经蝶窦入路手术切除垂体腺瘤的严重并发症分析

目的探讨经蝶切除垂体腺瘤术后主要严重并发症的发生率和原因，并提出防治措施。方法分析1000例经蝶手术切除垂体腺瘤病例的临床资料，并结合文献加以讨论。结果术后发生出血性并发症7例，永久性尿崩症9例，脑脊液鼻漏超过1个月而需行修补手术3例，脑膜炎8例，视力、视野恶化10例，第Ⅲ、Ⅴ、Ⅵ脑神经麻痹6例。本组死亡3例。结论垂体腺瘤经蝶手术与开颅手术相比，创伤小，恢复快，疗效好，并发症少，病死率低；但仍有一些并发症出现，且个别严重，必须引起重视。     

Cerebrospinal fluid shunt infections in infants

Infection remains a major cause of morbidity and mortality following CSF shunt procedures. In this study 191 shunt procedures carried out from January 1981 to December 1992 in a series of 81 infants (less than 6 months old) were retrospectively analyzed for possible risk factors. The overall surgical infection rate was 7.8%, with 15 infections occurring in 14 patients (17.2%). No significant difference in the rate of infections was found in relation to sex, birth weight, gestational age, and type of shunt procedure (primary insertion/revision). The occurrence of other infections during the period of shunt surgery did not influence the infection risk either. Intraventricular hemorrhage and central nervous system infections as causes of the hydrocephalus were found to correlate with septic risk. Young age (less than 6 months) seems to represent the main risk factor, and this is related both to the immunologic deficiency and to the particular features of residential bacterial flora in this age group.     

Clinical features, complications, and outcome in adults with pneumococcal meningitis: a prospective case series

BACKGROUND: Bacterial meningitis is a grave disease of high incidence, especially in less developed countries. Here, we describe its clinical presentation, spectrum of complications, prognostic factors, and outcome in adults with pneumococcal meningitis. METHODS: From October, 1998, to April, 2002, we assessed 352 episodes of community-acquired pneumococcal meningitis, confirmed by culture of cerebrospinal fluid (CSF), which occurred in patients older than 16 years. Predictors for an unfavourable outcome (Glasgow outcome scale score 1-4) were identified by logistic regression with multiple imputation techniques. FINDINGS: 245 (70%) episodes of pneumococcal meningitis were associated with an underlying disorder. Cranial CT was done for 85% of episodes and revealed underlying disorders in 17% (50/299) and meningitis-associated intracranial complications in 39% (117/299). Independent predictors for an unfavourable outcome were a low score on the Glasgow coma scale, cranial nerve palsies, a raised erythrocyte sedimentation rate, a CSF leucocyte count less than 1000 cells per mm(3), and a high CSF protein concentration on admission. Overall in-hospital mortality was 30%. Prevalence of neurological and systemic complications did not differ between patients aged younger than 60 years and those aged 60 years and older; however, systemic complications were the cause of death in 59% (32/54) of fatal episodes in patients aged 60 years and older, whereas neurological complications were the cause of death in 65% (20/31) of fatal episodes in younger patients. INTERPRETATION: Pneumococcal meningitis is associated with high mortality and morbidity rates in adults. Whereas neurological complications are the leading cause of death in younger patients, elderly patients die predominantly from systemic complications.     

In vivo quantitative ultrasonic evaluation of neonatal brain with a real time integrated backscatter imaging system

We applied the integrated backscatter (IBS) imaging system to the evaluation of the normal neonatal brain of different birth-weights: extremely low-birth-weight (N=13), very-low-birth-weight (N=14), low-birth weight (N=14), and normal birth weight (N=19). The IBS values in six regions of interest, the deep white matter, subcortical white matter, choroid plexus, thalamus, lateral ventricle, and occipital bone, were compared among groups of different birth weights, gestational age, and postnatal age: at the date of birth and 28 approximately 30 days after birth. The IBS values were higher in the order of bone>choroid plexus>deep white matter>subcortical white matter>thalamus>lateral ventricle and were significantly different except for the lateral ventricle in all the groups at days 0 and 28 approximately 30. The IBS values increased with the decrease of birth weight and gestational age. There was a decrease of IBS values at day 28 compared to that of day 0 in the extremely low birth weight and very low birth weight groups; however, they remained the same in infants with low birth weights and in the normal birth weight group. Further studies to evaluate the significance of this technique for the objective diagnosis of brain insults in neonates are necessary.     

