前颅底重建漏口修补治疗前颅底骨折合并脑脊液鼻漏7例

目的:总结颅底骨折合并脑脊液鼻漏行前颅底重建修复术的疗效。方法:颅脑外伤前颅底骨折合并脑脊液鼻漏7例,经术前颅底薄层CT三维重建及CT脑池造影冠状位成像(CTC)检查后行颅底重建修复脑脊液漏口。结果:经漏口修补前颅底重建术后均获得临床治愈,术后随访4~32个月,均未见脑脊液鼻漏。结论:前颅底重建漏口修补术可取得良好疗效,术前对于脑脊液鼻漏漏口准确定位是手术成功的关键。     

隐匿性脑脊液鼻漏的显像诊断及鼻内镜下手术修补

目的:探讨采用核素脑池显像结合CT或者MR定位漏口后经鼻内镜下修补治疗隐匿性脑脊液鼻漏的临床意义?方法:采用核素对18例隐匿性脑脊液鼻漏患者进行脑池显像,结合CT或者MR明确脑脊液鼻漏的漏口后,在鼻内镜下行手术修补?结果:18例患者鼻道核素均显示阳性,结合CT或者MR确诊后经鼻内镜下修补,全部成功修补,痊愈出院?结论:核素脑池显像可作为诊断隐匿性脑脊液鼻漏的一种灵敏?简便?准确的检查手段,结合CT或者MR可明确定位漏口,在鼻内镜下手术修补脑脊液鼻漏创伤小,封堵准确,成功率高?     

多排螺旋CT在脑脊液漏漏口定位的初步研究

目的:探讨多排螺旋CT三维容积漫游技术(VRT)对脑脊液漏漏口修补术前定位的诊断价值。方法:分析6例脑脊液鼻漏的薄层VRT重建表现,着重观察颅底骨折情况及漏口位置。结果:多排螺旋CT薄层VRT重建可直接显示出漏口的位置和立体形态。结论:多排螺旋CT薄层VRT重建对脑脊液漏漏口修补术前的诊断及手术定位具有重要价值。     

脑脊液鼻漏的CT检查技术(附6例分析)

目的寻找脑脊液鼻漏的CT检查技术。方法6例患者行CT常规轴扫,2例加扫冠状位和脑池造影,并由两名高年资神经放射学医师对图像进行分析。结果传统横断位扫描发现瘘孔有4例,2例加扫的冠状位和脑池造影均可发现瘘孔位置。结论冠状位扫描及脑池造影是明确脑脊液鼻漏瘘孔位置的有效方法。     

CT脑池造影诊断外伤性脑脊液鼻漏内口（附2例报告）

外伤性脑脊液漏在头部损伤的病人中发生率为2％～3％。脑脊液漏与颅骨骨折的部位有关,前颅窝底骨折的病人中有25％～50％发生脑脊液漏,大部分国内学者认为外伤性脑脊液漏的治疗应以非手术疗法为主,约50％～80％能自行闭合且效果可靠。但仍有部分病人虽经较长期的保守治疗仍不能自愈或出现迟发性鼻漏,这类病人又易并发颅内感染及低颅压综合征。不能自愈的鼻漏病人需手术治疗,手术治疗成功的关健在于找到痿口的内口及恰当处理痿口。我科对2例外伤性脑脊液鼻漏患者在手术前采用脑池造影CT扫描方法确定痿口的内口,手术修补瘿口效果良好,现介绍如下。     

CT 脑池造影诊断脑脊液鼻漏

脑脊液鼻漏是颅脑外伤常见的并发症之一,临床在行修补术之前,部位常不明确,通过脑池造影,螺旋 CT 扫描及图像后处理技术,可准确显示漏道的部位,给临床手术起到指导作用.本文总结6例报告如下.     

