垂体腺瘤术后延迟性脑脊液鼻漏影像学特点及鼻内镜修补术

目的总结垂体腺瘤术后延迟性脑脊液鼻漏影像学特点和鼻内镜修补术经验。方法共23例垂体腺瘤术后延迟性脑脊液鼻漏患者,脑脊液鼻漏均发生于垂体腺瘤术后1～5年,常规行腰椎穿刺脑脊液检查、头部MRI检查、脑池造影CT动态扫描和鼻内镜检查,明确漏口位置后行鼻内镜下脑脊液鼻漏修补术,漏口较大患者使用肌肉填塞,再使用异种脱细胞真皮基质修补,漏口较小患者直接使用异种脱细胞真皮基质修补,蝶窦内填塞明胶海绵和碘仿纱条。结果本组患者共住院3～5周,其中20例行1次鼻内镜修补术、2例行2次鼻内镜修补术、1例行3次鼻内镜修补术;术后随访3个月至5年,所有患者均未再出现脑脊液鼻漏。结论垂体腺瘤术后延迟性脑脊液鼻漏的主要原因是术后残留肿瘤组织生长和术后辅助放射治疗,由于肿瘤大部分位于鞍内,适用于鼻内镜下垂体腺瘤切除术和脑脊液鼻漏修补术,手术安全且成功率较高。     

外伤性脑脊液鼻漏的手术治疗（附12例报告）

目的研究外伤性脑脊液鼻漏的漏口定位、手术方法及治疗效果。方法外伤性脑脊液鼻漏患者12例,术前鼻漏病程平均2．4个月,患者术前均行三维CT、单光子发射计算机断层成像及磁共振水成像检查,确定漏口,并行手术治疗14次（其中2例二次手术）,幕上开颅11次,经鼻腔手术3次。结果其中10例经幕上开颅一次治愈,2例经鼻腔术后漏复发,其中1例与耳鼻喉科合作经鼻腔治愈,另1例再次经幕上开颅治愈。结论外伤性脑脊液鼻漏以筛窦、额窦为主,瘘口的确定至关重要,以三维CT确定瘘口的准确率最高,对同时累及额窦筛窦及蝶窦的复杂漏口术前定位易漏诊,术中应广泛探查。尤其经鼻腔内镜修补复杂瘘口,最好与耳鼻喉科协作完成。     

神经内镜技术治疗脑脊液鼻漏

目的 探讨神经内镜技术治疗脑脊液(CSF)鼻漏的方法和疗效. 方法 分析深圳大学第一附属医院神经外科自2012年11月至2013年4月使用神经内镜技术治疗5例CSF鼻漏患者的临床资料,总结其诊断方法、手术方法及临床效果. 结果 5例CSF鼻漏患者中外伤性CSF鼻漏2例,医源性CSF鼻漏3例.外伤后CSF鼻漏术前均通过颅脑MR平扫、CT薄扫颅底重建及CT脑池造影确定漏口;医源性CSF鼻漏根据临床经验判定漏口位置,漏口分别位于额窦后壁、筛窦顶壁、鞍底、蝶筛隐窝、中颅底鞍旁交界区,术中均能直视下观察漏口,行漏口修补.术后患者CSF鼻漏均治愈,无并发症发生,随访3个月以上无复发. 结论 术前影像学检查对CSF鼻漏口定位意义重大,神经内镜治疗CSF鼻漏具有微创、直观、修补成功率高等优点,可作为首选治疗方式.     

经蝶窦显微手术治疗蝶窦性脑脊液鼻漏(附7例报告)

目的探讨经蝶窦显微手术治疗蝶窦性脑脊液鼻漏的手术技巧及经验.方法7例蝶窦性脑脊液鼻漏患者,经4周保守治疗无效后,行经蝶窦入路颅外显微修补术.结果显微镜下凿开鞍底充分暴露硬膜漏口,向硬膜漏口内填塞肌肉块,无脑脊液流出后,用渍ZT胶的明胶海绵填塞于硬膜漏口的内、外侧和蝶窦腔.术后无一例复发.结论这种颅外修补术具有创伤小、并发症少、成功率高的优点,并可同时处理鞍内病变,是修补蝶窦性脑脊液鼻漏的最佳入路.     

