儿童颅内蛛网膜囊肿分流术后分流管临时结扎

目的 探讨儿童颅内蛛网膜囊肿分流术后分流管结扎并安全拔除的可能性.方法 选择2004年1月至2009年12月在天津市环湖医院进行囊肿-腹腔分流的9例患儿,在分流术后6个月随访囊肿消失或缩小,直至2年囊肿无变化者,于皮下分流管最明显部分进行结扎,然后继续随访(平均2.4年)观察.结果 9例患儿有4例在术后平均6个月时囊肿消失;5例中颅窝囊肿在随访6个月时病变缩小,症状消失;继续随访囊肿未见增大;1例囊肿在12个月时消失;结扎分流管后平均随访2.4年没有任何异常表现,影像学未见囊肿复发或原有囊肿增大.结论 囊肿-腹腔分流管在囊肿消失或稳定后平均2年可以试行临时结扎,再继续随访,如长时间无变化可以考虑拔除分流管.

Abstract：

Objective In the past decade, thousands of the pediatric patients with intracranial arachnoid cysts ( ACs) undertook the operation of the cyst - peritoneal shunt ( C - Ps). More and more complications caused by the insertion and long time staying in the body of the shunt device were reported in recent years. Therefore,it is just the aim of this article to make clear how to removal the shunt device timely and safely. Method 9 pediatric patients hospitalized in Tianjin Huanhu Hospital from January 2004 to December 2009 were taken into the study. We investigated the clinical symptoms and neuroimaging findings just at the time of 6 months after C - Ps. If the cyst disappear or reduce in size were found, follow - up would be continue for 2 years. When the change of the cyst in size could not be found, ligating of the shunt tube would be performed at an appropriate position subcutaneously, and a long time follow - up would be performed. Results The cysts disappeared in 4 out of 9 patients in an average 6 months of follow - up. At the same period the cysts reduced in size in 5 patients. No symptom or sign were found during the following up of 2.4 years after the shunt tube ligation. Conclusions Ligating of the shunt tube can be tried after 2 years of C-P shunt without any change in cyst size and clinical symptoms. The removal of the shunt device will be carried out finally.     

儿童颅内蛛网膜囊肿的外科干预

目的 探讨小儿颅内蛛网膜囊肿的治疗方法.方法 收治15岁以下颅内蛛网膜囊肿患者37例,其中手术切除囊肿壁同时打通颅底蛛网膜池12例,囊肿-腹腔分流术20例,神经内镜造瘘术5例.对患者术后症状体征改善、影像学囊肿变化以及术后并发症等进行回顾性对比分析.结果 37例患者神经系统症状和体征均有不同程度的改善.影像学随访结果表明无论是哪种方法均能够使囊肿有不同程度的缩小,脑组织膨隆比较理想.改善情况并未因手术方式的不同而存在明显的差异(P>0.05).但开颅手术组并发症发生率明显高于分流组和神经内镜组.结论 囊肿-腹腔分流术治疗儿童颅内蛛网膜囊肿具有近期效果明显和并发症少的优点.

Abstract：

Objective Arachnoid cysts are non-tumorous intra-arachnoid fluid collections that account for about 1 % of all intracranial space-occupying lesions.So far, the optimal method of treatment for symptomatic arachnoid cysts remains controversial.In this article,we want to find an ideal technique to deal with this condition.Method The hospital records of 37 consecutive patients with intracranial arachnoid cysts who were treated in Tianjin Huanhu Hospital between January 2004 and December 2009, were analyzed retrospectively.All the patients were children below the age of 15 years old with an average of 6, 7 years old.The diagnosis of arachnoid cyst was based on computerized tomography (CT) and MRI scan findings demonstrating a well-circumscribed and non-enhancing cystic lesion that had attenuation values similar to those of the cerebrospinal fluid ( CSF) and did not communicate with the ventricular system.They were divided into three groups as follow, group A ( 12 patients ) , open craniotomy; group B ( 20 patients ) , cyst-peritoneal shunting, and group C(5 patients), endoscopic fenestration.Results The symptoms and neurological signs were improved more or little in all the 3 group patients who accepted the neurosurgical treatment.There were no significant differences between among the 3 groups in releasing of the symptom and sign caused by cysts.On the other hand,there were high percentage of complications,including intracranial infections and subdural fluid collections in the group A.Conclusions The technique of cysto-peritoneal shunting is likely the optimal method for treating the intracranial arachnoid cysts in children.     