Shunts vs endoscopic third ventriculostomy in infants: are there different types and/or rates of complications?

Introduction The decision-making process when we compare endoscopic third ventriculostomy (ETV) with shunts as surgical options for the treatment of hydrocephalus in infants is conditioned by the incidence of specific and shared complications of the two surgical procedures. Review Our literature review shows that the advantages of ETV in terms of complications are almost all related to two factors: (a) the avoidance of a foreign body implantation and (b) the establishment of a ‘physiological’ cerebrospinal fluid (CSF) circulation. Both these kinds of achievements are particularly important in infants because of the relative high rate of some intraoperative (i.e. abdominal) and late (secondary craniosynostosis, slit-ventricle syndrome) shunt complications in this specific subset of patients. On the other side, the main factor which is claimed against ETV is the relatively high risk of immediate mortality and neurological complications. Clinical manifestations of neurological structure damage seem to be more frequent in infants, probably due to the more relevant effect of parenchymal and vascular damage in this age group; however, both the immediate mortality and neurological damage risk of ETV procedures should be weighted against the long-term mortality and the late neurological damage which is not infrequently described as a consequence of shunt malfunction and proximal shunt revision procedures. Infections are possible in both ETV and extrathecal CSF procedures, especially in infants. However, the incidence of infective complications is significantly lower in case of ETV (1–5% vs 1–20%). Moreover, different from shunting procedures, infections in children with third ventriculostomy have a more benign course, being generally controlled by antibiotic treatment alone.     

Brain growth in Down syndrome subjects 15 to 22 weeks of gestational age and birth to 60 months

We have found similarities of skull shape, brain growth and brain maturation in 17 DS and 10 non-DS (control) fetuses, ages 15-22 weeks of gestational age (Group A), and differences in 101 DS and 80 non-DS cases, from birth to 60 months (Group B). Postnatally, the gross neuropathological differences between DS and control brains are more distinct after 3-5 months of age. The anterior posterior diameter fronto-occipital length of the brain hemispheres is shortened and that is secondary to reduction of frontal lobe growth. Also flattening of occipital poles, narrowing of the superior temporal gyruses and generalized retardation of brain growth were common findings. Standard morphometric methods indicate changes from birth [Wisniewski et al. 1984, 1986, 1990]. The cerebral cortex of the DS cases had a 20-50% reduction of neurons since birth, mainly in the granular layers [Wisniewski et al. 1984, 1986, 1990]. Changes in brain weight with age were greater in the non-DS than in the DS cases, and greater in males than in females. CHD and GI malformations were associated with less brain weight in both DS and non-DS cases. We suggest that the prenatal retardation of neurogenesis begins after 22 weeks' gestational age. The postnatal retardation of brain growth is secondary to pre- and postnatal abnormalities in synaptogenesis.     

Neonatal bacterial meningitis: etiological agents in 109 cases during a 10 year period]

The etiology of purulent meningitis was investigated in 109 newborn infants admitted in a neonatal intensive care unit throughout a ten year period. Bacterial pathogens were isolated from the CSF in 57 (52.2%) neonates. There was a predominance of Gram-negative bacilli isolated in 38 (34.9%) neonates. Gram-positive cocci were isolated from CSF in only 12 (11.0%) neonates. Microorganisms associated with nosocomial septicemia and meningitis in neonates--Klebsiella sp, Salmonella sp. Enterobacter sp, Pseudomonas sp, Flavobacterium meningosepticum and Serratia marcescens--were responsible for presumptive etiology in 38 (49.3%) among 77 patients with positive cultures in "closed sites". They were isolated from 22 (57.0%) neonates with prior hospitalization but only from 12 (34.3%) neonates coming directly from their households (chi 2 = 4.08; p < 0.05). The mortality rate was significantly higher in patients with positive CSF cultures (47.4%) in comparison to patients with negative cultures (18.4%) (X2 = 5.01; p < 0.05). It is possible to conclude that Gram-negative bacilli, many of them of hospital origin, are the major pathogens in this study. An improvement on neonatal health care and a scrupulous control of neonatal nosocomial infections are recommended.     