神经内镜下手术修补脑脊液鼻漏(附14例报告)

<正>脑脊液鼻漏是神经外科较难处理的疾病。自1981年Wigand[1]首次报道应用鼻内镜修补全筛切除术后筛顶漏口以来,鼻内镜下脑脊液鼻漏修补的病例不断增多,其安全和有效性得到肯定[2]。国内许庚[3]等于1994年报道神经内镜下成功修补5例脑脊液鼻漏。我院神经外科自2010年10月至2013年8月对14例脑脊液鼻漏患者进行了手术修补,现报告如下。一、对象与方法     

术中经腰大池注射生理盐水修补复杂脑脊液鼻漏3例

目的 总结术中经腰大池注射生理盐水在修补脑脊液鼻漏复杂漏口的经验.方法 回顾性分析3例脑脊液鼻漏复杂漏口的病例资料,病人术中均经腰大池注射生理盐水.结果 2例经鼻内镜修补漏口,1例经鼻内镜联合硬膜外修补漏口.术中经腰大池注射生理盐水40～120 ml.1例麻醉苏醒后出现马尾刺激征,1例出现穿刺部位脑脊液漏.术后随访1～...     

经鼻入路神经内镜下手术修补脑脊液鼻漏

目的 探讨经鼻入路神经内镜下脑脊液漏修补术的方法及相关问题。方法 回顾性分析2011年12月至2017年12月经鼻入路神经内镜下手术修补治疗的51例脑脊液鼻漏的临床资料,其中外伤性47例,自发性3例,医源性1例。根据漏口大小选择不同方法修补。结果 51例中,修补成功49例,2例术后发生颅内感染、脑脊液鼻漏,经保守治疗治愈。所有病例术后随访2~5年,均未再发生脑脊液漏。结论 经鼻入路神经内镜下脑脊液鼻漏修补术是脑脊液鼻漏的有效治疗手段。     

内镜经鼻脑脊液鼻漏修补术

目的 介绍内镜经鼻脑脊液鼻漏修补术的外科技术及术中荧光示踪检查.方法 2003年9月至2007年5月诊治脑脊液鼻漏病人35例,25例行内镜经鼻手术,其中外伤性脑脊液鼻漏5例,自发性6例,其他原因14例.8例病人行术中荧光示踪检查.结果 术后随访6个月-3年,1次手术成功率为92%.2次及3次手术成功各1例,荧光示踪检查均能准确定位漏口,术后脑膜炎及梗阻性脑积水各1例.结论 内镜经鼻脑脊液鼻漏修补术成功率高,创伤小,应作为首选治疗方法;漏口定位及处理、适宜的外科修补技术是手术成功的关键;术中荧光示踪能提高漏口定位的准确性.     

放射性核素检查在脑脊液鼻漏诊断中的应用

我院2001年1月～2003年5月对6例病人采用放射性核素检查脑脊液鼻漏,现总结报道如下:1对象与方法1.1临床资料:本组男4例,女2例;年龄15～60岁。5例为颅脑外伤引起,鼻漏持续1个月余;1例为蝶窦淋巴瘤术后所致,鼻漏持续2个月未愈。均无核素检查禁忌证。1.2方法:在L3,4或L4,5椎间隙行腰椎穿刺,有脑脊液流出后缓慢注入99mTc-DTPA1～3ml,拔出腰穿针后病人采取平卧位或头低脚高位。1 h后行核素扫描检查,观察脑脊液中核素的分布情况,确定漏口的部位。对于1 h不能确定漏口部位者,可进行2h,3h,4h甚至24 h动态观察。2结果2例脑脊液鼻漏漏口在额窦,之后…     

内镜下经鼻脑脊液漏修补术

目的 介绍鼻内镜下经鼻脑脊液漏修补的手术方法，并就相关问题进行讨论。方法 鼻内镜下经鼻手术修补脑脊液鼻漏35例，外伤性20例，自发性12例，医源性3例，术前根据临床表现、实验室检查、辅助以颅底CT扫描、脑池造影等获得诊断，采用自体阔筋膜片修补颅底缺损。结果 本组35例均在术后3-32个月进行随访，其中1次手术修补成功32例，2次手术修补成功1例，1次手术失败后拒绝再次手术2例，手术成功率94％，无颅内出血、颅内感染，无神经功能受损等并发症。结论 鼻内镜下经鼻脑脊液漏修补成功率高、手术创伤小，可以作为脑脊液鼻漏的首选手术方法。     

