神经内镜在囊性颅咽管瘤治疗中的作用

目的 探讨神经内镜在巨大囊性颅咽管瘤治疗中的作用。方法 对巨大囊性颅咽管瘤伴有梗阻性脑积水的15例患者,应用神经内镜先缩小肿瘤体积、解除梗阻性脑积水并穿通囊内分隔,之后再辅以放射治疗或显微手术切除。结果 15例患者术后颅内压增高症状均消失、术前症状改善。影像学复查(CT或MR)见肿瘤均缩小至鞍区、脑积水消失。除1例有暂时多尿及低钠外,余无其他严重并发症。内镜治疗后再手术全切除肿瘤的3例患者术后反应明显减轻。结论 对有囊性变并伴有脑积水的巨大颅咽管瘤,先采用神经内镜手术,是进一步提高治疗效果、降低致残率和死亡率的有效方法。     

颅内蛛网膜囊肿研究进展

当前国内外对颅内蛛网膜囊肿(arachnoid cyst,AC)的研究越来越多,但在其发病机制、临床特征、诊断及治疗方法等方面仍存在较多的争议.囊肿的手术指征及手术方式也是目前争论的焦点之一.随着神经内镜技术的引进,越来越多的神经外科医生偏爱于神经内镜手术,但内镜治疗的可靠性即远期疗效仍缺乏长期的大宗的病例随访.AC是脑实质外非肿瘤性的良性病变,约占颅内占位性病变的1%~([1]).随着影像学设备的普遍运用,颅内囊肿的发现率有明显上升趋势.AC常多见于小孩,常因外伤后影像学检查发现,也因囊肿扩大或出血产生临床症状而发现.本文参阅了近几年国外文献研究进展,对AC的发病机制、诊断及治疗方法综述如下.     

A new method for transcutaneous coaxial neuroendoscopy

A new method of direct endoscopy of the subarachnoid space and a major part of the ventricles of the human central nervous system is presented. The technique was developed on more than 100 human bodies with the help of a bronchoscope. Percutaneous entry into the subarachnoidal space is performed from the dorsal side between vertebrae L5 and S1. The endoscope can be moved along the spinal cord on both the dorsal and the ventral side. From the dorsal side of spinal cord the cerebello-medullary cistern can be reached. The fourth ventricle is entered through the median aperture and then the third ventricle through the cerebral aqueduct. From the ventral side of the spinal cord the posterior cranial fossa is reached and the large arteries and the cranial nerves can be inspected. The main conclusion of the present report is that the subarachnoid space seems to be large enough for a coaxial exploration with a 3–5 mm diameter fibroscope if the investigator possesses a good knowledge of the subarachnoid anatomy. The technique provides new approaches in research and possibilities of clinical investigations and therapy.     

Microsurgical third ventriculocisternostomy as an alternative to ETV: report of two cases

Objective To describe a microsurgical alternative to endoscopic third ventriculocisternostomy. Methods Two children with shunt-dependent hydrocephalus and multiple shunt revisions were considered candidates for third ventriculocisternostomy (TVS). Because of slit ventricles, an endoscopic approach was not possible and, therefore, both patients received a microsurgical TVS by a supraorbital approach. Results In both cases, microsurgical TVS was successful and the patients became shunt free. Conclusion Microsurgical TVS by a supraorbital craniotomy is a viable alternative to endoscopic TVS in selected cases.     

Endoscopic third ventriculostomy for obstructive hydrocephalus

The indications for neuroendoscopy are not only constantly increasing, but even the currently accepted indications are constantly being adjusted and tailored. This is also true for one of the most frequently used neuroendoscopic procedures, the endoscopic 3rd ventriculostomy (ETV) for obstructive hydrocephalus. ETV has gained popularity and widespread acceptance during the past few years, but little attention has been paid to the techniques of the procedure. After a short introduction describing the history of ETV, an overview is given of all the different techniques that have been and still are employed to open the floor of the 3rd ventricle. The spectrum of indications for ETV has been widely enlarged over the last years. Initially, the use of this procedure was restricted to patients older than 2 years, to patients with an obvious triventricular hydrocephalus, and to those with a bulging, translucent floor of the 3rd ventricle. Nowadays, indications include all kinds of obstructive hydrocephalus but also communicating forms of hydrocephalus. The results of endoscopic procedures in treating these pathologies are given under special consideration of shunt technologies. In summary, from the review of the publications since the first ETV performed by Mixter in 1923, this technique is the treatment of choice for obstructive hydrocephalus caused by different etiologies and is an alternative to cerebrospinal fluid shunt application.Commentaries on this paper are available at and     

Role of neuroendoscopy in the management of patients with tuberculous meningitis hydrocephalus

The role of neuroendoscopy in patients of tuberculous meningitis with hydrocephalus (TBMH) is not yet established. We present details of endoscopic morphology, and analyze outcome of Neuroendoscopy performed in 28 patients (15 males and 13 females, average age 23 years) of TBMH in last 2.5 years. Endoscopic procedures performed included endoscopic third ventriculostomy (ETV) alone (n=19), ETV with monroplasty (n=2), and septostomy (n=2), ETV with decompression/biopsy of tuberculoma (n=2) and with abscess drainage (n=1). Outcome was assessed on the basis of clinico-radiological improvement, need for external shunt and complications. Outcome was satisfactory in 14 (50%), acceptable in five (18%) and unsatisfactory in nine (32%) patients. Overall, 19 (68%) patients benefited from endoscopic intervention. Cerebrospinal fluid (CSF) leak (n=2) and per-operative bleeding (n=1) were the only complications encountered. Endoscopy appears to be helpful in a considerable number of patients with TBMH, and should be considered as the first surgical option for CSF diversion surgery in these patients. External shunt should be reserved for those who fail the endoscopic CSF diversion.     

