第四脑室囊虫的内镜治疗(附二例报告)

目的 探讨电子神经内镜手术治疗第四脑室囊虫的价值.方法 应用电子神经内镜对2例第四脑室内囊虫经中脑导水管进行手术摘除.其中1例术前MRI检查提示第四脑室内囊性病变;另1例术前检查提示病变位于第三脑室内,术中脑室探查时发现病变已经进入第四脑室.结果 2例第四脑室内囊虫均在神经内镜下完整摘除,术后患者无任何不良反应,脑脊液电影检查枕骨大孔区脑脊液流动良好.结论 应用电子神经内镜能够方便地对脑室系统进行全面探查,神经内镜手术摘除第四脑室内囊虫创伤小,并发症少,住院时间短,费用低,应作为第四脑室囊虫的首选治疗.     

The role of neuroendoscopy in the management of solid or solid-cystic intra- and periventricular tumours

Objects The purpose of this study was to describe the surgical strategies of neuroendoscopic treatment in patients with solid or solid-cystic peri- and intraventricular tumours. Analysis of the postoperative histopathology and complication of neuroendoscopic interventions was also performed. Background A number of intracranial tumours do not ultimately require aggressive surgical intervention. Either definite or palliative treatment for the intra- and periventricular lesions could be accomplished using various neuroendoscopic techniques, depending on the histopathological diagnosis and aim of therapeutic intervention. Materials and methods Between 1994 and 2004, 46 patients with newly diagnosed solid or solid-cystic peri- and intraventricular tumours underwent neuroendoscopic procedures Twenty patients had associated hydrocephalus requiring the cerebrospinal fluid diversion procedures. Since 1997, neuronavigation has been applied to selected cases. Results Obstructive hydrocephalus was treated sufficiently by endoscopic third ventriculostomy or endoscopic stent placement. Partial or total extirpation of solid tumour was achieved in four cases. The majority of pathological examinations revealed astrocytoma (23), craniopharygioma (7) and metastasis (2). Subsequent mode of treatment such as chemotherapy, radiation therapy or microscopic surgery was determined according to the pathological findings. There were three transient morbidities and one permanent deficit, but no operative mortality. Conclusion Transventricular endoscopic approach is an effective and reliable alternative treatment of newly diagnosed peri- and intraventricular lesions. Neuroendocopic procedures offer the opportunity to combine tumour biopsy and treatment of hydrocephalus. In selected patients, partial or total tumour removal could be performed. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

Neuroendoscopic techniques in the treatment of arachnoid cysts in children and comparison with other operative methods

Objective: The authors intended to evaluate the application of neuroendoscopic techniques for the treatment of arachnoid cysts in children and compare it with other operative methods. Methods: The analysis covered the results of treatment of 44 children with arachnoid cysts who were subjected to neuroendoscopic procedures and 62 patients who underwent other operations. Results: The neuroendoscopic treatment of arachnoid cysts was very effective because of low rate of reoperative treatment (six out of 44 patients), no need to change the operative method (40 effective out of total 44 operative procedures), and low rate of persistent worsening (none of 44 patients worsened). Conclusions: Summing up all the mentioned aspects of neuroendoscopic techniques, the neuroendoscopic techniques were the most suitable operative procedures in the treatment of arachnoid cysts in the presented group of patients, providing that the connection between the lumen of the arachnoid cyst and the cerebrospinal fluid cisterns was of good quality.     

立体定向穿刺加Ommaya囊置入术在颅内囊性病变中的临床应用

目的探讨立体定向穿刺术和Ommaya囊置入术在治疗颅内囊性病变中的应用技巧及疗效。 方法回顾性分析上海华山医院伽马分院2012年11月至2013年4月收治的3例不同颅内囊性病变患者,对该3例诊断明确的颅内囊性患者(分别为右颞转移瘤、左侧CPA神经鞘瘤、颅内多发病变)在立体定向穿刺后置入Ommaya囊,再根据具体病情给予囊腔逐渐抽吸,使囊液逐渐减少至最少,给予伽玛刀的治疗方法。 结果3例病例均在多次抽取囊液后行伽玛刀治疗,无不适反应,均未出现皮肤感染、颅内感染、硬膜外血肿等因手术操作导致的并发症。 结论治疗颅内囊性病变,尤其是高龄病人或由于其他原因不能耐受全麻手术的患者时,立体定向加Ommaya囊置入术不失为一种简便、经济、有效、微创的好方法。     