Birth weight of infants after maternal exposure to typical and atypical antipsychotics: prospective comparison study

BACKGROUND: The effects of in utero exposure to atypical antipsychotics on infant birth weight are unknown. AIMS: To determine whether atypical and typical antipsychotics differ in their effects on birth weight after maternal exposure during pregnancy. METHOD: Prospective data on gestational age and birth weight collected by the National Teratology Information Service for infants exposed to typical (n=45) and atypical (n=25) antipsychotics was compared with data for a reference group of infants (n=38). RESULTS: Infants exposed to atypical antipsychotics had a significantly higher incidence of large for gestational age (LGA) than both comparison groups and a mean birth weight significantly heavier than those exposed to typical antipsychotics. In contrast those exposed to typical antipsychotics had a significantly lower mean birth weight and a higher incidence of small for gestational age infants than the reference group. CONCLUSIONS: In utero exposure to atypical antipsychotic drugs may increase infant birth weight and risk of LGA.     

Bacterial meningitis associated with lumbar drains: a retrospective cohort study

OBJECTIVES: The infective potential of lumbar drainage is an important topic deserving particular study. The aetiology, incidence, and clinical findings associated with bacterial meningitis are described in patients having continuous lumbar CSF drainage to treat communicating hydrocephalus after subarachnoid haemorrhage or CSF leaks after traumatic dural rents. METHODS: Retrospective review of the records of patients with a positive CSF bacterial culture who underwent lumbar drain placement over a 39 month period. RESULTS: Thirteen cases of bacterial meningitis occurred subsequent to the use of 312 lumbar drain kits (4.2%). All meningitic patients had CSF pleocytosis, but not all had peripheral leukocytosis. Fever, peripheral leukocytosis, and CSF pleocytosis did not help to differentiate the presence of bacterial meningitis from other infections. Eight patients had prior CSF drainage procedures, including ventriculostomy (n=5) or lumbar drain (n=5) placements; two patients received both procedures. Six of 13 patients developed their CSF infection within 24 hours of lumbar drain insertion. Six of 13 patients developed meningitis while receiving antibiotics for other reasons. CONCLUSIONS: External lumbar drainage seems to carry a low risk of infectious meningitis and offers a safe alternative to ventriculostomy or serial lumbar punctures. Antibiotics do not seem to protect completely against developing the infection. The infection happens most often with skin organisms. The meningitis often appears within 24 hours after lumbar drain placement. Daily CSF samples should include bacterial cultures but cell counts may not offer any additional useful information in diagnosing the complication. Lumbar drain insertion and management need not be confined to the intensive care unit.     

Transcranial Doppler sonographic studies of cerebral blood flow velocity in neonates

Using the transcranial Doppler technique to investigate the postnatal and developmental changes of cerebral blood flow in newborn infants, we found that the systolic and mean blood flow velocities increased after birth. A rapid increase in blood flow velocities was demonstrated during the first several days. Pulsatility index, which was initially high, gradually fell after birth and remained stable thereafter. The blood flow velocities of small-for-date infants were determined by their gestational ages. The systolic and mean blood flow velocities were influenced more by postnatal age than by gestational age, birth weight, or body weight. The increase in conceptional age was associated with a decrease in the pulsatility index and an increase in the systolic and mean flow velocities. The transcranial Doppler technique is a useful method and will provide more accurate information about the cerebral hemodynamics in neonates than the previously employed continuous wave Doppler technique.     

