软性神经内镜在神经外科手术中的应用

目的探讨软性神经内镜在神经外科的应用价值。方法应用光学纤维神经内镜和电子软性神经内镜,配合软性内镜专用手术器械单独或辅助显微外科手术治疗各种神经外科疾病228例。结果对63例慢性硬膜下血肿采用内镜下单纯钻孔冲洗术治疗,除早期1例术后血肿复发接受2次手术外,其余患者均一次治愈。10例侧脑室及三脑室后部肿瘤患者采用内镜下肿瘤活检、全切或部分切除,有8例明确病理诊断后改用其他治疗方式治疗。78例梗阻性脑积水患者在内镜下进行第三脑室底造瘘术,所有患者均获得成功造瘘,无1例造成副损伤。对19例因脑脊液吸收障碍导致的脑积水患者进行脉络丛烧灼术,其中13例仅单纯行脉络丛烧灼术,除1例单纯烧灼后颅压下降不明显、术后2周再行脑室-腹腔分流外,其余均获得满意疗效。内镜下打通脑室内多发分隔(感染或出血后)配合透明隔造瘘3例,均获成功。内镜下治疗颅内蛛网膜囊肿16例,手术效果满意。此外,完成内镜辅助下手术39例,效果满意。结论软性神经内镜有其独特的应用优势,和硬性神经内镜配合使用可以大大提高神经内镜在神经外科微创手术中的应用范围,值得推广。     

神经内镜下三脑室底造瘘术治疗交通性脑积水的影像分析

目的 探讨神经内镜下三脑室底造瘘术治疗交通性脑积水的磁共振特点,指导临床选择手术适应证.方法 15例患者行神经内镜下三脑室底造瘘术,磁共振常规扫描分析其术前术后的影像特点.结果 15例患者术后随访6个月至2年,术后影像显示梗阻部位的积水解除,脑室缩小,室周水肿现象减退,病人症状改善.结论 磁共振可通过显示脑池的大小,三脑室底的形态,室周水肿现象推断交通性脑积水在脑室外脑池内梗阻部位,通过对交通性脑积水的术前影像分析,可帮助确定交通性脑积水行神经内镜下三脑室底造瘘术的手术适应证.     

鞍上囊肿的内镜治疗

目的总结20例鞍上囊肿的临床表现、手术方法及疗效。方法术前均行CT和M RI检查,明确鞍上囊肿的诊断以及中脑导水管是否存在梗阻。手术中探查导水管上口情况,根据有无梗阻,行内镜下脑室囊肿造瘘术或脑室囊肿脑池造瘘术。结果16例术前诊断和术中探查证实存在导水管梗阻,行脑室囊肿脑池造瘘术;4例无导水管梗阻,行脑室囊肿造瘘术。术后随访3￣6个月,19例术后症状明显改善,1例无明显变化。结论鞍上囊肿主要表现为脑积水症状;内镜下行脑室囊肿造瘘术或脑室囊肿脑池造瘘术治疗鞍上囊肿疗效较好。     

内镜下行第三脑室底造瘘术治疗脑室炎后慢性脑积水

目的 探讨应用神经内镜在治疗慢性复杂脑积水的效果.方法 回顾性分析了15例用神经内镜行第三脑底造瘘术并脑室冲洗治疗的慢性复杂脑积水的病人资料.结果 15病人获得良好的效果,无并发症发生,1例病人术后15 d,脑积水复发,冉次行第三脑底造瘘时发现造瘘口闭合,二次造瘘后恢复良好.结论 神经内镜行第三脑底造瘘术并脑室冲洗治疗慢性复杂脑积水的病人有确实效果.     

脑室铸型血肿的软性神经内镜治疗

目的 探讨应用软性神经内镜治疗脑室铸型血肿的疗效.方法 回顾性分析2014年5月～2016年1月航空总医院神经外科采用软性神经内镜治疗11例脑室铸型血肿患者的临床资料.评估手术时间、术后脑室外引流时间,额外的脑脊液分流手术,术后3个月结果和相关并发症.结果 在发病后第4天和第5天接受软性神经内镜手术的2例患者需要随后的脑脊液分流手术.相比之下,在发病当天接受内镜手术的9例患者中,只有1例患者因为纤维粘连导致继发性梗阻,需要额外行第三脑室底造瘘术.术后3个月,所有6例mRS评分为2～3分的患者符合以下标准:初始格拉斯哥昏迷评分高于8分,在发病当天接受软性神经内镜手术,并且脑室外引流时间小于4d.结论 使用软性神经内镜早期干预和术后短时间脑室外引流对于脑室铸型血肿效果较好.     

