Membranous occlusion of the foramen of Monro following ventriculoperitoneal shunt insertion: a role for endoscopic foraminoplasty

We report two cases of lateral ventricle dilatation due to membranous occlusion of the foramen of Monro following ventriculoperitoneal shunt insertion. Both cases were treated successfully by endoscopic foraminoplasty of the obstructed foramen of Monro and III ventriculostomy. One child had meningomyelocele and hydrocephalus. She had CSF infection after repair of the back lesion. Isolated left lateral ventricle occurred after insertion of a right ventriculoperitoneal shunt for hydrocephalus when the girl was 2 months old. A right ventriculoperitoneal shunt was then inserted. Chronic shunt infection with abdominal pseudocyst was found 8 years later. The shunts were exteriorized. Membranous obstruction of the foramen of Monro was found endoscopically. Fenestration of the membranous obstruction along with a III ventriculostomy was performed. After the endoscopic procedure, the exteriorized ventriculoperitoneal shunt was removed 2 weeks later. The patient was still symptom free without shunting 14 months after the operation. The other child had hydrocephalus after a premature birth and hemorrhage. Repeated ventriculoperitoneal shunt infections contributed to membranous obstruction of bilateral foramen of Monro. After the shunt infection was treated this patient’s shunting procedure was simplified by endoscopic foraminoplasty of the left and right foramen of Monro along with a III ventriculostomy. He was symptom free with a new ventriculoperitoneal shunt 9 months after the operation. Received: 14 November 1999     

Predictive value of the cerebrospinal fluid tap-test

Twenty-seven patients with normal pressure hydrocephalus were operated upon by a ventriculo-peritoneal shunt. Selection for shunt surgery was based on typical symptoms (gait disturbancy, mental deterioration and urgency incontinence) and characteristic changes at cranial computed tomography and/or radionuclide cisternography. Prior to operation a cerebrospinal fluid tap-test (CSF-TT) was performed with measurements of psychometric functions and gait pattern before and after a lumbar puncture of 50 cc CSF. Nineteen patients improved and 5 were unchanged after shunt operation. Three patients could not be evaluated. Improvement in the psychometric functions and gait pattern after lumbar puncture correlated to improvement after the shunt operation (r = 0.64, p less than 0.01: r = 0.96, p less than 0.001, respectively). Improvement in 2 or more of the 4 tests used (3 psychometric and 1 gait test) at CSF-TT implied in all cases successful result of the shunt operation. It was concluded that CSF-TT could predict which NPH patient will improve by a shunt operation, and albeit to envisage the degree of improvement.     

脑桥梗死后皮质脊髓束的完整性：弥散张量纤维束成像验证

We report on a patient with subdural hematoma who was evaluated by diffusion tensor image(DTI) follow-up study before and after surgery. A 58-year-old male patient and ten age-matched control subjects were evaluated. The patient showed mild hemiparesis for 3 weeks prior to surgery. His hemiparesis was recovered to a nearly normal state at 5 weeks post-surgery when the follow up DTI was scanned. DTIs were acquired using a sensitivity-encoding head coil at 1.5 T. The corticospinal tract(CST) was evaluated using DTI-Studio software and the CST was ascertained by choosing the fibers passing through both the upper pons and the lower pons on the color map. Two DTI parameters(fractional anisotropy and apparent diffusion coefficient) were measured along the CST. Pre-surgery DTI showed that the CST of the affected hemisphere seemed to be injured or compressed according to the level. However, follow up DTI showed recovery of this CST to a normal state. It seems that DTI would be a useful tool for evaluation of the effect of subdural hematoma.     

优先颅骨修补后行脑积水分流术治疗创伤性脑积水合并颅骨缺损的疗效分析

目的探讨创伤性脑积水（PTH）合并颅骨缺损患者优先行颅骨修补而后行脑积水分流术的可行性,以及其对降低患者术后并发症、改善预后的临床意义。 方法选取济宁医学院附属医院邹城院区神经外科自2012年1月至2017年10月收治的32例PTH合并颅骨缺损患者为研究对象,均先以三维塑形钛网进行颅骨修补术,其中存在骨窗区明显脑膨出的患者,颅骨修补术中采取直接脑室穿刺释放脑脊液的方法促使膨出脑组织复位以利于钛网覆盖固定。颅骨修补术后1~3周根据脑积水临床症状变化将符合分流指征的患者择期再行脑脊液分流术。观察患者术后总体并发症发生情况及术后6个月GOS预后情况。 结果32例患者优先行颅骨修补术全部得以顺利实施,颅骨修补术后无明显相关并发症发生,其中28例再次接受脑积水分流术,4例因颅骨修补术后脑积水症状持续缓解未再接受分流术。术后脑积水症状较术前明显改善,有效率为94%;分期手术总并发症发生率为6.25%。术后6个月随访,本组患者中预后良好24例,中残4例,重残3例,死亡1例。 结论对于所有PTH合并颅骨缺损的患者,优先进行颅骨修补而后根据病情择期再行脑积水分流术的分期手术方案是切实可行的,且术后并发症发生率更低,对改善患者预后有重要临床意义。     