18例难治性外伤性脑脊液鼻漏的手术疗效分析

目的分析难治性外伤性脑脊液鼻漏的手术方法与疗效。方法对18例难治性外伤性脑脊液鼻漏采用扩大额下硬膜外入路手术方法修补治疗。用头颅X片、CT、冠状位薄层CT、MRI进行术前漏口定位。结果本组18例术后17例痊愈,仅1例复发,二次修补后痊愈,无严重并发症,无死亡。结论难治性外伤性脑脊液鼻漏需行手术治疗。术前漏口位置的判定是手术成功重要因素。     

脑脊液鼻漏的手术治疗

回顾分析20例脑脊液鼻漏病人手术疗效，并与术前定位比较。经随访17例鼻漏症状完全消失。经前额入路硬膜外手术修补是治疗脑脊液鼻漏的较好手段，薄层三维CT对于脑脊液鼻漏的诊断及漏口的定位提供较大帮助。     

脑脊液漏的MRI诊断与手术治疗

脑脊液漏好发于颅底骨折，是指蛛网膜和硬脑膜均有损伤和破损，脑脊液经破损处漏出到颅外。按病因可分为外伤性脑脊液漏和非外伤性脑脊液漏。按时间分为急性期脑脊液漏和延迟性脑脊液漏。急性期脑脊液漏多在1周左右可白行或经非手术治疗而痊愈，延迟性脑脊液漏则常迁延不愈，时停时漏，需手术行漏口修补。术前做好漏口的定位诊断是手术治疗的关键，临床根据病史，通过糖测定和红细胞计数分析，对脑脊液漏的定性诊断并不困难，以往临床主要采用头颅X线平片、CT、水溶性造影剂注入蛛网膜下腔行颅底薄层CT扫描以及放射性核素脑池造影等综合分析进行定位诊断。我们对1991-2005年经MRI进行定位诊断的25例脑脊液漏的手术治疗情况进行了回顾性分析，现报告如下。     

鞘内注射Gd-DTPA增强MR脊髓及脑池造影的临床应用价值

目和：评估鞘内注射Gd-DTPA增强MR脊髓和脑池造影。方法：对6例临床需要判断脑脊液流动性的患者进行鞘内注射Gd-DTPA增强MR脊髓和脑池造影检查。其中男性4例，女性2例；年龄20-60岁（平均38岁）。术前征得患者同意，经腰椎穿刺，蛛网膜腔内注入Gd-DTPA 0.5(n=4)-1.0(n=2)ml。采用西门子1.0T超导磁共振机，分别于脊髓造影前后进行脊柱及病变区横断及矢状T1W和T2W MR扫描并保持扫描参数不变，5例患者辅以患者MR平扫均不能显示脑脊液流动情况。鞘内注射Gd-DTPA后所有患者无任何不适，未发现殿堂神经系统体生。MR脊髓和脑池造影扫描显示，4例脊柱外伤病变，3例椎管完全闭塞，另1例部分闭塞，1例椎管内肿瘤术后囊腔与蛛网膜腔不交通；1例脑脊液鼻漏患者显示颅底的脑内外窦道。结论：鞘内注射小剂量Gd-DTPA安全可靠，脊髓和脑池造影增强MR扫描可显示常规MR扫描所不能显示的脑脊液动力学变化，对某些临床特定病例有重要意义。     

靶向硬膜外血贴治疗自发性颅内低压价值探讨

目的 报告脊髓脑脊液漏点精确定位后靶向硬膜外血贴治疗自发性颅内低压的经验,并对靶向硬膜外血贴的治疗机制和价值等进行讨论.方法 6例自发性颅内低压患者(男女各3例,年龄33～66岁),符合2004年国际头痛分类第2版诊断标准.CT脊髓造影6例均发现脊髓脑脊液漏点.根据CT脊髓造影发现的脑脊液漏点位置选择穿刺部位,透视下注射混合碘造影剂的自体静脉血.结果 6例患者经靶向硬膜外血贴治疗后获得临床痊愈.2例注射过程中出现局部神经根刺激症状,3例治疗后出现暂时性背痛和腰痛.术后观察3至9个月均无复发.结论 CT脊髓造影漏点精确定位后,靶向硬膜外血贴疗法是一种安全、有效的自发性颅内低压治疗手段.     

Intracranial subdural hematoma coexisting with improvement in spontaneous intracranial hypotension after an epidural blood patch

A 36-year-old male had spontaneous intracranial hypotension (SIH) presenting with refractory headache for 4 months. Multiple epidural blood patches (EBPs) yielded relief of symptoms, but the course was complicated, with asymptomatic intracranial subdural hematoma (SDH). Except for SDH, other radiological diagnostic signs of SIH were resolved and the patient’s headaches improved after EBP. Owing to a mass effect and persistent cerebrospinal fluid (CSF) leakage, surgical repair of the spinal leakage was performed, but no cranial procedures were carried out. Postoperatively, the SDH completely resolved, but there was still CSF leakage at the level where surgery was performed. The patient has remained free of headache or other events for 3 years. It was reduction rather than elimination of the spinal CSF leak that yielded remission of SIH. In summary, intracranial SDH can be a complication of inadequately treated SIH (i.e. persistent minor CSF leakage). Management of SDH should focus on correction of the underlying SIH rather than craniotomy for hematoma evacuation.     