蝶窦内脑膨出并自发性脑脊液鼻漏1例及文献复习

目的探讨蝶窦内脑膨出并自发性脑脊液鼻漏的发病机制和手术治疗经验。方法收集我科收治的l例蝶窦内脑膨出并自发性脑脊液鼻漏患者资料,结合文献复习进行临床分析。结果患者因左侧鼻腔反复流出清亮液体就诊;头颅MRI示左侧蝶窦侧壁骨质缺损,蝶窦内含脑组织信号影及脑脊液信号影;入院后行左侧翼点入路硬脑膜修补术;术后患者症状消失。术后随访6个月,未见复发。结论对于蝶窦内脑膨出发病机制目前并不明确,与侧颅咽管形成、蝶窦过度气化、颅内压增高等多个因素有关;术前准确诊断瘘口位置非常重要,同时应选择个体化的手术方式,术后长期随访。     

Incidental spontaneous CSF fistula with pterygoid process meningoencephalocele

Spontaneous cerebrospinal fluid (CSF) fistula is a rare entity, most commonly occurs at the ethmoid roof, cribriform plate, or the sphenoid sinus; at the perisella, inferolateral or pterygoid recesses. Imaging plays a major role in diagnosis, thereby guiding the treatment of a spontaneous CSF fistula, evolving multiple modalities. We report a case of a patient with spontaneous Meningio-encephalocele presented as an expansile lytic lesion in the left pterygoid body, this patient was successfully treated surgically.

A spontaneous cerebrospinal fluid (CSF) fistula is a rare disorder constitutes of nasal discharge of CSF with no underlying relation to trauma, surgery, malformation, tumor or a previous radiation therapy. Spontaneous CSF fistulas have a common incidence in middle-aged women and in patients with raised intracranial pressure. The usual clinical presentation is otorrhea, rhinorrhea, headache, seizure, meningitis, or as an incidental finding. The most common locations in the skull base are at the ethmoid roof, cribriform plate, the sphenoid sinus; at the perisella, inferolateral or pterygoid recesses. Imaging plays a major role in diagnosis, thereby guiding the treatment of the spontaneous CSF fistula. Imaging involves a multidetector, thin-section computed tomography (CT) imaging; utilizing bone algorithm, CT cisternography, conventional Magnetic Resonance Imaging (MRI) and Magnetic Resonance (MR) cisternography.We report a case of a patient with spontaneous meningoencephalocele that presented initially as an expansile lytic lesion in the left pterygoid body, the skull base bony defect in the left middle cranial fossa consisted of cortical permeation and multiple pitting on its inner cortex. It was successfully managed by endoscopic skull base reduction of the left pterygoid body meningoencephalocele and fixation of the bone defect by application of a multilayer nasoseptal flap, dural and fat patches.     

Extracranial repair of cerebrospinal fluid rhinorrhea

There has been a recent renewal of interest in the extracranial repair of cerebrospinal fluid rhinorrhea because of the relatively high morbidity associated with the transcranial approach. The authors describe an extracranial approach that involves packing of the sphenoid and ethmoid sinuses on the side of the CSF leak. A case of successful treatment of CSF rhinorrhea by this method is presented. The extracranial approach may be advantageous for the repair of CSF rhinorrhea and the authors advocate an increase in its utilization by neurosurgeons and otolaryngologists working as a team.     

CSF rhinorrhea from a transclival meningocele: a case report.

The most common site of cerebrospinal fluid (CSF) leakage is through the floor of the anterior fossa, which communicates with the ethmoid or frontal sinuses or with the nasal fossa. The sphenoid sinus is rarely implicated as a source of spontaneous CSF fistula. Transclival meningocele is an extremely rare lesion. A 36-year-old woman with a 1-year history of intermittent CSF rhinorrhea was found to have a transclival meningocele. The diagnosis of transclival meningocele was made by magnetic resonance (MR), 3-dimension-computerized tomography (CT). At operation, by a transsphenoidal approach, the transclival meningocele was packed with fasia lata graft, fat tissue, and bio-glue. This is the third case of transsphenoidal transclival meningocele producing rhinorrhea in an adult. Transclival meningocele should be taken into consideration in patients with spontaneous CSF rhinorrhea.     

Non-traumatic cerebrospinal fluid rhinorrhea caused by ethmoid sinus osteoma

Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of ethmoid sinus osteoma, considering its benign and indolent nature. We present a 36-year-old female patient with symptomatic CSF rhinorrhea as a primary presentation of ethmoid sinus osteoma. We have highlighted the imaging features and emphasised the importance of imaging in the diagnosis of spontaneous CSF leak.     

