神经内镜下第三脑室底造瘘术治疗梗阻性脑积水

梗阻性脑积水是神经外科的常见疾病之一,因患者往往伴有不同程度的颅内高压症状,随着病程的迁延,直接影响患者的生活质量。本院自2008年5月至2009年2月共收治梗阻性脑积水患者17例,     

神经内镜下第三脑室底造瘘术治疗非交通性脑积水（附37例分析）

目的总结神经内镜下第三脑室底造瘘术治疗非交通性脑积水的经验。方法对37例非交通性脑积水病人行神经内镜下第三脑室底造瘘术，随访12-36个月。结果35例病人术后症状明显缓解，且无明显并发症，2例无效者改行脑室-腹腔分流术后症状缓解。结论神经内镜下第三脑室底造瘘术治疗非交通性脑积水是一种微创、有效、术后恢复快、并发症少的手术方法。     

神经内镜下第三脑室底造瘘术治疗脑积水的临床效果

正目前,第三脑室底造瘘术是梗阻性脑积水的首选治疗方法~([1])。神经内镜下第三脑室底造瘘术(endoscopic third ventriculostomy,ETV)损伤小,并发症少。随着对于脑积水发病机制研究的不断加深和神经内镜技术的不断成熟,EVT逐渐应用于一些特殊类型的脑积水治疗,并且取得令人满意的效果。1 ETV治疗脑积水长期随访效果目前,ETV治疗脑积水的报道越来越多,但大多数只报道近期缓解率,远期缓解率的报道相对较     

神经内镜下第三脑室底造瘘术治疗梗阻性脑积水的疗效观察

目的 探讨神经内镜下第三脑室底造瘘术（ETV）治疗梗阻性脑积水的疗效。方法 2013年5月至2015年5月ETV治疗梗阻性脑积水42例。结果 成功造瘘39例,因术中出血二期行脑室-腹腔分流术3例。术中出现心率减慢4例、造瘘口少量出血3例,术后短暂发热21例、可疑感染1例、头皮切口漏2例。术后随访3~36个月,平均（10.4±2.7）个月;改善36例（85.7%）,无改变4例（9.5%）,恶化2例（4.8%）。术后3个月复查CT或MRI显示:侧脑室缩小33例（78.8%）,侧脑室无明显变化但前角间质性水肿减轻5例（11.9%）,侧脑室无变化4例（9.5%）。结论 ETV治疗梗阻性脑积水效果较好,手术操作简单,安全系数高,并发症少。     

神经内镜技术第三脑室底造瘘术治疗脑积水的进展

神经内镜技术在治疗脑积水方面发挥着重要而不可或缺的作用。在神经内镜技术中尤以第三脑室底造瘘术在治疗脑积水中最常见。本文阐述了第三脑室底造瘘术在治疗脑积水传统适应证——非交通性脑积水中的应用,同时也回顾了近些年该项技术在交通性脑积水和小儿脑积水中的应用进展。     

脑室镜三脑室造瘘术治疗小儿阻塞性脑积水

目的分析本组49例病例，就手术病种和年龄的选择、手术方法及技巧做一介绍。方法全组49例，年龄1个月-18岁，平均33个月。CT、MRI及^99Tc^m-DTPA证实为脑脊液吸收功能正常的阻塞性脑积水。手术方法为经侧脑室、室间孔、三脑室置入神经内镜，于三脑室底与脚间池造一瘘孔。结果术后随访半年-5年，39例有好转；10例因无改善于术后3个月再行脑室腹腔分流手术，术后脑脊液漏3例，未有出血、感染及神经功能损伤等并发症。结论脑室镜三脑室底脚间池造瘘适用于脑脊液吸收功能正常的阻塞性脑积水。脑脊液吸收功能判断需靠同位^99Tc^m-DTPA检查。继发性脑积水治疗效果好于原发性脑积水，大龄儿童效果好于婴幼儿。     

