内镜开窗治疗有症状的透明隔囊肿

目的 总结内镜开窗治疗有症状的透明隔囊肿的手术技巧与效果.方法 回顾性分析36例采用内镜开窗治疗有症状的透明隔囊肿病人的临床资料,其中采用纵裂-胼胝体入路1例,术前CT定位、枕外侧钻孔经侧脑室三角区入路8例,立体定向引导、额外侧钻孔经侧脑室额角入路27例.结果 所有病人均完成内镜下囊肿开窗操作,透明隔囊肿张力消失,本组无复发和死亡病例.32例随访3个月～7年,病人术前症状明显缓解或消失28例,症状无缓解4例.术后发生并发症4例,其中颅内感染2例,永久性轻偏瘫2例.结论 对有症状的透明隔囊肿,内镜下囊肿单侧壁开窗是一种较为合理的处理方式.立体定向或导航引导经侧脑室额角入路手术更可靠、安全.     

神经外科导航辅助神经内镜透明隔囊肿造瘘手术前后护理

目的总结神经外科导航辅助硬质内镜进行透明隔囊肿造瘘术的围手术期护理特点,提高专科护理质量。方法回顾性分析1998年4月至2006年4月,在我科进行神经外科导航下,应用Storz硬质内镜进行透明隔囊壁造瘘术13例,针对透明隔囊肿的形成,症状体征的产生原理,手术方法,及其手术特点,给予有针对性的围手术期重点护理。结果13例手术病人取得满意疗效,术后未出现护理缺陷,无心理障碍发生,无切口感染,无护理并发症。结论神经外科导航下,应用内镜行透明隔囊肿造瘘术前术后护理,可以帮助病人树立战胜疾病信心,自如应对复杂手术程序,减少术后并发症的发生。     

Cavum septum pellucidum and obstructive hydrocephalus.

Five patients presented with symptoms related directly to pressure effects from their cavum septum pellucidum with persistent or intermittent obstructive hydrocephalus. The most characteristic presenting symptoms were intermittent postural headache and postural loss of consciousness. If cysts of the cavum septum pellucidum are symptomatic and stereotactic cyst puncture or fenestration are ineffective, ventriculoperitoneal shunting should be carried out before resorting to more radical excision of the cyst.     

神经内镜下手术治疗透明隔囊肿

目的 探讨应用神经内镜手术治疗症状性透明隔囊肿的方法及价值。方法 症状性透明隔囊肿19例，应用神经内镜技术行囊肿脑室造瘘术，对伴有脑积水的病人行室间孔再通术。结果 16例头痛、晕厥等症状消失，3例有癫痫发作者术后未再发作；复查CT或MRI显示囊肿均缩小，脑积水的病人侧脑室有不同程度回缩。结论 应用神经内镜手术治疗透明隔囊肿具有操作简单、疗效可靠、并发症少等优点。     

透明隔囊肿的神经内窥镜治疗

目的对透明隔囊肿一种新的治疗方法进行探讨。方法采用神经内窥镜经纵裂入路行囊肿-侧脑室造瘘术治疗有症状的透明隔囊肿16例,年龄2～41岁,平均22．9岁,以头痛和癫痫为主要临床表现。结果16例术后均改善,其中症状完全消失12例,减轻4例;无并发症。结论神经内窥镜下囊肿-侧脑室造瘘术是治疗透明隔囊肿安全、有效的微创手术,可作为首选治疗方法。     

Symptomatic cyst of the septum pellucidum

The presentation and management of a patient with symptomatic hydrocephalus from a cyst of the septum pellucidum is described and the underlying pathophysiology in relation to treatment is considered. The cyst appeared to cause intermittent obstruction of the foramina of Munro according to the degree of ventricular dilatation. Drainage and collapse of the cyst by fenestration reestablished continuous drainage of the ventricles with immediate symptomatic relief.     

