Use of intrathecal hyaluronidase in the management of tuberculous meningitis with hydrocephalus

A preliminary study to evaluate the efficacy of intrathecal hyaluronidase was carried out in nine children suffering from tuberculous meningitis with communicating hydrocephalus. This was followed by a randomized trial in which five cases were treated with intrathecal hyaluronidase, while six cases were treated by the insertion of a ventriculoperitoneal shunt. No untoward reaction of any significance was noted. The results were judged in terms of improvement in the sensorium and mentation, in specific neurological deficit (e.g., visual impairment and hemiparesis), and in overall functional performance. Although most of the patients receiving hyaluronidase showed some improvement in the sensorium, only one of the nine preliminary cases and one of the five cases in the randomized trial showed a total recovery of function. Two of the six shunted patients, however, showed complete recovery. Shunt insertion led to further improvement in two of the nine preliminary cases who had failed to respond to treatment with hyaluronidase. This preliminary study shows that intrathecal hyaluronidase does, in most cases, lead to an improvement in the sensorium but does not offer any particular advantage over shunt insertion in terms of regression of specific neurological deficit or overall functional improvement.     

The role of an Ommaya reservoir in the management of children with cryptococcal meningitis

Cryptococcal meningitis is the most common life-threatening fungal infection and is associated with high mortality in children. Amphotericin B plus flucytosine and fluconazole is the optimal current therapy. Implantation of an Ommaya reservoir for intraventricular infusion of medication and aspiration of cerebrospinal fluid (CSF) for the treatment of increased intracranial pressure (ICP) has been reported. Intraventricular injection of amphotericin B through an Ommaya reservoir in children with cryptococcal meningitis has not been reported previously. We report two children who had cryptococcal meningitis and associated increased intracranial pressure, and were treated with an Ommaya reservoir. Both patients experienced rapid reversal of symptoms. At the time of discharge both patients had recovered and have remained asymptomatic.     

Successful management of intraventricular rupture of pyogenic brain abscess (IVROBA): Systematic review and illustrative case

ObjectivesIntraventricular rupture of brain abscess (IVROBA) is one of the most dreaded complications of pyogenic brain abscess due to its high mortality rate. Because of its relative infrequency and poor outcome, the optimal management of this condition remains to be determined.Patients and MethodsWe report the case of a 5-year old female with a presumptive diagnosis of IVROBA who was discharged with good neurologic outcome after completing intravenous antibiotic treatment and undergoing insertion of an external ventricular drain (EVD) and later, a ventriculoperitoneal (VP) shunt. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and series documenting patients who survived after undergoing treatment for IVROBA.ResultsA total of 24 cases of IVROBA survivors were reported in the literature, including the present case. The median age was 48.5 years (range: 5–71), with a male predilection (3:1). The most common location of the brain abscesses was temporal while the most common route of spread was hematogenous. Surgery was performed in 92% of cases, with EVD being the most common surgical procedure. Twenty nine percent of cases required a VP shunt. The duration of systemic antibiotic treatment ranged from 31 to 180 days (median: 56 days) while intraventricular antibiotics were given for 8–42 days (median: 14 days).ConclusionThe management of IVROBA in this series varied widely, with surgery playing an important role. Although IVROBA is still a devastating complication of intracranial abscess, a good neurologic outcome may still be possible with treatment.     

两种不同纤溶途径治疗脑室系统出血效果的临床观察

目的观察两种不同纤溶方法治疗脑室系统出血的疗效。方法 76例脑室系统出血患者中,40例采用双侧侧脑室外引流+脑室内纤溶治疗(A组),36例采用双侧侧脑室外引流+终池持续引流+脑室内及鞘内纤溶治疗(B组)。结果 A组脑室出血清除时间为(9.3±3.8)d,B组为(7.6±2.7)d,两者相较相差显著(P0.05)。A组的有效率为57.5%(23/40),B组为80.6%29/36),两者相较相差显著(P0.05)。结论本研究提示脑室系统出血患者同时给予脑室内与鞘内纤溶治疗效果较好。     