神经内镜下行三脑室底造瘘术治疗梗阻性脑积水的并发症分析和防治

目的:分析神经内镜下三脑室底造瘘术(ETV)的手术并发症原因,探讨其防治要点。方法:通过回顾性分析2004年9月至2006年2月应用ETV连续治疗梗阻性脑积水55例的手术并发症,对ETV的常见并发症的原因做了探讨。结果:54例患者ETV得以完成,术后50例患者恢复良好,脑积水症状明显减轻或消失。4例患者症状复发或加重,行脑室腹腔分流术。术后并发症包括硬膜下积液8例,发热15例,2例伴有脑膜刺激征为颅内感染,癫痫1例,硬膜外出血1例,头皮下积液8例。结论:熟悉三脑室底的解剖结构,选择合适的造瘘方法,并注意手术前后脑脊液动力学的变化,可以减少三脑室底造瘘治疗梗阻性脑积水的手术并发症。     

神经内镜下第三脑室底造瘘术治疗交通性脑积水

目的 探讨神经内镜下第三脑室底造瘘术成功治疗交通性脑积水的手术机制和指征.方法 回顾性分析18例神经内镜下第三脑室底造瘘术治疗交通性脑积水患者的临床资料.结果 11例患者术前MRI显示第四脑室异常扩张和“喇叭形”中脑导水管出口,其中9例效果良好;另外7例无此影像学特征的均失败而需进一步行分流术.结论 神经内镜下第三脑室底造瘘术是 治疗部分交通性脑积水的有效手段,而近端脑池梗阻可能是其重要的作用机制.第四脑室相对第三脑室异常扩张和“喇叭形”中脑导水管出口可能是此类患者的影像学特征,可作为第三脑室底造瘘术治疗交通性脑积水的手术指征之一.     

神经内窥镜第三脑室底造瘘术治疗梗阻性脑积水

目的 探讨对梗阻性脑积水患者采用神经内窥镜下进行第三脑室底造瘘的手术方法．分析手术成功与失败的原因。方法梗阻性脑积水原因分别为第三脑室后部肿瘤5例，中脑顶板胶质瘤2例，Chiari畸形2例，另12例为不明原因引起的导水管梗阻或狭窄。同位素^99Tcm-TPA脑池显像显示为非脑脊液吸收障碍性阻塞性脑积水。神经内窥镜从侧脑室经蒙氏孔进入第三脑室，在乳头体前方第三脑室底最薄处造一瘘口与脚间池相通。结果术后随访12～26个月，所有患者脑积水症状均缓解，脑室体积缩小。结论神经内窥镜行第三脑室底造瘘治疗非脑脊液吸收障碍性脑积水是一种有效的微创手术。     

神经内镜第三脑室底造瘘术治疗梗阻性脑积水及其术后颅内压的监测

目的探讨神经内镜第三脑室底造瘘术（ETV）治疗梗阻性脑积水的效果及其术后颅内压（ICP）监测的意义。方法采用ETV治疗梗阻性脑积水36例，其中术后行ICP动态监测9例。结果术后患者症状缓解33例（91．7％），复查头颅CT或MRI示脑室系统较术前缩小；3例（8.3％）肿瘤引起的梗阻性脑积水症状缓解不明显，改行脑室-腹腔分流术。本组无死亡病例。9例术后行ICP监测结果示：①ETV术后18h内平均ICP〈10mmHg，18h后平均ICP轻度上升，稳定于10-12mmHg之间，肿瘤引起的脑积水ICP上升较快；②4例单纯导水管梗阻性脑积水术后使用甘露醇，用药后1-2h ICP下降1-2mmHg，2h后ICP逐渐恢复至用药前水平。结论①ETV后18h内ICP稍低，可能与术中放出脑脊液过多有关，可暂不应用脱水药物；②肿瘤引起的梗阻性脑积水应积极治疗原发病变。     

The Efficacy Analysis of Endoscopic Third Ventriculostomy in Infantile Hydrocephalus

Objective

To investigate the efficacy of endoscopic third ventriculostomy (ETV) for infantile hydrocephalus.

Methods

Retrospectively reviewed the 17 infantile hydrocephalus cases who were treated with ETV between July 2009 and June 2013. The study includes 17 patients (4 Han and 13 Hui) between the ages of 51 and 337 days. Five cases with encephalitis history and 2 cases with cerebral hemorrhage, with the remaining 10 cases congenital hydrocephalus. ETVs were performed for all patients with 1 case failing because the severe ventricle inflammatory adhesion, excessive exudation, and vague basilar artery.