Endoscopic ventriculo-cystomy for non-communicating hydrocephalus secondary to quadrigeminal cistern arachnoid cyst

INTRODUCTION: Intracranial arachnoid cysts are developmental, anomalous collections of cerebrospinal fluid (CSF), and occasionally cause symptoms when large enough to obliterate the CSF outflow pathway and give rise to non-communicating hydrocephalus. The treatment of choice for symptomatic arachnoid cysts has been surgical excision or fenestration of the cyst, but less invasive endoscopic fenestration has been attempted with favorable preliminary results. CASE REPORT: We report a case of non-communicating hydrocephalus caused by a quadrigeminal cistern arachnoid cyst in a 35-year-old woman who presented with worsening headaches. She was successfully treated by endoscopic third ventriculostomy and fenestration of the cyst (ventriculo-cistomy). DISCUSSION: Endoscopic fenestration of symptomatic arachnoid cysts can be as effective as open surgery in terms of short-term efficacy, and it is certainly less invasive than open surgery. However, its long-term outcome remains unknown, and these rare cases require careful clinical and radiological follow-up.     

导航结合内镜治疗16例症状性透明隔囊肿

目的 探讨症状性透明隔囊肿外科治疗的手术指征和疗效.方法 对16例神经内镜单侧造瘘治疗症状性透明隔囊肿患者随访分析.结果 以颅高压症为表现者13例(4例伴癫痫)中,10例症状完全消失,3例偶有头晕;7例癫痫发作者,4例坚持口服抗癫痫药手术后3例未发作、1例偶发,3例未规律服药癫痫1例偶有发作、1例频发.复查CT或MRI透明隔囊肿缩小<50%4例,50%～90%9例,>90%3例,2例脑积水均消失.结论 对症状性透明隔囊肿应用神经内镜行囊肿壁单侧造瘘术具有微创、安全、颅高压症状摔制满意等优点,但癫痫症状缓解不理想.     

Cavum septum pellucidum cyst in children: a case-based update

Background

Cavum septum pellucidum (CSP) cysts are rare lesions which are frequently asymptomatic. Some clinical findings may be associated with CSP cysts, such as headache and other symptoms of increased intracranial pressure, neurological deficit, and mental status changes. There is still controversy in the management of symptomatic cases, especially in children. The main difficulty is to establish a correlation between symptoms and the cyst. When indicated, the treatment is essentially surgical, and the ideal operative technique is also a matter of debate.

Case report

We present a case of a 14-year-old boy with a symptomatic CSP cyst who was successfully treated by neuronavigation-assisted neuroendoscopy with a bilateral fenestration. A literature review is provided with regard to clinical presentation, treatment, and outcome in children.

Conclusion

The treatment is considered whenever there is an association of a CSP cyst on imaging studies and symptoms attributable to the obstruction of the cerebrospinal fluid flow or direct compression of surrounding structures by the cyst. Endoscopic fenestration is a less invasive and highly effective technique, and is currently the treatment of choice for such lesions in children.     

Unilateral hydrocephalus in paediatric patients, a trial of endoscopic fenestration

Two uncommon cases of unilateral, asymmetrical hydrocephalus secondary to membranous occlusion of foramen of monro are described. Both the cases presented with clinical features of raised intracranial pressure and their cranial computerized scans (CT) revealed asymmetrical dilatation of lateral ventricles with displacement of septum pellucidum towards the side of smaller ventricle. Neuroendoscopic fenestration of septum pellucidum and foramen of monro was tried in both the cases, which remained successful in first, while the second case required unilateral ventriculoperitoneal shunt, due to failed endoscopic negotiation of narrowed foramen of monro and intraoperative bleeding during endoscopic intervention.     