外伤性脑积水脑室-腹腔分流的临床观察

目的评价脑室-腹腔(V-P)分流对创伤性脑损伤后不同程度的脑积水的治疗效果。方法根据CT影像显示脑室大小,将创伤性脑损伤后脑积水患者50例分为轻度(19例),中度(17例),重度(14例)三组,行V-P分流手术治疗,比较手术前后脑室径与双顶径的比值(V/BP),室周水肿带直径及GOS评分。结果分流三个月后轻中度脑积水组三项指标均显著优于术前(P<0.05),重度脑积水组与术前相比,差异无显著性意义(P>0.05)。结论轻中度外伤性脑积水V-P分流效果较好,重度脑积水患者分流手术后恢复欠佳,临床上对外伤性脑积水患者应尽早发现、及时治疗。     

The CSF tap test in normal pressure hydrocephalus: evaluation time,reliability and the influence of pain

Background: The cerebrospinal fluid tap test (TT) is a diagnostic tool used to select patients with idiopathic normal pressure hydrocephalus (iNPH) for shunt surgery. The procedure and the evaluation of the TT vary between centres. We aimed to describe the evaluation time after the TT, to assess the variability between repeated measurements, the interrater agreement of the gait tests chosen and finally to investigate whether pain affects the gait performance post‐TT. Methods: Forty patients (21 men and 19 women) under evaluation for iNPH underwent a TT. Standardized gait analyses were performed before and 2, 4, 6, 8 and 24 h after the TT and repeated twice on every occasion. Independent of each other, two investigators evaluated the quality of gait. At each assessment time, the patients graded headache and back pain on a visual analogue scale. Results: Twenty‐seven patients (15 men and 12 women) responded to TT. Improvements in gait speed and number of steps were significant at every assessment time post‐TT. The variability between two measurements was low (Intra class correlation coefficient = 0.97), and the inter‐rater agreement was good with a κ = 0.74. Pain correlated negatively with improvement in gait speed (r = ?0.40, P < 0.05). Conclusions: We suggest that the TT can be evaluated at any time within the first 24 h and should be repeated if the patient does not initially improve. Gait analysis appears reliable between two evaluators. Further, it is indicated that post‐lumbar puncture pain negatively affects the gait and should be minimized.     

脑室-腹腔分流术治疗外伤性脑积水18例临床体会

目的 探讨重型颅脑损伤后脑积水的治疗。方法 对本人1998年1月～2004年8月收治的18例该类患者的临床表现、影像学改变及采用的治疗方法、效果进行回顾性分析。结果 入院时GCS评分3～8分，急性脑积水2例，先行脑室外引流术，直至脑脊液(CSF)澄清，拔除外引流管后又出现脑积水。慢性脑积水16例。18例均行脑室-腹腔分流术。术后症状好转者16例，无变化者1例，因颅内感染死亡1例。结论 颅脑损伤后蛛网膜下腔出血及脑室内积血是引起外伤性脑积水的主要原因，及时复查CT可明确诊断，采用脑室-腹腔分流术治疗有较好的疗效。     

Neuropsychological and psychological sequelae of shunt surgery in young adults with hydrocephalus

Three patients with hydrocephalus aged 16, 26, and 33 years demonstrated memory deficits before or after the insertion of a ventricular shunt but at no time demonstrated ataxia, incontinence, or dementia. Following shunt surgery, memory functions improved rapidly in the patient who had had a recent acute onset of hydrocephalus, but in the two patients with a long period of hydrocephalus before shunting, memory impairments did not recover significantly in one patient, and in the other, memory impairments had become more severe by 12 months postshunt. Other neuropsychological and psychological sequelae of adult hydrocephalus are discussed, and it is suggested that for patients with chronic hydrocephalus, an extended period of neurological and neuropsychological monitoring may be advantageous before a decision is made to perform shunt surgery.     