儿童蛛网膜囊肿-腹腔分流术后继发裂隙脑室综合征的治疗

目的 探讨颞叶蛛网膜囊肿行囊肿-腹腔分流术后出现的裂隙脑室综合征的早期诊断依据,合理有效的治疗方法以及预防这种并发症的措施.方法 回顾性分析研究了经过本文通信作者治疗的6例颞叶蛛网膜囊肿行囊肿-腹腔分流术后出现裂隙脑室综合征患儿的影像学资料、治疗经过和治疗结果.结果 男4例,女2例.平均发病年龄57.5个月.治疗方法为使用可调压力的抗虹吸分流管泵更换原有分流管泵或联合使用脑室-腹腔分流.6例患者临床症状完全消失,平均随访30个月,未见症状复发.结论 使用可调压力的抗虹吸分流管泵更换原有分流管泵或联合脑室-腹腔分流术对于裂隙脑室综合征是一种有效的治疗措施.避免使用低压的无抗虹吸作用的分流管能够有效地预防蛛网膜囊肿-腹腔分流术后出现裂隙脑室综合征.

Abstract：

Objective To investigate early diagnosis evidences, optimal therapeutic strategies and the prophylactic methods of the slit - ventricle syndrome(SVS) in the temporal lobe arachnoid cysts patients who received the cyst - peritoneal(CP) shunting.Method Six cases of SVS in the temporal lobe arachnoid cysts patients who received the CP shunting were treated by the senior author from Jan 2005 to Jan 2009.The radiological data, treatment process and therapeutic results were reviewed retrospectively.Results There were 4 male and 2 female patients.The mean age of presentation was 57.5 months.The final treatment was to change the original shunt with the programmable valve or combined with the ventricular - peritoneal(VP)shunting.All the symptoms of the patients disappeared totally, and the mean follow - up duration was 30mouths.Conclusions To use programmable shunts to substitute for the original shunt or combined with inserting a VP shunt is an optimal therapeutic method for SVS.The use of low - pressure shunts to treat the ararchoid systs should be abandoned unless dictated by specific indications.     

颅内蛛网膜囊肿的治疗策略

目的 探讨颅内蛛网膜囊肿治疗策略.方法 作者回顾分析于2010年9月1日至2010年12月1日在北京天坛医院神经外科门诊诊治的有完整临床资料的47例颅内蛛网膜囊肿,无干预治疗25例,手术治疗22例,神经内镜下蛛网膜囊肿壁部分切除+囊肿-脑池造瘘术13例,囊肿-腹腔分流术7例,显微下切除囊肿壁术2例.结果 无干预治疗25例,平均随访38.9个月,囊肿无变化.神经内镜治疗组,囊肿消失1例,囊肿缩小50%以上12例;分流治疗组,囊肿消失1例,缩小50%以上5例,无变化1例;显微手术治疗组,囊肿1例消失,1例无变化.并发症:神经内镜组,1例发现硬膜下积液;分流组中3例脑组织包裹分流管,1例硬膜下积液.结论 大多数颅内蛛网膜囊肿行无干预治疗;神经内镜治疗与囊肿-腹腔分流治疗,效果相似,前者更安全、微创,并发症少,应作为首选的治疗方法.

Abstract：

Objective To investigate treatment strategy of intracranial arachnoid cysts. Method 47 cases of Intracranial arachnoid cysts from Sep 1,2010 to Des 1,2010 were analyzed. 25 cases received no intervention but follow. 22 cases received operation, 13 of 22 cases neuroendoscopic partial cystectomy and communication between cystic cavity and brain cistern; 7 of 22 cases cysts - peritoneal shunt, 2 of 22 cases cranioectomy for cystectomy. Results All the cases of no intervention group showed no neuron - imaging change,in endoscopic treatment group,cyst disappearance occurred to 1 case, 12 cases reduced over 50%. In cyst -peritoneal shunt group,cyst disappearance occurred to 1 case,5 cases reduced over 50%. In microscopic cystectomy group, cyst disappearance occurred to 1 case. But no change to 1 case. Conclusions Most of intracranial arachnoid cysts should be given intervention but followed, neuroendoscopy is a safe and effective method with minima invasion in the treatment of intracranial arachnoid cyst. It should be first choice.     