颅内静脉系统血栓形成的早期诊断及治疗

目的探讨颅内静脉系统血栓形成的早期诊断及治疗方法。方法分析8例颅内静脉系统血栓形成的病因、症状、体征、头颅CT和MR检查、脑电图、脑脊液及血液流变学的特点。结果病因多为产褥期及感染,常表现为颅内高压征及局灶神经功能缺损,头颅CT和MR检查可确诊。结论对于临床有颅内高压和局灶神经功能缺损表现,尤其是产褥期或有感染者,应警惕颅内静脉系统血栓形成,需行头颅CT和MR检查确诊,并尽早抗凝治疗。     

颅内静脉系统血栓形成的早期诊断及治疗

目的 探讨颅内静脉系统血栓形成的早期诊断及治疗方法。方法 分析8例颅内静脉系统血栓形成的病因、症状、体征、头颅CT和MR捡查、脑电图、脑脊液及血液流变学的特点。结果 病因多为产褥期及感染，常表现为颅内高压征及局灶神经功能缺损，头颅CT和MR检查可确诊。结论 对于临床有颅内高压和局灶神经功能缺损表现，尤其是产褥期或有感染者，应警惕颅内静脉系统血栓形成，需行头颅CT和MR捡查确诊，并尽早抗凝治疗。     

Spontaneous intracranial hypotension in a patient with reversible pachymeningeal enhancement and brain descent

A 56-year-old woman presented with severe orthostatic headache in association with nausea and vomiting. Lumbar puncture for the patient revealed significantly low cerebrospinal fluid pressure (CSF) and the clinical diagnosis of intracranial hypotension syndrome was made. An initial gadolinium-enhanced brain magnetic resonance imaging (MRI) disclosed diffuse meningeal enhancement as well as brain sagging. No definite CSF leakage was found using radionuclide cisternography. Her headaches abated with proper usage of analgesics, strict bed rest, and intravenous hydration. Follow-up neuroimaging studies showed partially resolved meningeal enhancement 2 months after treatment and complete resolution 6 months after treatment. The temporal changes found on MRI suggest that the pachymeningeal enhancement is reversible in patients with spontaneous intracranial hypotension. Moreover, proliferation of meninges is likely to be responsible for this type of delayed resolution phenomenon.     

Delayed gadolinium enhancement in epidural space of the cervicothoracic spine in a patient with spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) due to a spinal cerebrospinal fluid leak is a rare but increasing cause of postural headache. Its extravasated epidural fluid collection tends to be non-enhanced or mildly enhanced on enhanced magnetic resonance (MR) imaging. The mild enhancement of the epidural fluid in SIH is usually attributed to fenestrated neovascularization provoked by an inflammatory component, such as blood, of the fluid collection. In this report, we present a case of SIH with a prominent delayed enhancement of the spinal epidural fluid collection on MR imaging. Subsequent vertebral angiography revealed that this delayed enhancement was related to contrast extravasation from a torn anterior meningeal branch of the right vertebral artery. Therefore, we suggest that contrast extravasation from a torn meningeal vessel may be a possible cause of the enhancement in the spinal epidural fluid of SIH.     

Total transferrin in cerebrospinal fluid is a novel biomarker for spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is caused by cerebrospinal fluid (CSF) leakage. Patients with SIH experience postural headaches, nausea, etc., due to CSF hypovolemia. Imaging studies and clinical examinations, such as radioisotope (RI) scintigraphy, are useful for diagnosing SIH. However, 20-30% of patients do not show typical morphology and clinical test results. We previously reported that CSF contains transferrin (Tf) isoforms: “brain-type” Tf derived from the choroid plexus and “serum-type” Tf derived from blood. We showed that both isoforms increased in the CSF of patients with SIH by Western blotting. In the present study, we demonstrate that conventional ELISA for quantifying total Tf is useful for diagnosing SIH more accurately than Western blotting. In addition, SIH with chronic subdural hematoma (CSDH) was also accurately diagnosed. Total Tf in the CSF can serve as a useful biomarker for diagnosing SIH with or without CSDH.     

