-腹腔分流术治疗非交通性脑积水的Meta分析

目的通过Meta分析对神经内镜下第三脑室底造瘘术(ETV)和脑室-腹腔(V-P)分流术治疗非交通性脑积水的疗效进行综合分析。方法通过计算机检索PubMed、EMBASE、Ovid、ScienceDirec、SpringerLink、中国知网数据库、万方、维普及中国生物医学文献数据库,查出2000-2010年发表的有关ETV和V-P分流术治疗非交通性脑积水的相关文献,选择RevMan5.0软件以固定效应模型进行Meta分析。结果纳入9项临床对照研究。Meta分析结果显示:与V-P分流术相比,ETV术后症状缓解率、颅内血肿形成率差异无统计学意义(P>0.01),而ETV术后并发症发生率及复发率均明显低于V-P分流术(P<0.01)。结论 ETV和V-P分流术疗效相当,但ETV术后并发症发生率和复发率较低。     

脑室-腹腔分流术后颅内感染的处理经验

目的总结脑室-腹腔分流术后颅内感染的临床特点和治疗效果。方法 2003年1月至2009年1月行脑室-腹腔分流术治疗脑积水患者254例,其中11例分流术后并发颅内感染。对颅内感染者在脑脊液细菌培养和药敏试验结果出来前,通过腰椎穿刺置管鞘内注射可在鞘内应用的广谱抗生素,并持续引流感染的脑脊液;细菌培养和药敏试验结果出来后,选用敏感抗生素鞘内注射;10例病情严重者拔除分流装置,行脑室外引流。结果 11例患者,1例经腰椎穿刺置管鞘内注射抗生素后治愈,10例不断调整引流装置同时脑室内注入抗生素后治愈。结论脑脊液脑室外引流、鞘内或脑室内注射抗生素,以及必要时拔除分流装置是治疗脑室-腹腔分流术后颅内感染的主要措施。     

神经内镜技术治疗脑积水14例报告

目的 分析神经内镜技术应用于治疗脑积水的疗效及价值。方法 回顾性地分析总结了14例脑积水病例，均行神经内镜技术治疗，11例行内镜第三脑室造瘘术(ETV)，1例行分流管侧脑室端校正术，2例交通性脑积水行分流管脑室端校正及脉络丛烧灼术。结果 所有病例均取得了满意的疗效，未出现术后并发症。结论 神经内镜技术治疗脑积水具有微创性、视野好、操作简单等优点，结合神经导航系统，计算机三维成像等新技术，可设计最佳手术人路，避免副损伤，术中往往只需一小骨孔，最大限度地减小了手术创伤。ETV的良好疗效及少有并发症充分显示了神经内镜技术治疗脑积水的优越性。     

神经内镜第三脑室底造瘘术在后颅窝肿瘤梗阻性脑积水中的应用价值

目的 探讨神经内镜下第三脑室底造瘘术(ETV)在后颅窝肿瘤梗阻性脑积水和同期行后颅窝肿瘤显微切除术中的临床应用价值。方法 回顾性分析重庆大学附属肿瘤医院神经肿瘤科2015年7月—2018年12月,应用ETV治疗53例后颅窝肿瘤并梗阻性脑积水并同期行肿瘤切除术患者的临床资料。分析患者的疗效及预后。结果 本组患者术后6 h内复查头部CT,均无脑室内积血、积气。术后出现短暂性发热患者5例;无出现继发性出血、手术死亡及严重后遗症的患者。术后随访患者6～31个月,其中有效患者50例(94. 3%);无效患者3例,后行腰大池引流1周,最终行脑室-腹腔分流。结论 后颅窝肿瘤并梗阻性脑积水患者行开颅显微手术前,行脑室外引流及分流是传统的处理方式,但也是并发症较多的治疗方法;同期ETV对于此类梗阻性脑积水的治疗符合生理机制,并发症少,疗效更好,值得在临床推广应用。     

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。     

第四脑室肿瘤的显微外科治疗

目的总结第四脑室肿瘤的显微外科治疗效果及手术策略。方法第四脑室肿瘤患者36例,均在显微镜下或神经内镜辅助下切除肿瘤。肿瘤全切除24例,次全切除12例。结果术后恢复良好13例,死亡3例,缄默症4例,脑积水16例,其中12例行侧脑室．腹腔分流术,4例行脑室心房分流术。术后随访：29例生活、学习良好,3例死亡,1例失访。结论正确及时的诊断、熟悉四脑室的显微解剖、选择合适的手术入路、熟练的显微手术技巧、适当应用神经内镜、积极处理术后脑积水是提高第四脑室肿瘤疗效的关键。     