Regional gray matter abnormality in hepatic myelopathy patients after transjugular intrahepatic portosystemic shunt: a voxel-based morphometry study

Hepatic myelopathy is a complication seen in patients with chronic liver failure with physiologic or iatrogenic portosystemic shunting. The main symptom is progressive lower limb dyskinesia. The role of the brain motor control center in hepatic myelopathy is unknown. This study aimed to investigate the gray matter changes in patients with hepatic myelopathy secondary to transjugular intrahepatic portosystemic shunt and to examine their clinical relevance. This was a cross-sectional study. Twenty-three liver failure patients with hepatic myelopathy(hepatic myelopathy group), 23 liver failure patients without hepatic myelopathy(non-hepatic myelopathy group) after transjugular intrahepatic portosystemic shunt, and 23 demographically matched healthy volunteers were enrolled from March 2014 to November 2016 at Xijing Hospital, Air Force Military Medical University(Fourth Military Medical University), China. High-resolution magnetization-prepared rapid gradient-echo brain imaging was acquired. Group differences in regional gray matter were assessed using voxel-based morphometry analysis. The relationship between aberrant gray matter and motor characteristics was investigated. Results demonstrated that compared with the non-hepatic myelopathy group, gray matter volume abnormalities were asymmetric, with decreased volume in the left insula(P = 0.003), left thalamus(P = 0.029), left superior frontal gyrus(P = 0.006), and right middle cingulate cortex(P = 0.021), and increased volume in the right caudate nucleus(P = 0.017), corrected with open-source software. The volume of the right caudate nucleus in the hepatic myelopathy group negatively correlated with the lower limb clinical rating of the Fugl-Meyer Assessment(r = –0.53, P = 0.01). Compared with healthy controls, patients with and without hepatic myelopathy exhibited overall increased gray matter volume in both thalami, and decreased gray matter volume in both putamen, as well as in the globus pallidus, cerebellum, and vermis. The gray matter abnormalities we found predominantly involved motor-related regions, and may be associated with motor dysfunction. An enlarged right caudate nucleus might help to predict weak lower limb motor performance in patients with preclinical hepatic myelopathy after transjugular intrahepatic portosystemic shunt. This study was approved by the Ethics Committee of Xijing Hospital, Air Force Military Medical University(Fourth Military Medical University), China(approval No. 20140227-6) on February 27, 2014.     

脑室-腹腔分流术中分流管腹腔端无需特殊处理

Objective To investigate the dynamic changes of peritoneal catheter of ventriculoperitoneal shunt (V- P shunt) prospectively, and to determine simple, effective disposal method of peritoneal catheter. Method From Jan 2007 to Oct 2010, consecutive 40 patients with hydrocephalus were treated by V - P shunt. All patients were operated through puncture of frontal horn of lateral ventricle. And 4 cm straight abdominal incision under xiphoid was made and after shunt system had been connected well, the abdominal catheter was put into peritoneal cavity through 3 mm incision of peritoneum. Head CT scans were regularly made at the 1st, 3rd and 7th day after shunt to determine the intracranial state for all patients, and abdominal X - ray plain films were also obtained to confirm the position of peritoneal catheters at the same time. All the clinical data and results of follow - up were reviewed.Results Dynamic head CT scans showed good results of V - P shunt after surgery in all cases. And abdominal X-ray plain films at the 1st day after operation showed peritoneal catheter was located in pelvic cavity in 31 cases and lower abdominal cavity in 5 cases. At the 3rd day and 7th day after operation, the numbers of peritoneal catheter located in pelvic cavity were 35 and 39 respectively. Among these patients, a large acute subdural hematoma occurred on the same side of V - P shunt at the 5th day after operation. This patient was discharged with GCS 6 as his family refused decompressive craniectomy. The remaining 39 patients were discharged with average hospital - stay time of 11 ± 4 days after shunt. On follow - up, 1patient developed peritoneal infection one year later. After the infection was controlled, he was changed to ventriculo -atrial (V -A) shunt. There was no shunt -related complication occurred on the others during 1 -24 month follow - up periods. Conclusion V - P shunt through small straight incision under xiphoid could reduce surgical injury, shorten the operating time and obtain good Results. Dynamic observation of the location of peritoneal catheter by abdominal X - ray plain film is a simple and practical method. The peritoneal catheter will located in pelvic cavity at the 1st day after shunt in vast majority. There is no special management for peritoneal catheter in V - P shunt in required.     