A neuropathological analysis of neonatal deaths over a 20-year period]

This study is an overview of 2,515 consecutive autopsies on newborn infants who died during the first 28 days of life at the Hospital for Sick Children, Toronto, during the period 1970-1989. The infants were grouped into 2 categories according to their gestational age and then subdivided into the groups of early (0-6 days) and late (7-28 days) neonatal deaths. In this overview trends in the occurrence of neuropathological observation were documented. In each 5-year time period and each gestational group the following diagnoses were recorded; hypoxic-ischemic neuronal changes, periventricular leukomalacia, infarction, kernicterus, meningitis, and hemorrhage (subependymal, parenchymal, choroidal). In these 20 years, the mortality in preterm infants has decreased due to a fall in the incidence of subependymal/intraventricular hemorrhage, kernicterus and meningitis. In contrast, the rate of mortality in term infants has increased due to a higher frequency of hypoxic-ischemic neuronal necrosis and choroid plexus hemorrhage.     

Diagnostic capability of CSF ferritin in children with meningitis

The current study was performed to determine the normal cerebrospinal fluid (CSF) ferritin level according to age and cut-off value for early diagnosis of bacterial menignitis. The subjects (N = 203) consisted of children who received the CSF examination at Department of Pediatrics in Chonnam National University Hospital between May 1996 and July 2001. The subjects were classified into four groups; non-meningitis, viral meningitis, bacterial meningitis, and bacterial meningitis suspected group. CSF ferritin of the meningitis group was significantly higher than that of the non-meningitis or viral meningitis groups. CSF ferritin had positive correlation with white blood cell (WBC) count and protein in CSF but negative correlation with CSF glucose (P < 0.01). CSF ferritin decreased progressively up to 1 year but such a tendency was not evident in patients over 1 year in age in the non-meningitis group. For early diagnosis of bacterial meningitis, 15.6 ng/mL was considered as the appropriate cut-off value of CSF ferritin (a sensitivity of 96.2% and a specificity of 96.6%).     

Evaluation of the use of BioGlue((R)) in neurosurgical procedures.

OBJECTIVE: Post-operative cerebrospinal fluid (CSF) fistula following neurosurgery is associated with increased morbidity and mortality. This prospective study evaluates the efficacy of a new bioadhesive - BioGlue, as a dural sealant in preventing CSF fistula. The complications associated with its use are investigated and the literature regarding dural closure reviewed. Methods: BioGlue was applied to the dura mater as a sealant in 210 patients undergoing 216 neurosurgical procedures over a period of 22 months at the Royal Melbourne Hospital. It was used where watertight closure of the dura mater could not be ensured by primary suture alone and for reconstruction of the sellar floor following transsphenoidal adenohypophysectomy. It was used in 114 supratentorial (52.7%), 53 infratentorial (24.5%) craniotomies, 41 (18.9%) transsphenoidal adenohypophysectomies and 8 spinal (3.7%) procedures. The incidence of CSF fistula as a complication of surgery with intradural exposure was analysed. RESULTS: The incidence of CSF fistula post-operatively was significantly low. Two patients (0.93%), both having undergone posterior fossa craniotomy - for evacuation of a cerebellar haematoma and redo excision of a metastasis respectively and both complicated by hydrocephalus, developed CSF fistula. There were no complications associated with the use of BioGlue. Conclusion: BioGlue reduced the incidence of complications associated with neurosurgery. It is an effective adjunct in dural closure to prevent CSF fistula with enhanced bonding properties and is simple to use. In this study there were no complications associated with its use.     