神经内镜下第三脑室底造瘘术治疗交通性脑积水

目的 探讨神经内镜下第三脑室底造瘘术成功治疗交通性脑积水的手术机制和指征.方法 回顾性分析18例神经内镜下第三脑室底造瘘术治疗交通性脑积水患者的临床资料.结果 11例患者术前MRI显示第四脑室异常扩张和“喇叭形”中脑导水管出口,其中9例效果良好;另外7例无此影像学特征的均失败而需进一步行分流术.结论 神经内镜下第三脑室底造瘘术是 治疗部分交通性脑积水的有效手段,而近端脑池梗阻可能是其重要的作用机制.第四脑室相对第三脑室异常扩张和“喇叭形”中脑导水管出口可能是此类患者的影像学特征,可作为第三脑室底造瘘术治疗交通性脑积水的手术指征之一.     

软性内镜下个性化手术治疗第四脑室流出道梗阻

目的 总结软性神经内镜下个性化手术治疗第四脑室流出道梗阻的指证、方法及效果.方法 对应用软性神经内镜个性化手术治疗第四脑室流出道梗阻32例患者的临床资料进行回顾性分析.结果 单纯第四脑室正中孔造瘘9例,第四脑室正中孔造瘘加第三脑室底造瘘5例,导水管成形加第三脑室底造瘘5例,导水管成形加第四脑室正中孔造瘘2例,单纯第三脑室底造瘘11例.术后脑脊液电影检查显示导水管区脑脊液流动良好26例,枕大孔区第四脑室正中孔脑脊液流动良好10例,第三脑室底瘘口脑脊液流动良好15例,脑脊液电影检查结果不满意但临床症状缓解者2例,术后仍有高颅压表现者5例,其中2例经脑脊液外引流数日后缓解,3例复行脑室-腹腔分流术.所有患者无明显手术并发症出现.结论 软性内镜下可以经额部锁孔导水管入路对第四脑室流出道梗阻进行个性化手术治疗,使部分患者恢复正常脑脊液循环,摆脱分流依赖,但应严格选择手术指证.     

神经内镜下第三脑室底造瘘术治疗非交通性脑积水（附37例分析）

目的总结神经内镜下第三脑室底造瘘术治疗非交通性脑积水的经验。方法对37例非交通性脑积水病人行神经内镜下第三脑室底造瘘术，随访12-36个月。结果35例病人术后症状明显缓解，且无明显并发症，2例无效者改行脑室-腹腔分流术后症状缓解。结论神经内镜下第三脑室底造瘘术治疗非交通性脑积水是一种微创、有效、术后恢复快、并发症少的手术方法。     

导水管梗阻所致巨大脑室脑积水的内镜治疗

目的 探讨导水管梗阻所致巨大脑室脑积水手术治疗的指征及并发症预防.方法 神经内镜下共治疗32例巨大脑室脑积水患者,其中25例行经额入路第三脑室底造瘘术,1例行经额小脑上池囊肿造瘘术,5例行枕下入路内镜下后颅窝囊肿切除、囊腔枕大池造瘘,1例行经枕下入路导水管成形术.结果 术后随访1-4年,32例具有行走不稳、尿失禁、智商下降、精神运动发育迟缓的患者中,26例症状明显改善,6例症状未继续进展.6例术前存在高颅压症状患者术后症状改善,除1例出现硬膜下积液外,无其他严重并发症发生.结论 巨大脑室脑积水并非内镜手术治疗禁忌,凡影像检查确定为导水管梗阻所致的巨大脑室脑积水,均应积极手术治疗,改进手术方法 可以避免严重并发症的发生.     

软性内镜下个性化手术治疗第四脑室流出道梗阻

目的 总结软性神经内镜下个性化手术治疗第四脑室流出道梗阻的指证、方法及效果.方法 对应用软性神经内镜个性化手术治疗第四脑室流出道梗阻32例患者的临床资料进行回顾性分析.结果 单纯第四脑室正中孔造瘘9例,第四脑室正中孔造瘘加第三脑室底造瘘5例,导水管成形加第三脑室底造瘘5例,导水管成形加第四脑室正中孔造瘘2例,单纯第三脑室底造瘘11例.术后脑脊液电影检查显示导水管区脑脊液流动良好26例,枕大孔区第四脑室正中孔脑脊液流动良好10例,第三脑室底瘘口脑脊液流动良好15例,脑脊液电影检查结果不满意但临床症状缓解者2例,术后仍有高颅压表现者5例,其中2例经脑脊液外引流数日后缓解,3例复行脑室-腹腔分流术.所有患者无明显手术并发症出现.结论 软性内镜下可以经额部锁孔导水管入路对第四脑室流出道梗阻进行个性化手术治疗,使部分患者恢复正常脑脊液循环,摆脱分流依赖,但应严格选择手术指证.     