脑室-腹腔分流术中分流管腹腔端无需特殊处理

Objective To investigate the dynamic changes of peritoneal catheter of ventriculoperitoneal shunt (V- P shunt) prospectively, and to determine simple, effective disposal method of peritoneal catheter. Method From Jan 2007 to Oct 2010, consecutive 40 patients with hydrocephalus were treated by V - P shunt. All patients were operated through puncture of frontal horn of lateral ventricle. And 4 cm straight abdominal incision under xiphoid was made and after shunt system had been connected well, the abdominal catheter was put into peritoneal cavity through 3 mm incision of peritoneum. Head CT scans were regularly made at the 1st, 3rd and 7th day after shunt to determine the intracranial state for all patients, and abdominal X - ray plain films were also obtained to confirm the position of peritoneal catheters at the same time. All the clinical data and results of follow - up were reviewed.Results Dynamic head CT scans showed good results of V - P shunt after surgery in all cases. And abdominal X-ray plain films at the 1st day after operation showed peritoneal catheter was located in pelvic cavity in 31 cases and lower abdominal cavity in 5 cases. At the 3rd day and 7th day after operation, the numbers of peritoneal catheter located in pelvic cavity were 35 and 39 respectively. Among these patients, a large acute subdural hematoma occurred on the same side of V - P shunt at the 5th day after operation. This patient was discharged with GCS 6 as his family refused decompressive craniectomy. The remaining 39 patients were discharged with average hospital - stay time of 11 ± 4 days after shunt. On follow - up, 1patient developed peritoneal infection one year later. After the infection was controlled, he was changed to ventriculo -atrial (V -A) shunt. There was no shunt -related complication occurred on the others during 1 -24 month follow - up periods. Conclusion V - P shunt through small straight incision under xiphoid could reduce surgical injury, shorten the operating time and obtain good Results. Dynamic observation of the location of peritoneal catheter by abdominal X - ray plain film is a simple and practical method. The peritoneal catheter will located in pelvic cavity at the 1st day after shunt in vast majority. There is no special management for peritoneal catheter in V - P shunt in required.     

颅内脉络膜囊肿四例临床分析

目的 总结脉络膜囊肿的诊治方法及治疗效果.方法 回顾性分析本院2005年3月至2010年3月收治的4例颅内脉络膜囊肿患者的临床资料、病理学改变、手术措施和治疗效果.结果 4例均临床表现为颅内囊性占位病变和局部压迫症状,MRI检查表现T1WI低信号,T2WI高信号,增强无包膜强化.病理检查见完整基底膜上被覆单层扁平或柱状上皮.开颅手术及脑室镜下囊肿大部分切除治疗各2例.术后随访0.5-5.0年,4例患者术前症状全部缓解,无并发症出现.结论 脉络膜囊肿无特征性临床表现.影像学检查侧脑室、小脑脑桥角区囊性病变应注意该病.开颅或脑室镜囊肿大部分切除术是有效的治疗方法.

Abstract：

Objective To summarize and report the diagnosis and management of choroid plexus cysts.Methods The clinical date of 4 choroid plexus cysts cases from March 2005 and 2010 March were analyzed retrospectively,and pathology appearances,surgical treatment were evaluated.Methods Intracranial cystic lesion and compression symptoms were represented in 4 cases.The MR feature of the choroid plexus cyst was low signal intensity on T1- weighted and high signal intensity on T2-weighted.The cyst walls were not reinforcement while contrast enhancement.Histological examination revealed the choroid plexus cyst consisted of complete basement membranes covered with a layer of cuboidal or flat choroid plexus epithelium.4 cases were followed up for 0.5-5.0 years and showed satisfying results with no complication.Conclusion The clinical presentations of choroids plexus cysts are not representative.Attention to the diagnosis of choroid plexus cyst while radiological examination review a cystic lesion within the lateral ventrical and the cerebellopontine angle.Craniotomy or endoscopic cyst resection to remove the cysts is an effective treatment method.     

Microsurgical efficacy in 326 children with tethered cord syndrome: a retrospective analysis