非靶向硬膜外自体静脉血补片疗法治疗自发性低颅压头痛的临床观察

目的 通常的硬膜外自体静脉血补片疗法操作过程复杂,危险性很高,且不能完全开展,本研究采用非靶向硬膜外自体静脉血补片疗法治疗低颅压头痛,对该方法的治疗机制及应用价值等方面进行讨论报告,并对非靶向硬膜外血贴的治疗机制和应用价值等进行讨论。 方法 6例自发性颅内低压患者(男性2例,女性4例,年龄44～70岁),符合2004年国际头痛分类第2版诊断标准,采用非靶向硬膜外自体静脉血补片疗法治疗,选择在腰椎1～2水平椎间隙进行穿刺,行硬膜外置管,将新鲜自体静脉血迅速通过硬膜外置管缓慢注入硬膜外间隙,并对所有患者进行随诊。 结果 6例患者经非靶向硬膜外自体静脉血补片治疗后均痊愈。其中有4例患者治疗1次后痊愈,1例患者治疗2次后痊愈,1例患者在原注射治疗处的下一椎间隙处行硬膜外自体静脉血补片治疗,头痛症状仍未得到完全缓解,后又在相同位置进行2次硬膜外自体静脉血补片疗法治疗,术后观察3～9个月均无复发。 结论 非靶向硬膜外自体静脉血补片疗法是一种安全、有效的自发性颅内低压治疗手段,该方法不仅操作简单,而且危险性小且无需影像学漏点定位,亦有不错的治疗效果,因此可得到较好的开展。      

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Context  Spontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid (CSF) leaks and is known for causing orthostatic headaches. It is an important cause of new headaches in young and middle-aged individuals, but initial misdiagnosis is common. Objective  To summarize existing evidence regarding the epidemiology, pathophysiology, diagnosis, and management of spontaneous spinal CSF leaks and intracranial hypotension. Evidence Acquisition  MEDLINE (1966-2005) and OLDMEDLINE (1950-1965) were searched using the terms intracranial hypotension, CSF leak, low pressure headache, and CSF hypovolemia. Reference lists of these articles and ongoing investigations in this area were used as well. Evidence Synthesis  Spontaneous intracranial hypotension is caused by single or multiple spinal CSF leaks. The incidence has been estimated at 5 per 100 000 per year, with a peak around age 40 years. Women are affected more commonly than men. Mechanical factors combine with an underlying connective tissue disorder to cause the CSF leaks. An orthostatic headache is the prototypical manifestation but other headache patterns occur as well, and associated symptoms are common. Typical magnetic resonance imaging findings include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain (mnemonic: SEEPS). Myelography is the study of choice to identify the spinal CSF leak. Treatments include bed rest, epidural blood patching, percutaneous placement of fibrin sealant, and surgical CSF leak repair, but outcomes have been poorly studied and no management strategies have been studied in properly controlled randomized trials. Conclusions  Spontaneous intracranial hypotension is not rare but it remains underdiagnosed. The spectrum of clinical and radiographic manifestations is varied, with diagnosis largely based on clinical suspicion, cranial magnetic resonance imaging, and myelography. Numerous treatment options are available, but much remains to be learned about this disorder.      

自发性低颅内压综合征20例分析

目的探讨自发性低颅内压综合征(SIH)的临床表现、脑脊液、影像学的改变,诊治及预后,提高对本病的认识。方法对20例自发性低颅内压综合征患者的临床资料进行回顾性分析。结果 20例患者均有体位性头痛,卧位时缓解或消失,腰穿压力均<0.588 kPa(60 mm H2O),其中8例呈血性CSF,蛋白增高。6例白细胞升高。17例行头CT检查正常,1例硬膜下积液,1例硬膜下血肿,1例脑室变小。MRI检查7例显示弥漫性硬脑膜增厚强化。结论 SIH患者以体位性头痛为主要症状,脑脊液压力<60 mm H2O。治疗以补充生理盐水为主,疗效不佳时可给予激素及鞘内注入生理盐水。一般预后良好。认识自发性低颅内压综合征的临床表现、脑脊液、影像学的改变至关重要。注意与颅内高压、蛛网膜下腔出血,原发性、肥厚性硬脑膜炎等鉴别。