Simultaneous endoscopic third ventriculostomy and ventriculoperitoneal shunt for infantile hydrocephalus

Objective We analyzed a series of consecutive hydrocephalic infants treated with implantation of a ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) simultaneously. Materials and methods Between 1995 and 2006, we treated the 111 hydrocephalic infants. Among those patients, 31 infants underwent VPS and ETV simultaneously, and 45 patients underwent only VPS. The ETV plus VPS group had 17 males and 14 females with a mean age of 6.32 months. The VPS only group consisted of 25 males and 20 females with a mean age of 4.43 months. There was no difference in etiology of hydrocephalus or clinical characteristics between the two groups. We compared shunt effectiveness by calculating the pre- and postoperative ventricular index and shunt failure rates during the follow-up period between the two groups. The follow-up period ranged from 6 to 140 months (mean, 53.23 months) in the ETV plus VPS group and from 6 to 148 months (mean, 75.98 months) in the VPS only group. The success rate was 83.9% (26 of 31) in the ETV plus VPS group and 68.9% (31 of 45) in the VPS only group. There were three infections and two shunt obstructions in the ETV plus VPS group versus eight obstructions, five infections, and one overdrainage in the VPS group. The preoperative and postoperative ventricular ratio of both groups showed statistically significant change (P < 0.000). Conclusion This simultaneous procedure could be the first choice of action for the hydrocephalic patients less than 1 year old.     

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in pediatric patients: a decision analysis

Introduction  Uncertainty persists on the best treatment for patients with obstructive hydrocephalus: endoscopic third ventriculostomy (ETV) or shunt, particularly in the younger age groups. We performed decision analysis for quality of life (QOL) outcomes comparing these two procedures. Materials and methods  Frequency of outcome events for ETV was obtained from the Canadian Pediatric Neurosurgery Study Group (368 patients) and for shunts from two prospective randomized trials, the Shunt Design Trial and the Endoscopic Shunt Insertion Trial (647 patients combined). Quality-adjusted life year (QALY) estimates for various outcomes were obtained from the literature. Decision analysis was performed at 1 year of follow-up for specific age groups, e.g., <1 month, 1–6 months, etc. Results  Failure from cerebrospinal fluid (CSF) diversion from either procedure was a function of age with higher failures rates in younger patients. Expected QALY at 1 year were marginally higher for ETV for all age groups, but the outcomes were similar enough to be regarded as equivalent. The results, however, were highly sensitive to the assigned health utility value estimates for patients who are well with a functioning ETV or shunt and the severe complication rate from ETV. Conclusion  Age is a major determinant of outcome from CSF diversion with worse outcomes in young patients. QALY estimates for either ETV or shunt are similar at 1 year.     

Endoscopic third ventriculostomy in children younger than 2 years of age

Introduction Endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus of different etiologies is still controversial in children younger than 2 years of age. The success rate of ETV in this group of patients is analyzed in this study. Materials and methods The series consisted of 21 patients treated with ETV. The mean age of the patients was 6.7 months, ranging from 9 days to 15 months (16 patients were younger than 1 year). The study included hydrocephalus due to idiopathic aqueductal stenosis (eight) and other congenital anomalies (four) as well as posthemorrhagic (three) and tumor-related occlusive hydrocephalus (three). Two patients presented with shunt infection and one with a shunt failure. ETV was considered to be successful when shunting could be avoided. Results ETV was successful in nine patients, with a mean follow-up period of 26.2 months. The procedure was successful in four patients with idiopathic aqueductal stenosis, in two with other congenital anomalies, in one posthemorrhagic, and in two with a tumor-related hydrocephalus. In 12 patients, the ETV was unsuccessful after a mean follow-up of 3.3 months. These patients required a shunt. Ten of them were less than 1 year old when ETV was performed. In one tumor-related hydrocephalus, a shunt was inserted after a meningitis after tumor removal. Conclusions The success of ETV in children younger than 2 years of age suffering from non-communicating hydrocephalus seems to be dependent on both age and etiology. Our results show an overall success rate of 43%. In 37.5% of the children younger than 1 year of age, ETV was successful. ETV in patients with hydrocephalus due to idiopathic aqueductal stenosis seems to be more beneficial than in other causes of hydrocephalus. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

Third ventriculostomy vs ventriculoperitoneal shunt in pediatric obstructive hydrocephalus: results from a Swiss series and literature review