Tethered cord syndrome is a progressive disease with a typically insidious onset in infants and children, and which can lead to persistent progress of neurological deficits and a high rate of disability without timely intervention. The purpose of this study was to investigate the curative effect of microsurgery in children with different types of tethered cord syndrome. In this study, we analyzed 326 patients with tethered cord syndrome, aged from 2 months to 14 years old, who were followed for 3–36 months after microscopic surgery. Based on clinical manifestations and imaging findings, these patients were classified into five types: tight filum terminale(53 cases), lipomyelomeningocele(55 cases), lipomatous malformation(124 cases), postoperative adhesions(56 cases), and split cord malformation(38 cases). All patients underwent microsurgery. Curative effects were measured before and 3 months after surgery by Spina Bifida Neurological Scale based on sensory and motor functions, reflexes, and bladder and bowel function. The results showed that Spina Bifida Neurological Scale scores improved in all five types after surgery. Overall effective rates in these patients were 75%. Effective rates were 91% in tight filum terminale, 84% in lipomyelomeningocele, 65% in lipomatous malformation, 75% in postoperative adhesion, and 79% in split cord malformation. Binary logistic regression analysis revealed that types of tethered cord syndrome(lipoma-type or not) and symptom duration before surgery were independent influencing factors of surgical outcome. These results show that therapeutic effect is markedly different in patients with different types of tethered cord syndrome. Suitable clinical classification for tethered cord syndrome will be helpful in predicting prognosis and guiding treatment.     

影响成人脊髓拴系患者手术结果的相关因素分析（英文）

This study aimed to find the factors that may affect the surgical outcomes of congenital tethered cord syndrome(TCS)in adults by evaluating the long-term surgical outcomes of 25 consecutive cases.Medical records of 79 TCS cases which underwent surgery in Bak Irky Research and Training Hospital for Neurology,Neurosurgery and Psychiatry(BRSHH),during an 11-year period from 2005 to2015,were retrospectively reviewed.All adult cases(patient age18 years)were selected as the core sample used for this study.Twenty-five cases of TCSs were surgically treated.The sample consists of 16 female and nine male patients.The mean age of the sample is30.1±10.3 years.Untethering was carried out in 88%of the patients.Sixty-four percent of the patients had good clinical outcomes at their last follow-up(after 73.8 months on average).The mean length of hospital stay was 4.76±2.88 days.In a multivariate regression model,laminectomy,bladder dysfunction when associated to muscular weakness,and long-term(6 months)symptoms were selected as the independent risk factors associated with poor or minimally improved(almost unchanged)surgical outcomes.When the urodynamic test showed overactive detrusor muscle,no improvement was recorded in postoperative urodynamic test.Laminoplasty(or hemilaminectomy),short-term(6 months)symptoms,patients without lipomas,and presentation with moderate or mild symptoms seem to be proper predictors for good surgical outcomes.Further prospective studies are necessary to investigate these findings systematically.Urodynamic study can be used as a predictive tool for close follow-up of asymptomatic adult patients involved with TCS.     

颅内蛛网膜囊肿伴发癫痫的手术治疗

目的 通过对37例颅内蛛网膜囊肿(intracranial arachnoid cyst,IAC)伴发癫痫患者手术治疗情况的回顾分析,以期对此类患者手术方法的选择提供依据.方法 25例患者归为囊肿手术组,方法有囊肿壁切除术、囊肿-腹腔分流术和囊肿造瘘术;12例患者归为癫痫手术组,行囊肿壁切除术同时,切除囊肿周围萎缩变性致痫脑组织,如果患者残存颞叶内侧及杏仁核、海马结构,也予以切除,如囊肿周围邻近功能区,则通过体感诱发电位确定中央沟后于功能区行多处软膜下横切术,必要时行脑皮质离断术和胼胝体切开术,12例均行术中皮层脑电图监测.结果 术后37例患者中6例囊肿消失,17例减小,14例无变化,两组相比无显著性差异;囊肿手术组2例无发作,8例改善,15例无效,手术总有效率40%;癫痫手术组7例无发作,3例改善,2例无效,手术总有效率83.3%,两组相比有显著性差异(P＜0.05).结论 IAC伴发癫痫患者术前进行癫痫灶的确认,术中行囊肿壁切除术同时切除癫痫灶,大大提高IAC伴发癫痫的手术疗效.     

Shunt-independent surgical treatment of middle cranial fossa arachnoid cysts in children