ZD立体定向手术系统的临床应用

目的：探讨ＺＤ（Ｚａｍｏｒａｎｏ－Ｄｕｊｏｖｎｙ）立体定手术系统的临床应用。方法：采用ＺＤ立体手术系统，将ＣＴ扫描的资料输入计算机工作站，ＳＴＰ软件对病灶进行精确的测量定位，制定治疗计划后，对７８例位于脑深部或位于运动区的颅内病灶进行定向手术。结果：ＺＤ系统可迅速对脑深部的小型病灶精确定位，本组所有的病灶均做到一次性定向成功，未出现永久性的手术并发症。结论：应用ＺＤ系统行脑深部及运动区的立体定向手     

神经内镜技术的临床应用

目的探讨神经内镜的临床应用。方法应用内镜手术治疗各种颅内病变22例，其中透明隔囊肿3例，脑积水2例，鞍上囊肿1例，单侧室间孔阻塞1例，垂体瘤13例，脑脊液鼻漏1例，桥小脑角胆脂瘤1例。结果用单纯内镜手术治疗7例颅内囊性病变及脑积水，6例症状改善，1例脑积水改行分流手术。用内镜控制的显微神经外科治疗垂体瘤13例，全切10例，次全切3例；脑脊鼻漏修补1例，效果良好。用内镜辅助显微神经外科全切1例桥小脑胆脂瘤。22例病人中2例出现一过性尿崩，1例出现一过性脑脊液鼻漏，1例出现视力恶化，经治疗后均愈。结论内镜治疗颅内囊性病变，手术副损伤小，疗效确切；内镜下经鼻腔切除垂体瘤，微创、安全、有效；神经内镜辅助显微外科可提高手术疗效。     

内镜下手术治疗颅内囊性病变

目的：探讨应用神经内镜手术治疗颅内囊性病变的手术适应证和手术方法。方法：采用单纯神经内镜下及神经内镜辅助显微镜下手术切除肿瘤、囊肿,囊肿－脑室和囊肿－脑池造瘘等方法治疗颅内囊性肿瘤、颅内蛛网膜囊肿、透明隔囊肿、侧脑室内囊肿等囊性病变51。结果：囊性肿瘤全切9例,囊肿切除6例,蛛网膜囊肿囊壁部分切除加囊腔－脑池造瘘23例,囊肿脑室造瘘13例,25例于术后3个月复诊,疗效较好。结论：应用神经内镜可以通过颅骨钻孔或小的骨瓣开颅手术治疗颅内囊性病变,手术副损伤小,疗效可靠。     

MRI立体定向活检术在颅内病变诊断中的应用

目的 探讨MRI引导下立体定向活检术在颅内病变诊断中的作用价值。方法 自2009年1月至2015年3月应用立体定向系统与手术计划软件对25例颅内病变诊断不明确的患者行MRI定位下立体定向活检术。结果 除1例活检阴性外,病理诊断与最后诊断（结合临床和其他检查结果）一致20例,不一致4例;最后诊断与术前MRI诊断相符合8例,不符合9例,影像未诊断6例;切除术后病理与影像相符合1例,无明确关系1例。术后6例病变内少量出血,保守治疗;1例左额叶出血30 ml,行开颅血肿清除+去骨瓣减压术。结论 MRI立体定向活检术对颅内多发、深部病变的诊断具有重要价值,其安全性较高,但仍需进一步避免脑出血的风险。     

颅内囊性病变的神经内窥镜手术治疗

目的：分析颅内囊性病变的神经内窥镜手术治疗及效果。方法：应用ｗｏｌｆ硬质神经内窥镜治疗颅内囊性病变１２例，其中颅咽管瘤３例，透明隔囊肿２例，蛛网膜囊肿７例。结果：临床症状改善１２例（１００％），影像检查改善１１例（９２％）。结论：神经内窥镜手术是治疗颅内囊性病变的一种安全有效的方法。     

Cystic abnormalities of the brain: stereotaxic diagnosis and therapy]