透明隔囊肿

透明隔囊肿分为症状性与非症状性两种，前又称为扩张性透明隔囊肿，它可造成室问孔的梗阻，产生头痛、呕吐、视乳头水肿及意识障碍等颅压增高症状。当透明隔囊肿累及下丘脑一隔三角区或影响脑深部的静脉回流时，可出现行为、自主神经以及感觉运动功能的异常。一旦发生脑积水，可压迫视神经通路，引起神经眼科方面的症状。根据MRI所见和临床表现特点可确定诊断。应用脑的内窥镜技术，施行透明隔囊肿-脑室造屡或分流手术，可解除梗阻性脑积水，迅速缓解临床症状。     

神经导航辅助内镜在脑室系统病变中的应用

目的探讨神经导航辅助内镜在脑室系统病变中的应用。方法对30例脑室系统病变,包括12例实质性肿瘤、10例梗阻性脑积水、8例囊性病变患者用神经导航制定手术计划,术中导航引导内镜,按投射轨迹、靶点进行穿刺、活检或肿瘤切除。结果全部病例均能顺利、准确进行手术操作。2例囊性肿瘤和3例实质性肿瘤全切除,8例实质性肿瘤行活检和第三脑室底造瘘,6例囊性病变行造瘘和囊壁部分切除,1例实质性肿瘤行透明隔造瘘和肿瘤部分切除,10例脑积水行第三脑室底造瘘,未出现并发症。结论神经导航辅助的内镜技术最大限度的减少了对脑组织的创伤,明显提高了神经内镜手术的安全性和准确性。     

Endoscopic treatment of suprasellar and third ventricle-related arachnoid cysts

OBJECTIVE: To evaluate the role of neuroendoscopy in the treatment of rare suprasellar and other third ventricle-related arachnoid cysts. METHODS: A review of supratentorial midline arachnoid cysts treated by endoscopic fenestration. RESULTS: Ten cases were identified. The median age of these ten patients was 7.5 years. In three a cysto- or ventriculoperitoneal shunt had previously been inserted. Six cysts were located in the suprasellar/prepontine area, one was a combined suprasellar/middle fossa cyst, and three were complex cysts arising mainly in the quadrigeminal cistern and extending into the third ventricle. Successful endoscopic fenestration to both the ventricular system and the basal cisterns ("bipolar" fenestration) was achieved in all cases. In seven cases a cystoventriculostomy and cystocisternostomy was performed, while in three a cystoventriculostomy was combined with a third ventriculostomy, achieving additional communication to the subarachnoid space. The previously inserted shunts were removed at the end of the procedure. The median follow-up period was 17 (range 1-30) months. The clinical outcome was excellent in all cases, despite only marginal reduction in the cyst size and persistence of ventriculomegaly in some cases. No further treatment to the cyst was required during the period of follow-up. CONCLUSION: Third ventricle-related arachnoid cysts can be satisfactorily and safely treated by endoscopy. This approach leaves the patient shunt independent.     

Callosal disconnection and limb-kinetic apraxia

According to Liepmann, patients with limb-kinetic apraxia (LKA) have a loss of upper limb deftness–dexterity. Prior studies have revealed in right-handed patients that, whereas injury of the left hemisphere induces an ipsilesional LKA, injury to the right hemisphere does not induce an ipsilesional LKA. There are at least two possible means by which the left hemisphere may influence the deftness of the left hand, either by callosal connections or by ipsilesional corticospinal projections. The purpose of this study was to learn whether a patient with a focal lesion of the corpus callosum had a callosal disconnection LKA. This 57-year-old right-handed man had a memory impairment, and upon brain imaging, was found to have a septum pellucidum cyst, which was causing mild ventricular obstruction to the occipital and temporal horns. He underwent an endoscopic-assisted fenestration of the septum pellucidum. Postoperative imaging revealed a lesion of the mesial portion of his corpus callosum and an assessment of praxis revealed that he had both a limb-kinetic and ideomotor apraxia of his left but not his right hand. The observation that this man had a callosal disconnection LKA of his left hand suggests that in some people it is the left hemisphere’s premotor or motor cortex that enables the right hemisphere’s motor system to program deft movements of the left hand.     