The best operative intervention for children with arachnoid cysts remains the subject of controversy. Recent reports stress that craniotomy for cyst fenestration is associated with a low incidence of morbidity and mortality and may leave the child shunt-independent. Among a total of 66 intracranial arachnoid cysts operated on in the authors’ department from 1985 to 1997, 44 cases (67%) were located in the middle cranial fossa. A higher incidence in the first decade of life (53 cases) and a marked male predominance (45 cases) were recognized. Headache, cranial deformities, symptoms of raised intracranial pressure, and seizures constituted the most frequent features of the clinical presentation. To determine which treatment provides the greatest benefit with the lowest incidence of complications, the records of the 44 patients with arachnoid cysts in the middle cranial fossa were reviewed. The mean age of these patients was 4.6 years (range 0–16 years). Different types of initial surgical procedures were performed. In 33 patients with middle cranial fossa arachnoid cysts (MCFAC) the initial surgery took the form of craniotomy with excision of the cyst walls and fenestration into the basal cisterns. Shunting procedures were performed in 9 patients: cysto-peritoneal shunts (CPS) were placed in 4 patients and ventriculo-peritoneal shunts (VPS), in 3 patients, and cyst excision was performed in addition to CPS in 2 patients. Excision of the cyst membrane alone without fenestration was performed in 2 patients. The initial treatment was successful in terms of reduced symptoms and decreased cyst size, with no additional treatment needed for the cyst, in 79% (26/33) of patients who had undergone excision of the cyst walls and fenestration into the basal cisterns, compared with 66% (6/9) of patients who had undergone shunting procedures. Cyst membrane excision was not successful in any of the patients who underwent this procedure alone. No significant difference in morbidity was noted between these different treatment options. On follow-up CT scan and MRI, cysts of types I and II (Galassi classification) exhibited a steady tendency to reduction or obliteration. These results confirm that radical excision of the outer and inner membranes of the cyst wall with fenestration into the basal cistern is a safe and effective shunt-independent procedure for MCFAC, especially for those of types I and II. Received: 28 May 1999 Revised: 10 August 1999     

儿童颞部蛛网膜囊肿不同术式的疗效分析

目的探讨儿童颅内颞叶蛛网膜囊肿的手术方法和疗效。方法颞部蛛网膜囊肿患儿65例,27例行囊肿-腹腔分流术,17例行显微镜下囊壁剥离＋脑池穿通术,21例行内镜下囊壁剥离＋脑池穿通术,并比较三种不同术式的治疗效果。结果囊肿-腹腔分流术、显微镜和内镜术后囊肿缩小率分别为88.9%、94.1%和95.2%,三者相比,无显著性差异（P〉0.05）。术后转流障碍是囊肿-腹腔分流术的主要并发症,且经受该手术患者并发感染后治疗效果差、囊肿消失后拔管率低;术后硬膜下积液和慢性硬膜下血肿则是显微镜和内镜手术的主要并发症。结论根据囊肿形态、大小、脑脊液吸收功能等进行评估,以微创为主导个体化选择手术治疗儿童颞部囊肿,可取得较满意效果。     

颅内蛛网膜囊肿治疗中的有关问题

目的 探讨颅内蛛网膜囊肿的手术指征和手术方法.方法 回顾性分析209例颅内蛛网膜囊肿患者的临床表现、影像学资料、治疗方法等临床资料.结果 其中198例行CT蛛网膜下腔-脑池造影,非交通性47例均行于术治疗.43例行囊肿大部切除+脑池开放术,3例行脑室-腹腔分流术,1例行囊肿-腹腔分流术.所有手术病人手术顺利,各种术式各有利弊.结论 颅内蛛网膜囊肿应根据囊肿大小、临床症状体征、与蛛网膜下腔是否交通及年龄来决定治疗方式.手术首选囊肿切除+脑池开放术.     

Evaluation of the management of arachnoid cyst of the posterior fossa in pediatric population: experience over 27 years

Introduction The necessity of surgical treatment of the arachnoid cyst in general and posterior fossa arachnoid cyst (PFAC) in particular is sometimes controversial. Surgery is warranted in symptomatic patients. In this study, we evaluated our experience throughout 27 years in the management of patients with PFAC. Materials and methods The study was designed with special emphasis on clinical features, surgery, and outcome. We investigated a total of 112 arachnoid cysts. Of them, 23 patients were symptomatic for PFAC. We assessed clinical characteristic and outcome for all patients. We obtained information from medical records and outpatient charts on age, sex, presenting symptoms, associated abnormalities, psychomotor status, modality of treatment, complications and follow-up in 23 patients (9 boys, 14 girls, ages 1 day–6 years) who had been admitted for evaluation and treatment of PFAC at Kobe Children’s Hospital between 1978 and 2004. Results The mean follow-up period was 93 months (range 5–313 months). More than half of the patients had a history of increased head size and signs of intracranial pressure as presenting symptoms. One-third of the patients had associated abnormalities and six patients (26%) presented hydrocephalus. Computed tomography cisternography displayed delayed filling of the cyst in 11 patients (48%). All patients were treated surgically; the total number of surgical procedures was 55 with a surgical rate of 2.4 per patients. The marsupialization and marsupialization with cyst-peritoneal (C-P) shunt were the most common open surgical procedure in 14 and 5 patients, respectively. Endoscopic cysternostomy was performed in three patients. In our series, 25 (45%) of 55 surgical procedures included shunt malfunction and removal. The marsupialization of the cyst wall was successful in 9 of 14 operated patients (64%); the other five patients needed additional C-P or ventriculoperitoneal (V-P) shunt. Marsupialization with cyst-peritoneal shunt was successful in only one of five patients (20%), and for the other four patients, additional C-P or V-P shunt was necessary. No mortality is reported. Eight patients presented minor surgical morbidities that were resolved conservatively. Discussion The relatively good results using marsupialization or endoscopic cisternostomy as surgical procedure and the high incidence of shunt malfunction buttresses our use of both operations as a first-line surgery at present. Surgical procedure that does not include shunting decreases the ratio of recurrent operation because this kind of complication develops over time and should be consider as a second-line procedure.     