We present the stereotactic treatment and evaluation of 33 patients with congenital cysts of the brain (6 cavum septi pellucidi/cavum vergae cysts, 5 suprasellar cysts, 3 intraventricular cysts, 4 cysts of the interhemispheric fissure, 4 cysts of the cerebral convexity, 5 supracollicular cysts, 3 cysts in the cisterna ambiens, 2 temporomedial cysts and 1 cyst in the pontomesencephalic junction). The patients were seen during an 8-year period (1984-1992) and had a mean follow-up time of 27 months. In 23 patients with cysts in or near the cerebral midline or at the cerebral convexity, a stereotactic ventriculocystostomy resulted in clinical improvement with diminished cyst size. Another 8 patients with relatively small cysts profited from stereotactic aspiration of the cyst contents. Three complications (bleeding, aseptic meningitis, catheter infection) remained without sequelae. The stereotactic procedure is the treatment of choice for these lesions because of the low operative risk, its minimal invasiveness and the possibility of distinguishing primary congenital cysts from other pseudocystic lesions. In well-chosen cases the carefully planned stereotactic internal derivation of the cysts in the ventricular system led to a long-lasting beneficial effect. Open craniotomy or shunting procedures can be avoided for most cases of congenital intracranial cysts.     

计算机体层摄影立体定向在神经外科的应用

目的:应用CT立体定向术对脑深部及功能区的病变进行病理学诊断和治疗.方法:自1990年以来采用CT立体定向技术对68例脑深部和功能区的颅内囊性肿瘤进行了定向病检,排除囊液,瘤腔内放置Omaya管和瘤腔胶体磷酸铬内放疗,功能区脑脓肿定向排脓,脑深部病灶定向病检.结果:31例囊性颅咽管瘤经12～66个月随访,25例(80.7%)瘤腔持续消失,3例较前显著缩小,3例瘤实质增大;7例囊性胶质瘤中,2例25～38个月无复发,5例13个月后相继复发;3例囊性转移癌虽在6～18个月内死亡,但颅内放疗病灶无复发;5例功能区脑脓肿全部治愈而无明显后遗症.22例脑深部病灶20例获得病理学诊断,全组无严重并发症和无死亡率.结论:CT立体定向瘤腔内放疗对治疗脑深部和功能区囊性为主的肿瘤应为首选的治疗方法.     

囊性颅咽管瘤内置管囊小剂量多次化疗的疗效观察

目的探索神经外科综合治疗位于视丘下部附近区域的囊性颅咽管瘤之方法。方法选择16例囊性或以囊性为主的颅咽管瘤,在CT介导立体定向内窥镜下切除部分囊壁或肿瘤实质,排除囊液减压后囊内置入Ommaya管,术后经反复抽吸囊液,并反复注入小剂量博来霉素30～40次。结果16例经治疗后视力、视野障碍明显好转,7例有颅内压增高者术后缓解。CT显示瘤腔缩小,无手术死亡,术后视丘下部功能紊乱反应轻。14例获随访2～3年,临床症状明显改善。结论该疗法安全、简便、有效,是采用微侵袭神经外科手段治疗颅咽管瘤的有效方法,有一定的临床应用价值。     

Endoscopic management of intra and paraventricular CSF cysts

Background The management of intra- and paraventricular lesions is one of the fields in which modern neuroendoscopic techniques have given the most significant contribution in terms of reduction in operative invasiveness and postoperative complications. In this context, fluid cysts represent an ideal ground on which results obtained with traditional surgical procedures (open surgery, shunting) have more and more to compare with the increasing number of encouraging results obtained by neuroendoscopy. Objective The objective of this study was to retrospectively evaluate the results of the endoscopic treatment of intra- and paraventricular cysts performed at our institution and how they compare with what has been reported in the literature, concerning the results of open surgery, shunting, and endoscopic management. Materials and methods All the patients with intra- and paraventricular cerebrospinal fluid (CSF) cysts endoscopically managed at our institution between March 2000 and October 2006 were included. Based on cyst location documented by magnetic resonance imaging (MRI), the cohort of patients examined was subdivided in five groups: A, paraventricular cysts; B, choroids plexuses cysts; C, secondary intraventricular cysts in previously hydrocephalus shunted patients; D, quadrigeminal cistern arachnoid cysts; and E, suprasellar arachnoid cysts. The neuroendoscopic procedures were performed with a 30° rigid endoscope (Storz Decq, 3.8 mm). The surgical plan and best trajectory were selected on preoperative MR imaging. Postoperatively, all patients underwent CT scans in the first 48 h after surgery and MR control 3 months after surgery. Results There were 26 patients (18 M/8F). The mean age at diagnosis was 8.95 years. Five of 26 cases were adult patients. Four patients had paraventricular cysts; 2 patients had a choroids plexuses cyst; 6 patients a secondary intraventricular cyst in previously shunted hydrocephalus; 11 patients had a quadrigeminal cistern arachnoid cyst and 3 patients had a suprasellar arachnoid cyst. Fifteen patients had an associated hydrocephalus at the time of the surgical treatment (one patient in group A, six patients in group C, six in group D, and two in group E). Twenty-three out of 26 patients underwent endoscopic management of their cystic lesion as primary procedure; in the remaining three cases, it represented a secondary procedure after open cyst marsupialization or/and the implant of a cystoperitoneal shunt. Endoscopic management consisted in a cystoventriculostomy (CV) in 19 patients. Third ventriculostomy (ETV) was associated to CV in seven cases, and it was performed at the same time of the CV procedure in all these cases. There was no mortality, neither operative morbidity. At a mean follow-up of 2.15 years (0.1–4 years), a complete resolution of preoperative clinical symptoms and signs was recorded in 80.9% of symptomatic patients. Control MRI showed a reduced cyst size in 25/26 patients and a stable cyst size in the last case, with signs of CSF flow between the cyst and the cerebral ventricles in all cases. One out of 15 patients with associated hydrocephalus had a persistent ventriculomegaly without signs of increased intracranial pressure. Conclusions Our results confirm that endoscopic management of intra- and paraventricular cysts is a valid alternative to open surgery as well as to shunting procedures. Control of clinical symptoms and signs was obtained in around 80% of our patients, while radiological evidence of cyst size reduction occurred in more than 95% of them. These rates are comparable with results of open surgery and shunting. The main advantage of neuroendoscopy is the low incidence of complications, a result that is confirmed by the present series. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