Treatment of sympathomimetic induced intraventricular hemorrhage with intraventricular urokinase

Intraventricular hemorrhage (IVH) occurred in a 32-year-old man following the use of both ephedrine and pseudoephedrine. Cerebral angiography and transcranial Doppler studies showed changes suggestive of vasculitis. We describe the management and investigations of a unique case of IVH. This patient was treated with ventriculostomy and intraventricular urokinase (UK). A favorable outcome was obtained with independent function at 10 weeks post hemorrhage. The use of intraventricular thrombolysis for drug-induced IVH has not previously been reported, although it has been shown to be a safe and potentially beneficial intervention.     

Isolated dementia in two patients with posterior intraventricular meningiomas

Although patients with brain lesions of neurosurgical interest may sometimes present with a cognitive profile very similar to a primary dementia, they usually have a history and/or a neurologic examination which alert the clinician. The occurrence of mass lesions with purely isolated cognitive deterioration has been mainly reported for locations at the level of the frontal lobes. A potentially positive prognosis is advocated in these cases, in terms of even complete reversibility of the mental impairment when surgical removal is feasible and successful. We report two rare cases of posterior intraventricular meningiomas presenting with isolated cognitive and behavioural changes consistent with a frontal type dementia; the outcome was favourable in one patient, whereas the second one suffered from massive intracerebral bleeding during the neurosurgical removal and required prolonged hospitalization and subsequent intensive neurorehabilitative efforts. By comparing our cases with previously published decision-rules regarding neuroimaging in dementia, we suggest that criteria should be enlarged, especially those regarding the age of the subject and the time elapsed from the first signs of the cognitive deterioration.     

大鼠脑室出血鞘内与脑室内纤溶治疗对比研究

目的研究大鼠鞘内与脑室内注射尿激酶两种纤溶治疗对脑室系统血凝块的影响。方法借助大鼠脑立体定位仪建立大鼠脑室出血模型;测定腩组织含水量,并比较不同途径纤溶治疗对脑组织水肿的影响;通过脑片及HE染色观察血凝块清除情况。结果两治疗组鞘内组和脑室组脑组织含水量较模型组明显减少（P〈0．05）,但鞘内组和脑室组之间脑组织含水量无显著性差异（P〉0．05）;脑片及HE染色观察到模型大鼠脑室系统内血凝块有残留,而两治疗组脑室血块大部分被清除。结论脑室出血后经鞘内和脑室内纤溶治疗均能加快血块溶解,促进脑脊液循环,减轻脑组织水肿和损伤。     

脑室内脑膜瘤的分布及显微手术治疗

目的 探讨脑室内脑膜瘤的分布及显微手术的疗效.方法 对35例行显微手术治疗的脑室内脑膜瘤患者的临床资料及手术效果进行分析总结.结果 30例位于一侧侧脑室,2例位于双侧侧脑室,1例位于侧脑室+第三脑室,1例位于第三脑室,1例位于第四脑室;其中30例全切(SimponⅠ,Ⅱ),4例次全切(Simpon Ⅲ),Ⅰ例大部分切除;术中去骨瓣减压3例,手术死亡1例.术前有颅高压23例术后早期缓解20例,加重3例;随访3个月-8年,7例肢体活动障碍者6例改善,1例加重;4例偏盲者2例改善,2例无变化;伴有脑积水5例,3例缓解,1例行脑室-腹腔分流术,1例行第三脑室底造瘘术.全切病例中,1例肿瘤复发行二次手术;失访3例.结论 脑室内脑膜瘤多位于侧脑室三角区,其位置深在,但显微手术的疗效良好.     