Complications following endoscopic intracranial procedures in children

Background The significant technological improvement of endoscopic instrumentation has allowed, in the last 10 years, a widespread diffusion of neuroendoscopic procedures. Nevertheless, severe, sometimes life-threatening, complications may occur during neuroendoscopic surgery, and the incidence and age specificity of complications in children have been underdescribed so far. Materials and methods Complications recorded in a prospectively collected database of pediatric patients undergoing neuroendoscopic procedures were analysed; the medical histories of the patients and the surgical procedures were reviewed. Results Complications occurred in 32 out of 231 (13.8%) procedures performed for the management of obstructive hydrocephalus (137), multiloculated hydrocephalus (53), arachnoid cysts (29) and intraventricular tumors (12). Subdural hygroma occurred in 11 cases, seven requiring subdural shunting. In one of these cases, infection of the subdural space occurred and required a craniotomy. Cerebrospinal fluid (CSF) infection occurred in 11 cases. In one case, a frontal abscess developed and was managed with craniotomy. CSF leak occurred in nine cases, intraventricular haemorrhages in two, technical failures in seven, subcutaneous CSF collection (managed with lumbo-peritoneal shunt) in one, thalamic contusion and post-operative transient akinetic mutism in one. This patient suddenly died 6 months later, probably as a consequence of closure of the stoma. Two patients developed secondary compartmentalisation of the ventricles after complicated endoscopic third ventriculostomy. In nine cases, these complications were associated. Overall, no patient died after the procedure (operative mortality 0), one patient died 6 months after the procedure for unexplained events (sudden death rate 0.4%), and three patients presented permanent disability as a consequence of surgical complication (permanent morbidity 1.3%). Conclusions Complication rate of neuro-endoscopic procedures is not negligible even in experienced hands. The majority are minor complications which do not affect the final outcome, but sporadically major events may occur, leading to significant problems in surgical management and, occasionally, to permanent disabilities. Careful selection of patients on pre-operative imaging studies and intensive training of surgeons are mandatory to improve results. Presented at the Third World Conference of the International Study Group on Neuroendoscopy (ISGNE), Marburg, Germany, 15–18 June 2005.     

Thyrotropin-releasing hormone metabolism is attenuated in the cerebrospinal fluid of the human neonate

The present study was designed to investigate the ontogeny of thyrotropin-releasing hormone (TRH) metabolism in human cerebrospinal fluid (CFS). The activity of pyroglutamate aminopeptidase (EC 3.4.11.8), the major enzyme catalyzing TRH metabolism in human CSF, was measured in CSF of 11 premature infants (gestational age, 29-39 weeks; birth weight, 1774 +/- 274 g), 8 newborn infants (term delivery; birth weight, 3648 +/- 240 g), and 11 adults (mean age, 29.6 +/- 1.5 years). Pyroglutamate aminopeptidase activity in CSF of premature and newborn infants was significantly lower (p less than 0.05) than that of adult CSF. These observed differences in the enzymatic activities were not due to changes in the affinity of the enzyme for its substrate TRH or the presence of enzyme inhibitor(s)/stimulator(s).     

Development of nystagmus in response to vestibular stimulation in infants.

Nystagmus in response to perotatory stimulation by torsion swing or ice-cold caloric (ICC) irrigation of the ear canals was studied in 276 infants from birth to 12 months of age. The percentage of positive responses to perotatory stimulation correlated with gestational age and weight at birth during the first 3 months of life and became comparable among groups by 6 months of age. The quality of perotatory nystagmus did not differ among groups. A direct correlation between the caloric-induced intensity and duration of nystagmus with gestational age and weight at birth was noted during the first 3 months of life. Premature infants showed the weakest responses, and term-delivered, large for gestational age children the strongest responses. ICC-induced nystagmus reached comparable levels for all groups by 6 months except for premature infants, in whom comparable responses were attainedby 9 months of age. Vestibular responses mature over time, with patterns that correlate with gestational age and weight at birth.     

Early Emergence of Behavior and Social-Emotional Problems in Very Preterm Infants

ObjectiveChildren born very preterm are reported to have an increased frequency of social, emotional, and behavioral problems at school age compared with their peers born at term. The primary aim of this study was to compare social-emotional difficulties and competencies of very preterm and full-term children at 2 years' corrected age. In addition, the relation between perinatal variables and early behavior problems was also examined to help identify those very preterm children most at risk.MethodAt 2 years' corrected age, the parents of 188 very preterm (gestational age <30 weeks or birth weight <1,250 g) and 70 full-term (gestational age ≥37 weeks) children completed the Infant Toddler Social and Emotional Assessment to determine externalizing, internalizing, and dysregulation problems and social-emotional competencies. For the very preterm sample, extensive perinatal data were collected including sex, birth weight, gestational age, chronic lung disease, and postnatal steroids, as well as neonatal cerebral white matter abnormalities detected by magnetic resonance imaging.ResultsThe very preterm children at 2 years demonstrated significantly higher internalizing and dysregulation scores and lower competence scores than peers born at term. There was no significant difference in externalizing scores between groups. Female sex, lower birth weight z score, white matter abnormalities, and postnatal corticosteroids were significantly associated with lower competence scores in the very preterm group.ConclusionsVery preterm children exhibit higher rates of behavior problems early in development, in particular internalizing and dysregulation problems and poorer competence.     