Endoscopic third ventriculostomy for obstructive hydrocephalus in children younger than 6 months of age: is it a first-choice method?

INTRODUCTION: Endoscopic third ventriculostomy (ETV) is considered a safe procedure and is a method of choice in treatment of obstructive hydrocephalus nowadays. In case of Sylvian aqueduct stenosis, the success rate reaches 90%. In children younger than 6 to 24 months, respectively, however, some authors report lower effectiveness ranging between 0% and 64%. The reasons of ETV failure are discussed: hyporesorption in patients with obstruction as a consequence of hemorrhage or infection, suboptimal ETV performance, especially in premature newborns, or the theory of different cerebrospinal fluid circulation in newborn babies. MATERIALS AND METHODS: Between January 2005 and December 2006 in our clinic, 14 patients younger than 6 months having presented with obstructive hydrocephalus were treated endoscopically. Obstruction was revealed by preoperative magnetic resonance imaging. The etiology of hydrocephalus was congenital aqueduct stenosis in five patients, posthemorrhagic obstruction in eight patients, and combination of posthemorrhagic and postinfection etiology in one patient. ETV was considered successful when no shunt operation was needed in the patient. RESULTS: ETV was successful in eight patients who experienced regression of signs of intracranial hypertension and were not forced to undergo ventriculo-peritoneal (V-P) shunting. In one patient, a successful repeat ETV was performed. In the remaining six patients, V-P shunt implantation was necessary. Total success rate in our group of patients was 57%. The only complication was subdural hygroma in one patient requiring evacuation. CONCLUSION: Based on our experience, we recommend ETV as the method of choice in children younger than 6 month of age.     

Chronic subdural hematoma after endoscopic third ventriculostomy: case report

Endoscopic third ventriculostomy (ETV) is an effective and rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. It has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although it is a safe procedure, several complications related to this procedure have been reported in the literature. We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. A 42-year-old female patient presented with acute symptoms of obstructive hydrocephalus, headaches and blurring of consciousness. A computerized tomogram (CT) of the patient's brain revealed marked triventricular supratentorial hydrocephalus and an external ventricular drainage (EVD) was performed first. After this procedure, magnetic resonance imaging (MRI) demonstrated hydrocephalus secondary to aqueductal stenosis. ETV was performed and the EVD removed uneventfully. The patient was discharged home after a few days without any complications. She then presented with headaches 4 weeks following ETV. A CT demonstrated chronic subdural hematoma on the contralateral side. This was treated with burr-hole evacuation. Postoperatively, her headaches improved. During the follow-up period, she remains symptom-free and has radiographic evidence of a patent ventriculostomy. This case confirms chronic subdural hematoma formation is a possible complication following endoscopic third ventriculostomy.     

Endoscopic surgical anatomy of the paediatric third ventricle studied using virtual neuroendoscopy based on 3-D ultrasonography

INTRODUCTION: Endoscopic treatment for occlusive hydrocephalus requires knowledge of individual ventricular and vascular anatomies of the ventricular system. METHODS: We studied the feasibility of virtual neuroendoscopy (VNE) based on 3-D ultrasonography (3-D US) for the identification of parenchymal and vascular anatomical landmarks of the third ventricle and its impact on the surgical planning of endoscopic third ventriculostomy (ETV) in paediatric patients. 3-D US was performed through the anterior fontanel in four infants with hydrocephalus. RESULTS: Virtual neuroendoscopy revealed the size of the foramen of Monro, anatomical landmarks of the floor of the third ventricle crucial for correct fenestration during ETV, but not the premesencephalic cistern. The basilar bifurcation was identified in relation to the floor of the third ventricle by VNE (power-Doppler ultrasonography) and confirmed intraoperatively after ETV. CONCLUSION: 3-D US-based VNE reveals detailed anatomical information on the ventricular system including the foramen of Monro and the floor of the third ventricle. Within the premesencephalic cistern vascular anatomy can be visualized, but not non-vascular structures.     

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.     

Chronic subdural hematoma after endoscopic third ventriculostomy: a case report and literature review

Chronic subdural hematoma is a very rarely observed complication after endoscopic third ventriculostomy (ETV). A 21-year-old male patient was admitted to our clinic with complaining of headache, weakness and tremor. The fundoscopic examination revealed slightly indistinct border of the papilla and neurological examination findings were normal. The cranial computed tomographic (CT) and magnetic resonance imaging (MRI) findings demonstrated three-ventricular hydrocephalus due to aqueductal stenosis and ETV was performed. The symptoms got better after the operation. At 1? month postoperatively the patient reapplied to our clinic with a symptom of severe headache. Cranial BT imaging demonstrated enlargement of subdural hematoma. The hematoma was treated by burr-hole evacuation and drainage and totally disappeared in the postoperative period. The follow-up CT scan was evaluated as normal. Nowadays, ETV is accepted as a safe and an alternative method for the treatment of obstructive hydrocephalus instead of shunt operation. Chronic subdural hematoma is a rarely observed complication after ETV.     