Introduction Few series compare endoscopic third ventriculostomies (ETV) and ventriculoperitoneal shunts (VPS). To avoid the complications after a shunt insertion, there is an increased tendency to perform a third ventriculostomy. We reviewed all pediatric patients operated in the French-speaking part of Switzerland for a newly diagnosed obstructive hydrocephalus since 1992 and compared the outcome of patients who benefited from ETV to the outcome of patients who benefited from VPS. There were 24 ETV and 31 VPS. Discussion At 5 years of follow-up, the failure rate of ETV was 26%, as compared to 42% for the VPS group. This trend is also found in the pediatric series published since 1990 (27 peer-reviewed articles analyzed). Conclusion In accordance to this trend, although a statistical difference cannot be assessed, we believe that ETV should be the procedure of choice in pediatric obstructive hydrocephalus.     

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。     

Endoscopic Third Ventriculostomy in Patients with Shunt Malfunction

Objective

This paper presents data from a retrospective study of endoscopic third ventriculostomy (ETV) in patients with shunt malfunction and proposes a simple and reasonable post-operative protocol that can detect ETV failure.

Methods

We enrolled 19 consecutive hydrocephalus patients (11 male and 8 female) who were treated with ETV between April 2001 and July 2010 after failure of previously placed shunts. We evaluated for correlations between the success rate of ETV and the following parameters : age at the time of surgery, etiology of hydrocephalus, number of shunt revisions, interval between the initial diagnosis of hydrocephalus or the last shunt placement and ETV, and the indwelling time of external ventricular drainage.

Results

At the time of ETV after shunt failure, 14 of the 19 patients were in the pediatric age group and 5 were adults, with ages ranging from 14 months to 42 years (median age, 12 years). The patients had initially been diagnosed with hydrocephalus between the ages of 1 month 24 days and 32 years (median age, 6 years 3 months). The etiology of hydrocephalus was neoplasm in 7 patients; infection in 5; malformation, such as aqueductal stenosis or megacisterna magna in 3; trauma in 1; and unknown in 3. The overall success rate during the median follow-up duration of 1.4 years (9 days to 8.7 years) after secondary ETV was 68.4%. None of the possible contributing factors for successful ETV, including age (p=0.97) and the etiology of hydrocephalus (p=0.79), were statistically correlated with outcomes in our series.

Conclusion

The use of ETV in patients with shunt malfunction resulted in shunt independence in 68.4% of cases. Age, etiology of hydrocephalus, and other contributing factors were not statistically correlated with ETV success. External ventricular drainage management during the immediate post-ETV period is a good means of detecting ETV failure.     

婴幼儿脊髓脊膜膨出术后并发脑积水的影响因素及治疗方法分析

目的 探讨婴幼儿脊髓脊膜膨出修补术后合并脑积水的影响因素及治疗方法.方法 回顾性分析182例显微外科手术治疗脊髓脊膜膨出病儿的临床资料.根据术后是否并发脑积水分为脑积水组和对照组,多变量Logistic回归分析术后并发脑积水的影响因素;对脑积水组均先采取内科脱水治疗,再根据病情选择脑室外引流术(引流术)、第三脑室底造瘘术(造瘘术)和脑室-腹腔分流术(分流术)治疗.结果 本组病儿术后发生脑积水26例,多变量Logistic回归分析:膨出部位在颈胸段、术后并发感染或脑脊液漏、脊膜膨出平均周径大、术前颅高压均为术后并发脑积水的影响因素.脑积水组采用单纯脱水治疗2例,脱水+引流术3例,脱水+引流术+造瘘术3例,脱水+引流术+分流术16例,脱水+引流术+造瘘术+分流术2例;经治疗治愈23例,死亡3例.结论 针对脊髓脊膜膨出修补术后产生脑积水的不同病因,综合采用不同的治疗方式,可取得较好疗效.     

腹腔镜下脑室-腹腔分流术治疗脑积水的疗效观察

目的 观察腹腔镜下脑室-腹腔分流术治疗脑积水的临床疗效。方法 回顾性分析2009-06-2012-06我科收治的68例脑积水患者的临床资料,按手术方式分为腹腔镜下脑室-腹腔分流术治疗组（观察组）34例,常规手术组（对照组）34例,对比2组临床疗效和术后并发症情况。结果 2组患者随访12～24个月,观察组和对照组治疗有效率分别为91.2%（31/34）、61.8%（21/34）,差异有统计学意义（P＜0.05）;观察组分流管腹腔端梗阻率和腹部感染率均明显低于对照组,差异均有统计学意义（P＜0.05）。结论 腹腔镜辅助下脑室腹腔分流术治疗脑积水安全、有效,术后分流管阻塞及感染发生率低。