脑室镜治疗脑室出血的临床疗效

目的 探讨应用脑室镜清除脑室内血肿治疗脑室出血的疗效.方法 回顾性分析18例脑室出血患者的临床资料.结果 患者入院12 h内在脑室镜下清除脑室内血肿,手术结束术区置管,术后向脑室内注入尿激酶,拔管后腰穿腰大池置管持续引流脑脊液;术后24 h复查头颅CT,脑室内血肿清除80％以上者占12例;术后2个月对患者进行GOS评分,5分(优)4例,4分(良)8例,3分(中)3例,2分(差)2例,1分(死亡)1例,恢复优良率为67％.结论 早期应用脑室镜清除脑室内血肿可改善患者的预后、降低并发症,具有直视下操作、迅速有效地清除脑室内血肿、术后恢复快等优点.     

Sleep disorders are long-term sequelae of both bacterial and viral meningitis

BACKGROUND: Many bacterial meningitis patients experience neurological or neuropsychological sequelae, predominantly deficits in short-term memory, learning, and attention. Neuropsychological symptoms after viral meningitis are observed less frequently. Sleep disturbance has been reported after both viral and bacterial meningitis. OBJECTIVES: To examine systematically the frequency and extent of sleep disturbance in meningitis patients. METHODS: Eighty six viral or bacterial meningitis (onset of acute disease at least 1 year previously) patients were examined using two standardised questionnaires (Schlaffragebogen B and the Pittsburgh Sleep Quality Index, PSQI) in conjunction with a standardised neurological examination, and compared to a control group of 42 healthy age-matched volunteers. RESULTS: Patients after both viral and bacterial meningitis described their sleep as reduced in quality and less restful than that of healthy control subjects; both patient groups had a pathological mean PSQI total score. Impaired sleep scores after meningitis were not correlated to either the Glasgow Coma Scale or the Glasgow Outcome Scale. Moreover, no relationship between residual neurological dysfunction or depressivity and sleep quality was observed. CONCLUSIONS: Impaired sleep is a long-term consequence of meningitis. Additional, so far undetermined, factors other than the severity of concomitant neurological deficits are responsible for the development of this sequela.     

脑室外引流并腰大池引流治疗脑室内积血

一、资料和方法 1．病例资料：收集2003年1月～2007年5月海南省临高县医院收治的28例脑室内积血（intraventricula rhematoma，IVH）患者资料，其中男性17例，女性11例；年龄42-75岁，平均59-3岁。有高血压病史16例，外伤史2例，10例病史不详。入院时GCS〈8分20例，8～12分8例。双瞳散大4例，双瞳缩小3例，双瞳不等大15例，一侧瞳孔不圆6例。CT扫描：一侧脑室积血10例，双侧脑室12例，合并第三脑室积血2例，全脑室铸形4例。[第一段]     

神经内镜在脑室内肿瘤术中的应用

目的 探讨神经内镜治疗脑室内肿瘤的手术技术及疗效.方法 回顾性分析2005年7月至2013年2月首都医科大学附属北京世纪坛医院神经外科应用神经内镜治疗的脑室内肿瘤患者的临床资料及手术效果,共15例.侧脑室肿瘤7例,第三脑室肿瘤7例,脑室内多发肿瘤1例.均于导航指引下手术,术后常规随访,并进行Karnofsky评分(KPS).结果 15例中,单纯神经内镜下活检5例,肿瘤全切除3例,近全切1例;神经内镜结合显微镜全切除肿瘤3例,近全切除3例.合并脑积水10例,其中9例行第三脑室底造瘘术,2例同时行透明隔造瘘术.术后6例行化疗,3例行放射治疗.术后随访2 ～36个月,平均15.8个月.KPS＞ 80分12例,60～ 80分2例,0分(死亡)1例.结论 神经内镜手术治疗脑室内肿瘤既可通过活检明确肿瘤的病理学性质,又可根据肿瘤的大小及性质选择单纯神经内镜切除,或神经内镜结合显微镜切除.     