Prognosis of dementia in normal-pressure hydrocephalus after a shunt operation

Forty patients who had normal-pressure hydrocephalus were examined neuropsychologically before and 12 months after a ventriculoatrial shunt operation. Comparison of the preoperative and postoperative test results showed that cognitive functions improved in 16 patients, were unchanged in 19, and deteriorated in 5. Moreover, we found that the outcome of the operation depended on patient selection criteria. When three or more of the following preoperative signs were present (known cause, short history, low cerebrospinal fluid outflow, small sulci and/or periventricular hypodensity indicated by computed tomography), an improvement in cognitive function was seen in 80% of the patients after a shunt operation.     

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。     

颅脑损伤去骨瓣减压术后脑积水危险因素分析及分流时机

目的 探讨颅脑损伤病人去骨瓣减压术后发生脑积水的危险因素及分流术时机。方法 回顾性分析2017年1月~2019年12月去骨瓣减压术治疗的128例颅脑损伤的临床资料。多因素logistic回归分析检验脑积水危险因素。结果 128例中,术后发生脑积水28例,发生率为21.9%。多因素Logistic回归分析结果表明,蛛网膜下腔出血、脑室出血、骨窗面积≥7 cm2是颅脑损伤去骨瓣减压术后继发脑积水的独立危险因素（P<0.05）。28例脑积水中,22例行脑室-腹腔分流术,按照分流中位时间的3.5 d分为早期分流组和晚期分流组,各11例;早期分流组术后颅内压改善效果更好（P<0.05）,颅内压恢复时间明显缩短（P<0.05）;但是两组脑脊液指标和并发症发生率均无统计学差异（P>0.05）。结论 脑积水是颅脑损伤去骨瓣减压术后常见并发症,手术治疗前应充分评估脑积水发生的因素,一旦发生脑积水应查明原因并早期进行分流手术治疗     

The clinical effect of lumbar puncture in normal pressure hydrocephalus.

Owing to all the difficulties involved in selecting patients with normal pressure hydrocephalus for shunt-operation, a cerebrospinal fluid-tap-test (CSF-TT) is introduced. Psychometric and motor capacities of the patients are measured before and after lumbar puncture and removal of 40-50 ml CSF. Patients fulfilling criteria for normal pressure hydrocephalus were compared to patients with dementia and atrophy shown by computed tomography. Normal pressure hydrocephalus patients showed temporary improvement after lumbar puncture. The extent of the temporary improvement appeared to be well correlated with the improvement after shunt operation. Accordingly, the CSF-TT seems to be of value when selecting those patients who will probably benefit from a shunt operation.     

腰大池引流对继发性脑积水分流术疗效预判的作用

目的探讨脑室-腹腔分流术(V-P分流术)前行腰大池引流对继发性脑积水患者预后的提前判断。方法回顾性分析30例继发性脑积水行腰大池引流患者的临床资料,对患者腰大池引流前后的临床表现、格拉斯哥昏迷量表(glasgow coma scale,GCS)评分、影像学表现及预后进行分析。结果本组患者中脑外伤术后16例、脑出血术后10例、脑肿瘤术后2例、矢状窦血栓形成2例,均出现脑积水,均行腰大池引流。引流后减压窗凹陷者14例,患者引流前后GCS评分均无明显变化;18例引流时间超过1周者额角指数下降,脑室周围水肿减轻。结论腰大池引流可作为继发性脑积水V-P分流疗效的一种提前预判方法。     