Thrombophilia does not increase risk for neonatal complications in preterm infants

The association between thrombophilia and neonatal complications was evaluated in a single-center prospective study. Prevalence of genetic prothrombotic markers (FVL, MTHFR, FIIG20210A) and levels of plasma homocysteine were assayed in 166 premature (mean gestational age: 30.9+/-2.3 weeks) and low birth weight (mean weight: 1327+/-319 grams) infants. The incidence of any neonatal complications was compared in infants with and without thrombophilia. A total of 38 infants were defined as "thrombophilic" due to heterozygous FVL (n=4) and/or FIIG20210A (n=8, including one case of combination with FVL) or homozygous 677T MTHFR (n=22) or homocysteine plasma levels above 15 micro mole/liter. Neonatal complications included: small for gestational age (28.8%), respiratory distress syndrome (51.8%), broncho-pulmonary dysplasia (10.2%), patent ductus arteriosus (12.7%), intraventricular hemorrhage (17%), periventricular leucomalacia (8.4%), retinopathy of prematurity (15.1%) and necrotizing enterocolitis in 1.2% of infants. No thrombosis was documented. The prevalence of perinatal complications and the severity of diseases were similar among infants with or without thrombophilia (p = 0.564). Our data suggest that preterm infants with thrombophilia are not at increased risk for developing neonatal complications.     

经单侧鼻腔蝶窦入路垂体手术并发症的防范与处理

目的 探讨经单侧鼻腔蝶窦入路垂体手术并发症的防范与处理。方法 回顾性分析1994年4月-2002年12月1152倒经单侧鼻腔蝶窦入路垂体腺瘤手术并发症。结果 手术病死率0.2%，脑脊液鼻漏的发生率2.7%，其中1.8%自行停止，0.8%行腰穿置管引流，0.2%行2次手术修补。尿崩的发生率为4.7%,4.1%为一次性，0.6%为持久性。其他并发症如眼球运动神经损伤、脑膜炎、鞍内血肿、鼻出血、脑损伤等的发生率为0.1%-0.2%。结论：熟知局部的相关解剖，不断提高手术技巧，将有助于进一步降低经蝶窦垂体手术并发症的发生。     

Incidence of varicella zoster virus infections of the central nervous system in the elderly: a large tertiary hospital-based series (2007–2014)

The aim of the study was to describe the clinical and epidemiological characteristics of the central nervous system (CNS) infection by varicella zoster virus (VZV) in patients older than 65 years in a tertiary community hospital. We retrospectively analysed the results of cerebrospinal fluid (CSF) testing in patients older than 65 years between 2007 and 2014 with clinically suspected VZV infection with CNS involvement. Patients whose CSF samples were positive for VZV DNA were included, as were those with negative results who simultaneously presented herpes zoster and CSF or magnetic resonance imaging findings suggestive of CNS infection, and in whom other possible aetiologies had been ruled out. The study included 280 patients. The disease was considered to be caused by a VZV infection in 32 patients (11.4%), of which 23 cases were virologically confirmed (detection of VZV DNA in CSF). The most frequent diagnosis of the patients with VZV CNS infection was encephalitis (83.3%), followed by meningitis (13.3%) and cerebellitis (3.3%). The mean annual incidence of VZV CNS infection was 3.0 cases per 100,000 inhabitants. VZV was the most common cause of encephalitis and viral meningitis, ahead of herpes simplex virus (n = 9). At the time of discharge, 12 (40%) patients showed neurological sequelae. Five patients (20%) died during hospitalization, all with encephalitis. Patients with a fatal outcome had significantly higher median age and longer delay before initiating acyclovir. In conclusion, VZV was the first cause of encephalitis in our elderly population. Despite acyclovir treatment, there was a high rate of case fatality and sequelae at discharge.