新型隐球菌性脑膜炎与结核性脑膜炎的鉴别

目的探讨新型隐球菌性脑膜炎(CNM)和结核性脑膜炎(TBM)在临床、脑脊液方面的区别,以期早期诊断、治疗,改善病人的预后。方法回顾性比较10例CNM和86例TBM患者的临床特点、脑脊液改变的异同。结果两种脑膜炎均以亚急性或慢性形式起病,CNM组患者视盘水肿和呕吐症状明显多于TBM组;CNM组患者脑脊液开放压力和细胞数增加更明显,但头痛、发热、抽搐、精神症状、消瘦、盗汗、大小便障碍、意识障碍、脑膜刺激征、病理征阳性、脑神经损伤、肢体瘫痪、感觉障碍以及脑脊液蛋白质、葡萄糖、氯化物改变等均无显著差异。结论综合分析临床资料和脑脊液资料有助于鉴别两种脑膜炎。     

立体定向靶向脑室内注射尿激酶治疗脑室出血铸型疗效分析

目的探讨立体定向靶向注射尿激酶治疗脑室出血铸型的疗效。方法采用立体定向靶向穿刺单侧或双侧脑室,后予以脑室内注射尿激酶行纤溶治疗,拔管后联合腰大池持续引流,预后采用ADL评定。结果全部未见颅内感染及再出血等并发症,ADLⅠ级2例,ADLⅡ级8例,ADLⅢ级8例,ADLⅣ级4例,ADLⅤ级2例,自动出院2例。结论立体定向靶向脑室内注射尿激酶治疗脑室出血铸型是挽救生命的一种重要方法,其方法安全、有效。     

Morphological changes following experimental intraventricular haemorrhage and intraventricular fibrinolytic treatment with recombinant tissue plasminogen activator

Intraventricular haemorrhage (IVH) occurs in up to 50% of patients with primary intracerebral haemorrhage and aneurysmal subarachnoid haemorrhage. It is a significant and independent contributor to mortality and morbidity in these intracranial haemorrhages. Using a model of isolated IVH, we assessed the morphological changes induced by intraventricular bleeding and investigated the effects of intraventricular fibrinolytic treatment following IVH. IVH was induced in 32 pigs by intraventricular infusion of 10 ml autologous blood along with thrombin. The treatment group received an intraventricular injection of 1.5 mg (1 mg/ml) tissue plasminogen activator (tPA) following the injection of blood. The placebo group received the same volume of normal saline. Morphological examinations of the brains were carried out 7 days and 6 weeks following IVH. The ventricles were incompletely filled with blood and significantly enlarged in the placebo group 7 days after the IVH. In contrast, no residual intraventricular clots were visible in the animals treated with tPA, and the diameters of the lateral ventricles had returned to normal within 7 days. Marked losses of the ependymal covering of the ventricular walls were found in the placebo-treated animals, while the ependymal layer was largely intact in the animals treated with tPA. No haemorrhages induced by tPA were observed. The results indicate that intraventricularly administered tPA significantly enhances the lysis of intraventricular blood clots, accelerates the resolution of acute posthaemorrhagic hydrocephalus, and preserves the integrity of the ependymal layer. Received: 6 October 1999 / Revised, accepted: 26 January 2000     

重组组织型纤溶酶原激活剂治疗脑室内出血

目的 探讨利用重组组织型纤溶酶原激活剂(rt-PA)脑室内给药治疗脑室出血的疗效和安全性. 方法 对自2005年11月至2007年10月收入我院的10例脑室出血患者CT确诊后,进行(单侧或双侧)脑室穿刺置管,4～6 h后经弓l流管缓慢注入rt-PA 4～8 mg,12～24 h重复1次,每24～48小时复查CT了解脑室内血肿清除情况,直至头颅CT扫描显示脑室内高密度影像消失.于脑室出血后30 d时对患者情况利用GOS评分进行评估. 结果 每个患者应用rt-PA总剂量为13～24 mg,30 d后GOS评分为良好4例,中残3例,重残2例,植物生存1例,无患者死亡,无出血、颅内感染等并发症,未发生引流管被血块堵塞情况. 结论 选择适宜剂量和方法的rt-PA脑室内给药能够加速脑室内血块溶解,保持脑室引流管通畅,减少血块占位效应.该方法能够安全有效地改善患者的预后.     