腹腔镜辅助置管在脑室-腹腔分流术中的应用效果

目的探讨腹腔镜辅助放置分流管腹腔端在脑室-腹腔分流术中的应用效果。方法回顾性分析2018年5月至2019年11月北京大学第三医院神经外科收治的32例脑积水患者的临床资料。所有患者均采用脑室-腹腔分流术治疗,术中行腹腔镜辅助放置分流管腹腔端。临床随访结果以Salmon标准和Karnofsky功能状态评分(KPS)评估;同时行影像学随访,采用Evans指数评估脑积水的变化情况。结果32例患者在腹腔镜辅助下均顺利完成脑室-腹腔分流术,手术时间为(70.1±2.9)min(65~75 min),其中腹腔端操作时间为(16.1±1.5)min(14~20 min);术后住院时间为6~9 d(中位时间为7 d),其中卧床时间为2~3 d(中位时间为2 d)。无一例发生颅内感染、脑脊液漏、腹腔脏器损伤、分流管堵塞或死亡。1例出现呃逆症状,对症保守治疗后症状消失。术后随访(12.2±6.1)个月(3~22个月),按Salmon标准,3级2例(6.3%),2级18例(56.2%),1级12例(37.5%);32例患者的KPS由术前的(59.1±10.0)分(40~80分)增至(77.5±10.8)分(50~100分),差异有统计学意义(t=-13.826,P<0.001);Evans指数[中位数(四分位间距)]由术前的0.36(0.02)降至0.29(0.04),差异亦有统计学意义(Z=-4.961,P<0.001)。结论腹腔镜辅助脑室-腹腔分流术具有微创、精准的优点,有利于患者术后的快速康复,有助于减少分流管腹腔端的堵塞、腹部并发症和感染的发生。     

Long-term results of hydrocephalus with myelomeningocele

This paper reviews long-term follow-up studies of 78 hydrocephalic patients with myelomeningocele. Seventy-eight (95%) out of 82 patients with myelomeningocele had hydrocephalus. CT, MRI, CT cisternography, and monitoring of intracranial pressure (ICP) with infusion methods were performed to evaluate the indication of shunt insertion or shunt independency. These hydrocephalic patients consisted of the following two groups: (1) Early treated group. Sixty-four cases received initial cerebrospinal fluid (CSF) diversion operation within 2 years of life. Sixty-three patients had a ventriculoperitoneal (VP) or a ventriculoatrial (VA) shunt. All the patients of this group showed progressive signs and symptoms of increased ICP due to hydrocephalus. The mean age at the initial shunt placement was 10 weeks. The mean value of Evans' index before shunting was 47%, which corresponded to moderate ventriculomegaly. 48% of this group showed slit-like ventricles on postoperative CT scans, where 52% had normal or only mildly dilated ventricles subsequent to shunting. There were two instances (3%) of the so-called "slit ventricle syndrome" and one instance of "isolated fourth ventricle", who had undergone multiple shunt revisions. Shunt revisions were performed on fifty-two occasions in this group. The mean number of shunt revisions per child was 2.8. Sixty among 64 patients of this group were suitable for evaluating shunt dependency with long-term follow-up period. Forty-two out of 60 patients were considered to be shunt dependent, who underwent multiple shunt revisions after 6 months of age. These patients had signs and symptoms of increased ICP, neurological deterioration, and enlarged ventricles when their shunts were blocked. There were four cases of slowly progressive (shunt dependent) hydrocephalus, who did not show clinical signs and symptoms of shunts malfunction in spite of progressive ventriculomegaly and abnormal findings of CT cisternography and ICP monitoring. Only two patients (3%) proved to be shunt independent. Consistently their ventricles were mildly dilated. These results suggest a very low incidence of true arrest of hydrocephalus after shunt operation. (2) Late treated group. Fourteen cases were diagnosed or treated for hydrocephalus after 7 years of age. Six out of fourteen patients had remarkable hydrocephalus whose Evans' index exceeded 51%. The mean value of Evans' index was 48% in this group. Six patients had progressive signs and symptoms of hydrocephalus and were shunted. ICP monitoring and studies of CSF dynamics revealed abnormal findings in ten out of 14 cases in spite of preservation of good intelligence.(ABSTRACT TRUNCATED AT 400 WORDS)     

Der Stellenwert hydrostatischer Ventile in der Therapie des chronischen Hydrozephalus

Earlier design changes in hydrocephalus valves focusing on reducing overdrainage failed. Since the middle of the 1990s, hydrostatic valve constructions have been available which are claimed to solve this problem. The objective of this study was to evaluate the efficiency of these constructions. Clinical status and ventricular size were evaluated in 45 patients with chronic hydrocephalus before and 1, 6, and 26 weeks after operation. In 35 of these, a Miethke dual-switch valve was implanted (treatment group 1), and the others received a combination of a programmable Codman-Hakim valve and a Miethke shunt assistant as the hydrostatic element of the configuration (treatment group 2). A third group (n = 6) had already been shunted but suffered from overdrainage symptoms which could not be overcome by conservative measures. In these cases, the only operative treatment was the implantation of a Miethke shunt assistant adjunctively to the existing valve. In groups 1 and 2, there was a significant permanent improvement in the clinical state in nearly 80% of cases and a moderate permanent improvement in about 10%. Mild clinical and radiological signs of overdrainage occurred in three patients during the first postoperative week but resolved without further operative measures within the next 5 weeks. Typically, the ventricular width was not or only marginally reduced in these 45 patients. In the patients treated for symptoms of overdrainage (group 3), complaints resolved within the first week after implantation of the shunt assistant. The study indicates that gravitational shunts may be very effective in preventing overdrainage in chronic hydrocephalus, and therefore these constructions could represent the gold standard in the treatment of chronic hydrocephalus.     