Subdural hygroma: an unwanted result of Sylvian arachnoid cyst marsupialization

INTRODUCTION: Subdural hygroma is a known complication of Sylvian fissure arachnoid cysts (SACs). However, most of the data in the literature refer to spontaneous or posttraumatic occurrence of subdural hygromas, regarded as either a favorable or an unfavorable event. Little is known about this phenomenon as a consequence of the surgical management of SACs. The present study was carried out to evaluate the significance of postoperative subdural hygromas in children with temporal arachnoid cysts, who have been treated with craniotomy and wide marsupialization of the cystic membrane. CLINICAL MATERIAL AND RESULTS: Between 1980 and March 2002, 104 children were operated on for a SAC at the Pediatric Neurosurgical Unit of the Catholic University Medical School in Rome. Six patients (5.8%; boys/girls=4/2; mean age 3.28 years) developed a subdural hygroma postoperatively, which required further treatment. According to Galassi's classification 4 children had a Type III cyst and 2 children a Type II cyst. All the patients had previously been submitted to open marsupialization of their arachnoid cyst and extensive removal of the cyst wall. In 5 patients (Type III cyst: 4 patients; Type II cyst: 1 patient), acute or subacute symptoms and signs of increased intracranial pressure (ICP) developed at a temporal distance, varying from 5 days to 1 month (mean interval: 14.3 days). All these children needed surgical treatment for the hygroma. A subduro-peritoneal (SDP) shunt was implanted as the first step in 3 patients (Type III cyst: 2 patients; Type II cyst: 1 patient). In the remaining 2 patients of this group (Type III cysts) medical therapy was initially attempted (acetazolamide: 24 mg/kg) without any improvement in clinical manifestations; on these grounds an external spinal subarachnoid drainage was implanted, but led only to the transient clearance of symptoms. The direct drainage of the subdural collection (SDP shunt in 1 patient and temporary external subdural drainage in the other), was followed by complete clinical recovery in both cases. The last patient in this series showed a pathologic increase in head circumference during the 1st month after surgery for his arachnoid cyst, followed by a subsequent stabilization. A CT scan documented a subdural hygroma, which first of all increased in size, but stabilized 2 months after surgery. No surgical treatment was performed in this case. At a mean follow-up of 2.38 years (minimum: 1 month; maximum: 5 years) all the patients are in excellent clinical conditions. Complete neuroradiological resolution of the hygroma was observed in 2 of the 4 shunted patients, who have both been submitted to shunt removal (2 and 3 years after the implant respectively). CONCLUSIONS: It is our opinion that a wide opening of the external membrane of SACs may predispose the CSF fluid to accumulate within the subdural space, where its absorption is insufficient. A ball mechanism created by CSF pulsation may further increase the subdural fluid accumulation. Secondary distortion and occlusion at the level of the basal cisterns may also contribute to the persistence of the subdural fluid collection. Clinical manifestations may be transient, but frequently have a progressive course and the drainage of the subdural collection is, though transient, required in most cases. On these grounds we suggest the selective opening of the basal cisterns associated with a limited resection of the outer cyst walls in order to limit CSF access to the subdural space.     