发生脑脊液鼻漏的垂体腺瘤经蝶手术治疗

目的　介绍发生脑脊液鼻漏的垂体腺瘤的临床特征和经蝶手术治疗方法。方法　分析１９９１ 年至１９９７ 年北京协和医院经蝶手术治疗的５ 例发生脑脊液鼻漏的垂体腺瘤, 并结合文献加以讨论。结果　５ 例中４ 例为巨大型泌乳素腺瘤, １ 例为部分空泡蝶鞍合并垂体无功能腺瘤, ２ 例以脑脊液鼻漏为首发症状。术后随访半年至６ 年, ３ 例肿瘤全切除, ２ 例次全切除, 脑脊液鼻漏均消失。结论垂体腺瘤自发性脑脊液鼻漏可见于巨大型垂体腺瘤; 也可见于合并部分空泡蝶鞍的垂体腺瘤; 放疗、服溴隐亭治疗可促进垂体腺瘤脑脊液鼻漏的发生。经蝶入路是最适手术入路; 肿瘤切除后严密填塞蝶窦是补漏的主要措施; 术后去枕平卧和腰蛛网膜下腔引流有助于所修补漏口的愈合。     

MRI T2加权像在脑脊液鼻漏中的应用

目的 研究MRI T2加权像在脑脊液鼻漏漏口定位中的应用价值.方法 10例脑脊液鼻漏患者经MRI T2加权像检查,通过观察动态脑脊液经漏口流入鼻旁窦腔形成的长T2高信号漏迹进行术前漏口定位,其中通过改变体位致动态脑脊液鼻漏者6例;通过压迫双侧颈静脉以增加颅内压形成动态腩脊液鼻漏者4例.将MRI检查结果 与手术中探查所见进行比较.结果 10例患者术中探查的漏口位置与术前MRI定位完全相符.MRI T2加权像表现为漏口呈锥形长T2高信号疝入漏道,漏迹呈连续或不连续的线样长T2高信号及患侧鼻旁窦腔内积聚脑脊液样长T2高信号.其中漏入筛窦者7例;漏入蝶窦者2例;另1例在自由水抑制成像(fluid attenuated inversion recovery,FLAIR)及脂肪抑制FSET2W1上见左侧乳突气房及鼓室有不规则线样高信号,判断漏口位于乳突气房及鼓室盖,脑脊液经漏口至内耳通过耳咽鼓管漏出鼻腔.结论 MRI T2加权像成像技术对术前脑脊液漏的漏口定位具有定位准确、无侵袭性、无放射性以及解剖结构清楚等优点,可作为无创检查方法 之一.不同患者采取个体化MRI检查方法 (如改变体位或压迫双侧颈静脉等)是准确进行漏口定位的关键.     

Cerebrospinal fluid fistula as the presenting manifestation of pituitary adenoma: case report with a 4-year follow-up

We report the case of a young woman who presented with cerebrospinal fluid (CSF) rhinorrhea due to an undiagnosed and untreated pituitary adenoma. The tumor had extended well beyond sella turcica and caused bony erosion. The patient initially refused surgery and was treated with bromocriptine and a radiation therapy. CSF leakage did not improved and she was submitted to surgery by the transsphenoidal approach with removal of a tumor mass located in sphenoid sinus and sellar region. Origin of the leak was localized and repaired with fascia lata and a lumbar subarachnoid drain was left in place for 5 days. After 4 years she has normal serum PRL levels and no rhinorrhea. The management, complications and mechanisms involved in this rare condition are discussed.     

Transcranial approach for spontaneous CSF rhinorrhea due to Sternberg's canal intrasphenoidal meningoencephalocele: case report and review of the literature

One type of congenital intrasphenoidal meningoencephalocele is remnant of lateral craniopharyngeal (Sternberg's) canal. We present a case of a 23-year girl with 10-month history of right side CSF rhinorrhea. CT scan, MRI revealed congenital meningoencephalocele and CSF leak from middle fossa to right side of sphenoid sinus, and there were bony defects at the floor of the anterior aspect of the right middle fossa. Transcranial repair was performed with right side pterional craniotomy. Careful preoperative evaluation and localization of the sphenoid defect are essential for selection of the best possible surgical approach and skull base reconstruction for repair of sphenoid sinus CSF leaks and meningoencephaloceles. In this case, an endoscopic technique was not successful so, transcranial repair was performed with right side pterional craniotomy.