Endoscopic Management of Cranial Arachnoid Cysts Using Extra-Channel Method

Objective

Arachnoid cysts (ACs) can be cured by making the definite and wide communication between the cyst and arachnoid space using endoscopy, but often it is impossible only through the usual working-channel (intra-channel) procedures. We discuss and propose a more valuable endoscopic technique with the presentation of our series of cases.

Methods

We treated 9 patients with cortical AC in various locations with extra-channel endoscopic techniques. The patients ranged in age from 3 years to 60 years (mean age, 37.2 yrs). The follow-up period ranged from 12 to 26 months (mean follow-up duration, 17.2 months). All patients had large AC compressing the adjacent brain with clinical symptoms or signs. The authors performed extensive fenestration via single burr hole with the aid of endoscope. Being bypassed the rigid endoscope, through the space between the shaft of endoscope and guiding cannula (extra-channel method), fenestration procedures were done in the dry fields.

Results

Eight (88.9%) patients had been treated successfully with endoscope. One patient required shunt procedure. Among the eight patients who were treated with endoscopic procedure, 6 patients (66.7%) showed cyst reduction, and two (22.2%) showed disappearance of cyst.

Conclusion

We suggest that extra-channel method will be simple and easy to perform using more valuable instruments with wider working area, and may promise better results compared to the conventional intra-channel endoscopic procedures.     

Neuroendoscopic options in the treatment of mesencephalic expanding cysts: Report of four cases and review of the literature

Objective

Mesencephalic expanding cysts, also called lacunae, are rare intraparenchymal, multilobulated cavities of variable diameter mostly localized in the thalamo-mesencephalic region. In symptomatic cases, usually presenting with hydrocephalus or midbrain syndrome, surgical treatment is required and, considering their position, a minimally invasive approach should be preferred.

Methods

Four cases of expanding mesencephalic cysts endoscopically treated in three different Italian centers are described. Other possible causes of intracerebral cyst were excluded in all cases by complete neuroimaging and laboratory screening. All patients presented with signs and symptoms of midbrain compression and a slight to moderate ventricular dilation was present in three cases.

Results

All patients underwent endoscopic cyst fenestration into the ventricle, associated with endoscopic third-ventriculostomy (ETV) in two cases and with cyst wall biopsy in one case. One patient suffered from transient worsening of her hemiparesis due to intraoperative bleeding. All patients showed clinical improvement and a reduction in cyst size on follow-up magnetic resonance images (MRI).

Conclusion

Neuroendoscopy appears to be an effective, probably definitive surgical option in the treatment of symptomatic mesencephalic expanding cysts. Associating ETV with cyst fenestration seems to offer more complete treatment. Deep intracystic navigation and cyst wall biopsy should be avoided.     

Cyst of the septum pellucidum presenting as hemiparesis

An 11-year-old boy with Down syndrome is presented who suffered progressive hemiparesis on the left side for a period of 5 years. Computed tomography demonstrated a large cyst of the septum pellucidum and a calcified spot in the head of caudate nucleus on the right side. By penetrating the cyst wall to create a communication into the lateral ventricle, shrinkage of the cyst and improvement of the hemiparesis were obtained. The pathogenesis of the hemiparesis was presumed to be attributed to circulatory compromise in the deep cerebral veins, secondary to the cyst.     

Assessment of endoscopic treatment for quadrigeminal cistern arachnoid cysts: A 7-year experience with 28 cases

Background

Quadrigeminal cistern arachnoid cysts (QACs) are difficult to treat because of their deep location and the presence of nervous and vascular structures of the pineal–quadrigeminal region. There are several surgical procedures available for QACs, including craniotomy and cyst excision or fenestration, ventriculoperitoneal or cystoperitoneal shunting, and endoscopic fenestration. There is a debate about which method is the best.