Symptomatic, expansive middle cranial fossa arachnoid cyst treated by a cysto-peritoneal shunt Case report and evaluation of treatment options

We report a symptomatic space-occupying arachnoid cyst in a 16-year-old boy. During the last two years, he was frequently absent from school because of headaches. Due to symptoms of nausea, fever and headache the patient was primarily referred to a surgical unit, where appendectomy was performed, revealing a normal appendix. Postoperatively, the patient complained of severe headache. Computed tomography (CT) of the head demonstrated a large left-sided middle cranial fossa arachnoid cyst. The patient was operated with insertion of a cysto-peritoneal shunt. A total regress of the clinical symptoms was seen at follow-up examination 3 months after shunting.     

成人后颅窝巨大蛛网膜囊肿的诊断与手术治疗

目的 探讨成人后颅窝蛛网膜囊肿的诊断和治疗方法.方法 回顾性总结分析10例成人后颅窝巨大蛛网膜囊肿的临床资料和手术效果,10例全部采取开颅囊壁切除造口粘连松解术,并使之与第四脑室和蛛网膜下腔交通,1例同期行颅内多发性硬膜下积液钻孔引流术.结果 所有病人术后恢复良好,出院前症状改善6例,无变化4例.术后1周常规复查头部MRI,囊肿缩小、小脑部分复位6例.3个月后随访复查头部CT,无囊肿复发.其中小脑完全复位4例,大部分复位6例;脑积水消失、脑室恢复正常4例,脑积水减轻6例;临床症状消失7例,好转3例.结论 开颅在显微镜下获得囊肿腔与脑室及蛛网膜下腔的交通是避免后颅窝巨大蛛网膜囊肿复发和治疗脑积水的关键,手术效果良好.     

儿童颞部蛛网膜囊肿的手术治疗

目的探讨儿童颞部蛛网膜囊肿的手术方法。方法回顾性分析手术治疗儿童颞部蛛网膜囊肿68例患者的临床资料,56例行显微镜下囊壁切除+脑池交通术,7例行囊肿-腹腔分流术,5例行内镜下囊壁切除+脑池交通术。结果术后随访6个月到3年,28例影像学复查显示:13例囊肿完全消失,46例囊肿体积较术前有不同程度缩小,无明显变化的有9例。结论显微镜下囊壁切除+脑池交通术对儿童颅内蛛网膜囊肿有着良好的治疗效果,可以作为首选的手术方式。     

A comparison of neuro-endoscopic techniques with other surgical procedures in the treatment of arachnoid cysts in children

The aim of the study was to evaluate the use of neuroendoscopic techniques (in comparison with other surgical procedures) in the treatment for arachnoid cysts in children. The analysis was performed on results of treatment 22 children with arachnoid cysts submitted to neuroendoscopic procedures. The group consisted of 6 girls and 16 boys, aged from 1 day to 18 years (mean age 5.3 years, SD +/- 5.6). The control group treated with other, non-endoscopic surgical procedures consisted of 61 patients (20 girls and 41 boys aged from 10 days to 17 years, mean age 7 years, SD +/- 6). Criteria of success varied according to the type of surgical treatment. In the case of procedures other than shunt implantation, the treatment was regarded as effective, if there was no need to change the surgical method, while shunt implantation was considered effective, if shunt revision was not necessary. The operative treatment outcome was assessed using the Glasgow Outcome Scale. Post-treatment changes in the clinical state were graded as improvement, no change, or deterioration. In terms of the assumed criteria of success in the treatment for arachnoid cysts, neuroendoscopic procedures and microsurgical cyst excisions were among the most effective methods. As many as 90.9% of neuroendoscopically treated children needed no other operation, in comparison with 92.6% of patients submitted to microsurgical procedures, who needed no change in the operative treatment. In the group of neuroendoscopically treated patients the effectiveness of neuroendoscopic operations varied according to the type of procedure used. Cystocysternostomies or cystoventriculostomies were successful in 100%. The analysis of clinical outcome has shown that deterioration was observed only in 13% of the patients with shunt implantation. Analyzing each type of arachnoid cyst separately, a statistically significant relationship was found between improvement of the clinical state and the use of craniotomy in the surgical treatment for cysts localized in the posterior fossa. Improvement in the case of neuroendoscopically treated children was related to a larger reduction in the cyst size after surgery and to a lower intensity of intraoperative bleeding. Neuroendoscopic techniques allowed to reduce the average period of hospitalization. Neuroendoscopic cystocysternostomy and cystoventriculostomy were the most effective techniques, besides microsurgical excision of arachnoid cysts. Neuroendoscopic treatment efficacy depends on the type of procedure used. The application of neuroendoscopic techniques allows to reduce the period of hospitalization.