Results

Among the 16 successful cases 7 cases improved remarkably : heads and ventricles reduced and cerebral cortexes thickening morphologically. The ventricles of the remaining cases were unchanged.

Conclusion

The ethnic minority account for the majority of the patients in this study. ETV is effective for infantile obstructive hydrocephalus.     

神经内镜下三脑室底造瘘术治疗交通性脑积水(15例报告)

目的 探讨神经内镜下行三脑室底造瘘术治疗交通性脑积水的手术适应证.方法 15例交通性脑积水病人均行神经内镜下三脑室底造瘘术,术前术后行NPH评分,测Evans指数,腰穿测颅内压,脑池显像观察脑脊液动力学的改变.结果 患者术后NPH评分平均提高(3.26±1.83),Evans指数平均减小(0.11±0.09),颅内压平均下降(66.3±65.8)mmH2O,均较术前改善,差异有统计学意义(P<0.05),脑池显像表明放射性示踪剂在术后1~3h进入侧脑室,术后6h离开侧脑室,术后24h于大脑凸面呈大致对称的放射性分布.结论 神经内镜下三脑室底造瘘术可应用于交通性脑积水,造瘘同时穿透Liliequist膜间脑叶具有重要意义.     

Endoscopic Third Ventriculostomy in Patients with Shunt Malfunction

Objective

This paper presents data from a retrospective study of endoscopic third ventriculostomy (ETV) in patients with shunt malfunction and proposes a simple and reasonable post-operative protocol that can detect ETV failure.

Methods

We enrolled 19 consecutive hydrocephalus patients (11 male and 8 female) who were treated with ETV between April 2001 and July 2010 after failure of previously placed shunts. We evaluated for correlations between the success rate of ETV and the following parameters : age at the time of surgery, etiology of hydrocephalus, number of shunt revisions, interval between the initial diagnosis of hydrocephalus or the last shunt placement and ETV, and the indwelling time of external ventricular drainage.

Results

At the time of ETV after shunt failure, 14 of the 19 patients were in the pediatric age group and 5 were adults, with ages ranging from 14 months to 42 years (median age, 12 years). The patients had initially been diagnosed with hydrocephalus between the ages of 1 month 24 days and 32 years (median age, 6 years 3 months). The etiology of hydrocephalus was neoplasm in 7 patients; infection in 5; malformation, such as aqueductal stenosis or megacisterna magna in 3; trauma in 1; and unknown in 3. The overall success rate during the median follow-up duration of 1.4 years (9 days to 8.7 years) after secondary ETV was 68.4%. None of the possible contributing factors for successful ETV, including age (p=0.97) and the etiology of hydrocephalus (p=0.79), were statistically correlated with outcomes in our series.

Conclusion

The use of ETV in patients with shunt malfunction resulted in shunt independence in 68.4% of cases. Age, etiology of hydrocephalus, and other contributing factors were not statistically correlated with ETV success. External ventricular drainage management during the immediate post-ETV period is a good means of detecting ETV failure.     

A Case of Osteogenesis Imperfecta Type II Caused by a Novel COL1A2 Gene Mutation: Endoscopic Third Ventriculostomy to Prevent Hydrocephalus

Osteogenesis imperfecta (OI) is a hereditary connective tissue disorder caused by defects in type I collagen synthesis. OI is generally classified into four types (I to IV), and the clinical prognosis varies from a lethal outcome for type II and varying deformities for type III to a normal lifespan for the other types. We describe a female patient with biochemically confirmed OI caused by a novel mutation in the COL1A2 gene. Persistence of blue sclerae supported the diagnosis of OI type II. The case was complicated with obstructive hydrocephalus, for which endoscopic third ventriculostomy (ETV) was performed. The ETV was transiently effective for the obstructive hydrocephalus. The patient subsequently developed brain atrophy, partly through ischemic events after the ETV, which appeared to contribute to maintenance of smooth circulation of the cerebrospinal fluid. We conclude that continuous and adequate medical care including ETV can facilitate long-term survival even in lethal OI type II.     