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。     

Endoscopic third ventriculostomy in infants of less than 1 year of age: which factors influence the outcome?

Objectives Endoscopic third ventriculostomy (ETV) is a successful method of treatment for obstructive hydrocephalus. In infants, however, it is reported to have a higher failure rate. On the basis of our own data and a meta-analysis of the literature, we try to define factors prognosticating potential failure in infants aged less than 1 year.Methods Data were collected retrospectively. Between October 1994 and October 2002, 20 ETVs were performed in 16 patients younger than 1 year. Ages ranged from 8 to 311 days (median 103). Etiology was aqueductal stenosis in all 16 patients (idiopathic in 7, posthemorrhagic in 3, postmeningitic in 3, and related to CNS or vascular malformation in 3). ETV failure was defined as subsequent need for shunt implantation. For non-shunted patients, follow up was 16–52 months (median 25).Results ETV was successful in 5 patients and eventually failed in 11. There was no mortality or permanent morbidity following ETV. In the successful cases, etiology was idiopathic aqueductal stenosis in 4 and postmeningitic aqueductal stenosis in 1; the median age was 206 days (range 82–311). In the 11 unsuccessful patients, it was idiopathic aqueductal stenosis in 3, posthemorrhagic in 3, postmeningitic in 2 and CNS/vascular malformation in 3 cases; median age was 94 days (range 8–299). Median time interval between (last) ETV and shunt was 38 days (range 2–70). The difference in median age between the success group and the failure group roughly corresponded to data gained from a meta-analysis of the literature. Four patients underwent a second ETV. In intraoperative ventriculoscopy, the stoma was closed or there were new membranes below the floor of the third ventricle and a second ETV was performed. But finally, all re-ETVs failed and the patients needed a shunt.Conclusion Factors indicating potential failure of ETV were very young age and etiology other than idiopathic aqueductal stenosis. Probability of success seems to increase during the first 2 or 3 months of life. Ventriculoscopy with the option of a second ETV should be regularly performed after failure of ETV.     

Increasing chronic subdural hematoma after endoscopic III ventriculostomy

Object: Endoscopic III ventriculostomy (ETV) is an effective and a rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. Though not devoid of risk, ETV is increasingly replacing shunt operations, and it prevents related complications, including overdrainage. Methods: We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. Three weeks after he was shunted elsewhere, he presented to us with clinical symptoms of intracranial hypotension and overdrainage. ETV was performed and the shunt removed uneventfully. On routine postoperative MRI a few weeks later, a large ChSDH was noted, the patient being totally asymptomatic. Since the ChSDH grew significantly, causing a mass effect on the follow-up MRI, it was finally drained. Large and increasing ChSDHs have previously been reported secondary to overdrainage after shunt placement, but not after ETV. Conclusions: We conclude that though rare, a ChSDH may evolve even after ETV, if there is a substantial decrease in previously elevated intracranial pressure. Received: 28 December 1999     

Endoscopic third ventriculostomy in children: early and late complications and their avoidance

Introduction Endoscopic third ventriculostomy (ETV) is considered by many authors the initial surgical procedure of choice for the treatment of non-communicant hydrocephalus. However, this procedure has early and late complications that neurosurgeons must be aware of when performing it.Materials and results A retrospective study of infants and children treated with ETV at Children’s Memorial Hospital (Chicago, IL) between 1993 and 2004 is presented. A total of 136 ETVs in 122 patients were performed with 8.8% early complication rate (hemorrhage, CSF leak, infection, diabetes insipidus, and seizures). There were no fatalities but one patient had severe neurological disturbances due to intracranial hemorrhage at the second ETV. We identified several significant factors that influence the late ETV failure rate: age under 12 months (p=0.012), cases performed early in our experience (p=0.009), patients with hydrocephalus without expansive lesions (p=0.026), patients that had an external ventricular drain (EVD) after ETV (p<0.005), and patients who developed early complications (p=0.035).Conclusion A careful patient selection and preoperative planning lead to better results of ETV. A higher early and late complication rate in children younger than 1-year-old were noted in our series. There is definitely a learning curve for this technique, and several technical considerations are helpful to avoid adverse events. Most of the early complications are transient, while potential devastating injuries can occur. Long-term follow-up is needed to identify delayed closure of the fenestration. Ventricular access devise is helpful for diagnostic and therapeutic purposes during the follow-up.