Objective

The aim of this study is to evaluate the effectiveness and safety of endoscopic ventriculocystostomy (VC) and third ventriculostomy (ETV) for treatment of arachnoid cysts of the quadrigeminal cistern.

Methods

Twenty-eight patients with QACs who had undergone endoscopic treatment in our department between August 2007 and June 2014 were studied retrospectively. Patient age at the time of endoscopic treatment ranged from 5 months to 42 years, including 25 children (14 males and 11 females) and 3 adults (one male and two females). All patients presented with hydrocephalus and did not undergo shunting prior to neuroendoscopic surgery. The first endoscopic procedures included lateral ventricle cystostomy (LVC) together with ETV in 18 cases, third ventricle cystostomy (3rd VC) together with ETV in 3 cases, and double VC (3rd VC and LVC) together with ETV in 7 cases. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up.

Results

Complete success was achieved in 25 (89.3 %) of 28 cases. During the follow-up period, one case underwent endoscopic reoperation with success. Shunts were implanted in 2 patients due to progression of symptoms and increase in hydrocephalus after the first endoscopic operation. Shunt independency was achieved in 26 (92.9 %) of 28 cases. The cyst was reduced in size in 22 cases (78.6 %). Postoperative images showed a reduction in the size of the ventricles in 23 cases (82.1 %). There was no surgical mortality. Subdural collection developed in 4 cases (14.3 %) and required a transient subduroperitoneal shunt in 2 cases, whereas the other 2 patients were asymptomatic and did not require any surgical treatment.

Conclusions

VC together with ETV through precoronal approach is an effective treatment for symptomatic QACs and should be the initial surgical procedure. The surgical indications should include signs of elevated ICP (including increased head circumference), Parinaud syndrome, gait ataxia, and nystagmus. Also, surgery is indicated by progressive enlargement of the cyst and young children with large cysts even if the patients are asymptomatic. Contraindications to surgery include the absence of symptoms (older children and adult) and isolated developmental delay. The main criterion for successful surgery should be improvement of clinical symptoms instead of reduced cyst volume and/or ventricular size. Repeated endoscopic procedures may be considered only for the patients whose symptoms improved after first endoscopic operation.

     

神经内镜治疗不对称性脑积水

目的探讨不对称性脑积水的原因、诊断、治疗和愈后。方法全部病例应用神经内镜治疗,19例行囊肿壁电凝切除或行囊肿脑室造瘘术,5例行室间孔肿瘤切除术,7例行透明隔穿通造瘘术。结果侧脑室内囊肿切除及囊肿脑室造瘘术19例,一侧室间孔肿瘤切除术并打通室间孔5例,室间孔粘连闭塞行透明隔造瘘7例;全部病例获得良好的近远期效果,无不良反应发生。结论神经内镜治疗不对称性脑积水既解除梗阻的原因,也能建立新的脑脊液的循环通路,且为微创性手术,是有效的方法。     

神经内镜技术的临床应用

目的探讨神经内镜的临床应用。方法应用内镜手术治疗各种颅内病变22例，其中透明隔囊肿3例，脑积水2例，鞍上囊肿1例，单侧室间孔阻塞1例，垂体瘤13例，脑脊液鼻漏1例，桥小脑角胆脂瘤1例。结果用单纯内镜手术治疗7例颅内囊性病变及脑积水，6例症状改善，1例脑积水改行分流手术。用内镜控制的显微神经外科治疗垂体瘤13例，全切10例，次全切3例；脑脊鼻漏修补1例，效果良好。用内镜辅助显微神经外科全切1例桥小脑胆脂瘤。22例病人中2例出现一过性尿崩，1例出现一过性脑脊液鼻漏，1例出现视力恶化，经治疗后均愈。结论内镜治疗颅内囊性病变，手术副损伤小，疗效确切；内镜下经鼻腔切除垂体瘤，微创、安全、有效；神经内镜辅助显微外科可提高手术疗效。