Hydrocephalus in posterior fossa lesions: Ventriculostomy and permanent shunt rates by diagnosis

Abstract

Objectives: The rate of ventriculostomy for acute hydrocephalus and progression to shunt-dependent chronic hydrocephalus in patients with posterior fossa lesions are not well known.

Methods: We retrospectively reviewed 104 consecutive cases with posterior fossa lesions on admission to the University of Illinois Hospital from June 2002 to December 2005. We recorded the rate of ventriculostomy and permanent ventricular shunting, which were compared among etiologic groups, using chi-squared and Fisher's exact tests.

Results: Overall, 35 patients had ventriculostomy for acute hydrocephalus and 16 had permanent shunting for shunt-dependent chronic hydrocephalus. Of those with primary posterior fossa intracranial hemorrhage (ICH) (42 cases), 19 (45%) required ventriculostomy, with five (26%) requiring subsequent permanent shunting; 13 patients had hematoma evacuation, with two having permanent shunting. Of those with cerebellar infarction (14 cases), four (29%) required ventriculostomy and one (25%) had a permanent shunt; two had a decompressive craniectomy. Of those with neoplasms (43 cases, 33 surgically resected), ten (23%) required ventriculostomy and nine (21%) required permanent shunting. In addition, two of the three cases with infectious processes required ventriculostomy and one required a permanent shunt. In-hospital mortality was 21% (9/42 cases) for patients with ICH, 14% (2/14 cases) for patients with infarction and 0% for all others.

Discussion: Acute primary posterior fossa hemorrhage has the highest rate of ventriculostomy for acute hydrocephalus and highest inpatient mortality but a surprisingly low rate of permanent shunt-dependency. When hydrocephalus was caused by a neoplasm, there was a higher rate of permanent shunt placement.     

体外可调压分流管经皮穿刺腰大池-腹腔分流术治疗交通性脑积水

目的探讨体外可调压分流管经皮穿刺腰大池-腹腔分流术治疗交通性脑积水的可行性及其优势。方法对23例各种原因引起的交通性脑积水病人行体外可调压分流管经皮穿刺腰大池-腹腔分流术,评价此手术与传统手术的优越性。结果随访3~18个月,23例病人治疗效果明显,经CT检查见脑室系统均恢复正常大小,无分流过度或不足表现,并发症少。结论体外可调压分流管经皮穿刺腰大池-腹腔分流术治疗交通性脑积水的手术效果均优于固定阈值分流管微创腰大池-腹腔分流手术及传统脑室-腹腔分流术。     

Ventriculostomy and Risk of Upward Herniation in Patients with Obstructive Hydrocephalus from Posterior Fossa Mass Lesions

Background

Patients with posterior fossa lesions causing obstructive hydrocephalus present a unique clinical challenge, as relief of hydrocephalus can improve symptoms, but the perceived risk of upward herniation must also be weighed against the risk of worsening or continued hydrocephalus and its consequences. The aim of our study was to evaluate for clinically relevant upward herniation following external ventricular drainage (EVD) in patients with obstructive hydrocephalus due to posterior fossa lesions.

Methods

We performed a retrospective review of patients undergoing urgent/emergent EVD placement at our institution between 2007 and 2014, evaluating the radiographic and clinical changes following treatment of obstructive hydrocephalus.

Results

Even prior to EVD placement, radiographic upward herniation was present in 22 of 25 (88%) patients. The average Glasgow Coma Scale of patients before and after EVD placement was 10 and 11, respectively. Radiographic worsening of upward herniation occurred in two patients, and upward herniation in general persisted in 21 patients. Clinical worsening occurred in two patients (8%), though in all others the clinical examination remained stable (44%) or improved (48%) following EVD placement. Of the patients who had a worsening clinical exam, other variables likely also contributed to their decline, and cerebrospinal fluid diversion was likely not the main factor that prompted the clinical change.

Conclusions

Radiographic presence of upward herniation was often present prior to EVD placement. Clinically relevant upward herniation was rare, with only two patients worsening after the procedure, in the presence of other clinical confounders that likely contributed as well.