Angiographic catheter: unique tool for neuroendoscopic surgery

BACKGROUND: Neuroendoscopic removal of intraventricular and juxtaventricular space-occupying lesions (SOL) requires long and thin instruments that can be maneuvered through the compromised working channels. Currently, various rigid and flexible forceps and scissors are being used for this purpose. We present our experience of using cut segment of angiographic catheters for removal of intraventricular and juxtaventricular SOL by neuroendoscopic surgery. METHOD: Seventy-one patients having intraventricular and juxtaventricular lesions were excised, decompressed, or biopsied by endoscopic method using angiographic catheters. Lesions were cystic, solid, or mixed cystic and solid. Cystic lesions were aspirated; solid tumors were biopsied, decompressed, or excised by sucking them using 5F to 8F angiographic catheters cut to the length of 30 to 35 cm. RESULT: Total excision, near total removal, and biopsy of the lesions could be achieved in 14, 19, and 38 patients, respectively; however, in 2 patients of thalamic tumor, the biopsied tissue was negative for tumor. Tumor consistency was the deciding factor for their removal by angiographic catheters; soft lesions were sucked easily, whereas only biopsy could be done in firm and nonsuckable lesions. Major bleeding in a case of craniopharyngioma was the complication managed by irrigation followed by external ventricular drain. CONCLUSION: Angiographic catheter is a simple and unique tool for neuroendoscopic surgery. It aids in endoscopic management of diverse intraventricular and juxtaventricular lesions.     

神经内镜与显微镜经远外侧锁孔入路在颅颈交界区手术中应用的解剖学对比研究

目的 探讨神经内镜与显微镜经远外侧锁孔入路行颅颈交界区手术中,枕髁磨除前后的解剖观察范围,并分析枕髁磨除的意义。方法 纳入10%甲醛固定的5例（10侧）成年国人尸头标本,动静脉分别以红、蓝乳胶灌注,其中男3具、女2具,年龄58~70岁、平均61岁。模拟远外侧手术入路：取乳突后“S”形切口、枕髁后微骨窗开颅,分别在显微镜和神经内镜下操作,观察磨除枕髁前后镜下术野显露的解剖结构,测量并计算延髓腹外侧的显露面积,对比2种手术入路的观察范围。结果 显微镜经远外侧锁孔入路可显露成人尸头标本后组颅神经、椎动脉、基底动脉、小脑前下动脉和小脑后下动脉,枕髁磨除后扩大了对椎动脉、舌下神经、延髓侧方及腹侧的显露。神经内镜经远外侧锁孔入路通过面听-舌咽神经间隙、舌咽-迷走神经间隙、迷走-副神经颅根间隙和副神经脊髓根腹侧间隙,可观察后组颅神经、椎动脉、基底动脉、小脑前下动脉、小脑后下动脉、脑干侧面及腹侧面;磨除枕髁前、后内镜下延髓腹外侧显露面积分别为（331.0±6.6）mm²和（464.7±10.6）mm²,差异有统计学意义（t=52.99, P<0.001）;磨除枕髁前、后显微镜下延髓腹外侧显露面积分别为（205.8±9.6）mm²和（329.1±6.7）mm²,差异有统计学意义（t=75.07, P<0.001）;磨除枕髁前、后内镜下延髓腹外侧显露面积均大于显微镜下,差异均有统计学意义（t=62.18、64.62, P值均<0.001）;内镜磨除枕髁前与显微镜磨除枕髁后的显露面积差异无统计学意义（t=1.63, P=0.137）。结论 远外侧锁孔入路磨除枕髁后神经内镜与显微镜2种手术方式均能增加延髓腹外侧的显露面积;神经内镜远外侧锁孔入路不磨除枕髁即可获得良好的、与显微镜远外侧锁孔入路磨除枕髁后相似的显露范围,对脑干腹侧面、椎动脉、基底动脉等深部结构的显露更具优势,临床手术中可免于磨除枕髁。     

神经内窥镜手术治疗难治性脑积水

目的：探讨治疗难治性脑积水的新方法。方法：采用神经内窥镜的新技术,对３４例难治性脑积水进行治疗,对其中１８例梗阻性脑积水第三脑室底造瘘,对１４例交通性脑积水行脉络丛凝固,对２例伴有单侧室间孔闭塞的交通性脑积水透明隔造瘘。结果：随访６￣２５个月、３４例中２８例（８２％）有效,其中１８例梗阻性脑积水全部有效,１４例交通性脑积水８例有效,６例无效,２例伴有单侧室间孔闭塞的交通性脑积水均有效。无严重并发症     

经鼻蝶窦神经内镜下垂体瘤切除术并发脑脊液漏的处理策略

目的 探讨神经内镜下经蝶窦垂体瘤切除术中及术后出现脑脊液漏的处理策略.方法 回顾性分析158例垂体瘤病人的临床资料,出现脑脊液漏病例31例,根据脑脊液漏分级标准,术中给予处理.结果 31例脑脊液漏病例术后恢复均佳.结论 术前预判,术中出现脑脊液漏根据分级进行处理,术后仍有脑脊液漏则进行腰大池置管引流.