内窥镜技术在神经外科手术中的应用研究

目的探讨内窥镜技术在神经外科手术治疗中的价值。方法采用神经内窥镜进行内镜下和内镜控制下以及内镜辅助下的各种神经外科手术122例,包括各种颅内肿瘤切除68例,颅内血肿清除51例,颅内囊肿切除2例,脑积水造瘘1例。结果30例高血压性脑出血患者血肿清除满意,21例慢性硬膜下血肿术后无复发;48例肿瘤全切除,15例次全切除,5例大部切除;1例囊肿全切除,另1例囊肿缩小;1例脑积水患者术后症状明显改善,脑室明显缩小。结论内窥镜技术在微侵袭神经外科手术中具有广泛的临床应用前景。     

颅内不同靶点定向毁损术后的小脑症状与手术灶的关系

目的：评价并探讨立体定向毁损颅内不同靶点治疗帕金森病（PD）术后出现小脑体征与手术灶关系。方法：随机抽出颅内3个不同靶点毁损治疗PD共90例进行回顾性分析。所有病例均采用Leksell定向仪,选择常规靶点。结果：丘脑外侧苍白球（VpLp）毁损术后一周以上出现小脑体征者占3．3％,在丘脑腹测中间校（Vim）毁损出现小脑体征者占6．6％。而毁损丘脑腹外侧核（VL）出现率最高。结论：毁损灶越靠近丘脑脑底部,术后出现小脑症状的发生率越高,说明走向毁损灶的位置与小脑症状的出现有着很大的关系。     

伽玛刀联合立体定向手术治疗颅内囊性肿瘤

目的探讨立体定向穿刺抽吸手术与伽玛刀联合治疗颅内囊性肿瘤在立体定向放射外科治疗中的作用。方法分析颅内囊性肿瘤40例,单纯立体定向穿刺抽液19例,留置Ommaya囊抽液19例,内窥镜下手术切除肿瘤并排除囊液2例。肿瘤体积缩小后再行立体定向磁共振成像（MRI）定位、伽玛刀治疗,并计算抽液前后肿瘤体积的变化。依据Logistic综合方程计算抽液前后风险概率的变化,将抽液前后的肿瘤体积和风险概率进行配对t检验。结果抽液后瘤囊完全消失,病灶体积明显缩小。抽液前后肿瘤容积和风险概率均显著降低（容积变化：t＝8.108,P＜0．001;风险概率：t＝5．933,P＜0．001）。随访时间6个月～42个月,平均17.5个月。经伽玛刀治疗后,瘤结节消失10例,缩小12例,无变化17例,增大1例。结论颅内囊性肿瘤立体定向穿刺抽液后肿瘤体积缩小,使立体定向放射外科治疗并发症的风险概率显著降低,是联合伽玛刀治疗囊性肿瘤一种有效方法;针对肿瘤病理类型的不同采用伽玛刀放射外科联合单纯穿刺或置管抽取囊液、结合囊内治疗是囊性肿瘤治疗成功的关键。     

CT-guided stereotactic biopsies using a modified frame and Gildenberg techniques.