脑室内、鞘内应用抗生素联合脑脊液外引流治疗重症颅内感染

目的探讨重症颅内感染治疗的方法和效果。方法选择重症颅内感染60例,分成治疗组和对照组各30例,治疗组为抗生素静脉给药＋脑室内、鞘内应用抗生素联合脑脊液外引流组。根据病情选择放置腰椎蛛网膜下腔置管或脑室外引流管,鞘内注射或脑室内注射抗生素,每天持续引流排出脑脊液100～300ml,引流持续时间一般3～15d,最长20d。对照组为传统抗生素静脉给药组。结果治疗组意识恢复快,感染控制时间短,平均治疗天数（9．96±1．37）d,减少了并发症扣后遗症,病死率降低,疗效显著。治疗组有效率达到100％,好转率提高到90％,病死率10％,无严重并发症,明显优于对照组（P〈0．05）。结论脑室内、鞘内应用抗生素联合脑脊液外引流,可使脑脊液达到较高的药物浓度,并能不断置换蛛网膜下腔及脑室内的炎性脑脊液、减轻细菌毒素和有害物质对神经组织的损害,是治疗重症颅内感染的一种简便、微创、安全、疗效显著的新技术、新方法。     

21例脑室内中枢神经细胞瘤的临床分析

目的探讨脑室内中枢神经细胞瘤的临床特征和治疗方法。方法回顾性分析2009.10至2014.5收治的21例脑室内中枢神经细胞瘤患者的临床资料。结果其主要临床表现为头痛、呕吐、视力下降及视乳头水肿。全部病例均行显微手术治疗,肿瘤全切除17例,次全切除4例。21例随访患者,KPS80分者17例,60~80分3例,60分1例。结论脑室内中枢神经细胞瘤的临床表现和影像学无特异性,确诊需依靠病理检查;该病首选显微手术切除,次全切除患者术后应行辅助放疗;Brainlab神经导航结合术中使用管状脑牵开器(VBAS)能提高肿瘤的切除程度,有效减少手术创伤与围手术期并发症,改善患者术后生活质量。     

Terson syndrome caused by intraventricular hemorrhage associated with moyamoya disease

Terson syndrome was originally used to describe a vitreous hemorrhage arising from aneurysmal subrarachnoid hemorrhage. Terson syndrome can be caused by intracranial hemorrhage, subdural or epidural hematoma and severe brain injury but is extremely rare in intraventricular hemorrhage associated with moyamoya disease. A 41-year-old man presented with left visual disturbance. He had a history of intraventicular hemorrhage associated with moyamoya disease three months prior to admission. At that time he was in comatose mentality. Ophthalmologic examination at our hospital detected a vitreous hemorrhage in his left eye, with right eye remaining normal. Vitrectomy with epiretinal membrane removal was performed. After operation his left visual acuity was recovered. Careful ophthalmologic examination is mandatory in patients with hemorrhagic moyamoya disease.     

Ommaya管植入并持续腰大池引流治疗重症脑室出血

脑室出血临床较为常见.出血后脑脊液循环通路被堵塞,导致出血后急性脑积水发生,此为脑室出血最常见的并发症,并认为是导致脑室出血预后不良的主要原因Ⅲ.脑室外引流、反复腰大池穿刺或持续腰大池引流行脑脊液置换是治疗脑室出血的有效措施,目前在临床已得到普遍应用,但却有引流时间短、易感染、患者痛苦、引流管易堵塞等缺点.常熟市第二人民医院神经外科自2007年1月至2010年3月共收治27例重症脑室出血患者,对其应用Ommaya管进行侧脑室前角穿刺外引流加尿激酶冲洗,必要时清除脑室外血肿,同时采用美敦力体外引流及监测系统进行持续腰大池引流,取得了较为满意的疗效,现报道如下.