Neuropsychological and psychological sequelae of shunt surgery in young adults with hydrocephalus

Abstract

Three patients with hydrocephalus aged 16, 26, and 33 years demonstrated memory deficits before or after the insertion of a ventricular shunt but at no time demonstrated ataxia, incontinence, or dementia. Following shunt surgery, memory functions improved rapidly in the patient who had had a recent acute onset of hydrocephalus, but in the two patients with a long period of hydrocephalus before shunting, memory impairments did not recover significantly in one patient, and in the other, memory impairments had become more severe by 12 months postshunt. Other neuropsychological and psychological sequelae of adult hydrocephalus are discussed, and it is suggested that for patients with chronic hydrocephalus, an extended period of neurological and neuropsychological monitoring may be advantageous before a decision is made to perform shunt surgery.     

硬膜下积液治疗经验总结（附27例临床分析）

目的总结不同类型硬膜下积液治疗经验。 方法对解放军总医院第六医学中心神经外科自2009年1月至2014年10月手术治疗并完整随访的27例硬膜下积液患者进行回顾性分析。根据术前影像学特征鉴别积液是否为血性,将患者分为血性硬膜下积液患者（9例）和非血性硬膜下积液患者（18例）。根据积液是否为血性选择个性化治疗方案,观察其疗法。 结果9例血性硬膜下积液患者接受钻孔外引流手术,8例积液消退,另外1例无效,之后接受硬膜下腹腔分流后治愈。非血性硬膜下积液患者中14例接受硬膜下腹腔分流,12例有效,2例术后出现脑积水,经脑室-腹腔分流术治愈;2例术前合并脑积水接受脑室-腹腔分流术,均有效;另外2例最初接受积液外引流,无效,之后行硬膜下腹腔分流后积液消退。 结论对于硬膜下积液患者,术前需仔细评估积液是否为血性,是否合并脑积水。血性积液采取钻孔外引流,非血性积液采取硬膜下腹腔分流,合并脑积水的积液采取脑室-腹腔分流手术方式,给予个体化治疗,可获得满意疗效。     

Motor performance in normal pressure hydrocephalus assessed with an optoelectronic measurement technique

The motor performance of 10 patients with normal pressure hydrocephalus (NPH) was clinically assessed with the aid of a computer assisted optoelectronic movement analysis system (Mac Reflex). We used the Posturo Locomotion Manual (PLM) method that gives a quantitative estimation of the postural, locomotor and manual performance in freely moving humans. Measurements were done before intervention, after CSF tap test and 3 months post installation of a CSF ventriculo peritoneal shunt. Comparison was made to data from 10 matched normal subjects and 10 patients with Parkinson's disease (PD). Shunt operation of the NPH patients and 1-dopa treatment of the Parkinson patients improved the motor performance to a comparable degree. However, while the NPH patients improved the speed in the PLM test after the operation, the PD patients also improved the co-ordination after 1-dopa treatment. This could indicate a different mechanism behind the improvement of motor performance in NPH and PD after intervention.     

无气腹单孔腹腔镜辅助侧脑室-腹腔分流术治疗交通性脑积水

目的探讨无气腹单孔腹腔镜技术用于侧脑室-腹腔分流术治疗交通性脑积水的可行性。方法回顾性分析6例开颅术后交通性脑积水病人的临床资料,采用无气腹单孔腹腔镜技术进行侧脑室-腹腔分流术,将分流管腹腔端置于右下腹。统计腹部手术操作时间,观察术后脑室缩小及临床症状改善情况。结果手术的腹部操作时间平均8．5min。术后2-4周CT复查显示：脑室缩小,间质水肿减轻。病人临床症状均改善。随访10—12个月,平均10．8个月,未出现分流管堵塞、感染等并发症。结论无气腹单孔腹腔镜辅助侧脑室一腹腔分流术能简化腹部操作,缩短手术时间,有利于减少术后感染、堵管等并发症。