Eighteen patients underwent CT guided stereotactic biopsies using either a Riechert-Mundinger stereotactic frame modified for use in the CT scanner or the CT-based intracranial landmark technique of Gildenberg and a Todd-Wells frame. In seven patients undergoing biopsy with the modified frame technique, representative tissue samples were obtained in all cases. Eleven patients had biopsies using the Gildenberg technique and representative tissue samples were obtained in 10 of the 11. No major postoperative complications occurred in either group. Both techniques allowed samples of intracranial tissue to be obtained safely and efficiently. The modified frame technique provided a higher degree of accuracy while the Gildenberg technique required significantly less CT time and provided a satisfactory degree of accuracy. In seven patients with ring enhancing lesions, biopsies of the enhancing rim provided diagnostic tissue while biopsy of the central low density center of the lesion in three patients provided necrotic material which was useful in histologically grading the tumour.     

Neuroendoscopic placement of Ommaya reservoir into a cystic craniopharyngioma

INTRODUCTION: Total removal of the tumor is the most acceptable therapeutic modality in the management of craniopharyngioma; however, there are innumerable factors that can upset treatment plans. Unresectable lesions are often treated with gamma knife surgery (GKS). Reduction of the cystic volume is necessary, to decrease the area to be treated with GKS. An Ommaya reservoir system is usually placed during open surgery or by stereotactic access. MATERIALS AND METHODS: The authors use a neuroendoscope for safer and less invasive placement of the Ommaya reservoir into deep-seated cystic lesions. The cystic component is aspirated, and the Ommaya reservoir tube is precisely guided and placed into the cyst cavity under neuroendoscopic control with a newly developed two-burr-hole technique. This neuroendoscopic procedure could make it easier to reduce cystic volume prior to GKS as the final procedure. This technique may also be used for instillation of chemotherapeutic agents and for repeat aspirations, making the achievement of cystic control more likely. This type of neuroendoscopic management is a safe and effective procedure and could be considered as an alternative management technique for some stubborn cystic craniopharyngiomas.     

Stereotactic procedures in neurosurgery – indications and results of 71 cases

Summary CT- or MRI-guided stereotactic procedures should be a standard in a modern neurosurgical unit. Analysing 71 cases the indications and results of stereotactic neurosurgery are presented. In 53 patients stereotactic serial biopsies of different intraaxial lesions were performed, in 5 patients a spontaneous haemorrhage of the basal ganglia was removed by lysis with r-tPA. In 3 patients suffering from hydrocephalus due to diencephalic cysts a cystventricular shunt device was implanted. In 3 patients an intracerebral abscess was aspirated and drained. A stereotactic guided craniotomy and excision of small deep-seated lesions was performed in 6 cases. The accuracy of stereotactic tumour biopsies was 88.7 % in our series, in accordance to other authors. The stereotactic aspiration and drainage of an intracerebral abscess provides accurate localization and minimal cortical damage and offers the possibility of intracavitary application of antibiotics. The stereotactic internal shunt implantation seems to be an alternative approach in the treatment of diencephalic cysts due to its minimal invasiveness and low operative risk. The aspiration of basal ganglia haematomas with insertion of an external drainage allows the lysis of the haematoma with r-tPA or urokinase. With stereotactic guidance small, deep-seated intraaxial lesions can be well localized and removed.      

Operative indications and neuroendoscopic management of symptomatic cysts of the septum pellucidum

Objective Since there is no current consensus on the diagnostic standards or surgical indications for symptomatic cysts of the septum pellucidum (CSP), we presented our experience treating such cases with neuroendoscopic surgery in order to possibly make a contribution to the attainment of such a consensus.Methods In the last 5 years, we effectively treated 5 patients (4 males and 1 female) with CSP by neuroendoscopic surgery. The 3 congenital cases were young: 9, 14, and 29 years old. The 2 secondary cases were adults aged 51 and 65 years old. We were able to fenestrate, and biopsy for pathological analysis, the cyst walls of symptomatic CSP using a minimally invasive neuroendoscopic technique, with postoperative improvement in compression of adjacent structures, as well as clinical signs.Conclusions It is necessary to consider the overall picture including clinical signs, progress of the condition, intracranial pressure, and cerebral circulation, in deciding whether surgery is indicated. Neuroendoscopic surgery is an effective, optimal, and convenient therapeutic modality for symptomatic CSP.