小脑扁桃体下疝合并脑积水的手术治疗策略

目的 探讨小脑扁桃体下疝合并脑积水的术前评估方法和手术治疗策略.方法 回顾性分析24例小脑扁桃体下疝合并脑积水患者,年龄2～27岁,其中男17例,女7例.手术前后均行磁共振脑脊液电影成像(Cine MRI)检查来测量相关部位(中脑导水管、四脑室出口、枕大孔)脑脊液的流速流量,根据患者具体情况行内镜下三脑室底造瘘术(ETV)或行ETV术+内镜下后颅凹减压术.结果 术前Cine MRI发现所有患者枕骨大孔区脑脊液流体动力学均有不同程度异常,术后复查头Cine MRI显示所有患者三脑室底造瘘口处均有脑脊液通过.随访时间6～36个月,有21例患者的临床症状改善,2例患者临床症状无缓解,二期行内镜下后颅凹减压术.有14例患者小脑扁桃体下疝有不同程度改善.结论 Cine MRI能准确测量枕骨大孔区脑脊液的流速流量和流动方式,是判断手术时机和制定手术方案的重要参考.小脑扁桃体下疝合并脑积水多为梗阻性脑积水,ETV术治疗这类脑积水疗效确切,可代替传统的分流术.此外,它还有助于缓解小脑扁桃体下疝,对合并的脊髓空洞症也有治疗作用.

Operative approach for hydrocephalus associated with cerebellar tonsillar hernia

Objective To assess the pre-operative examination and operative approach for hydrocephalus associated with cerebellar tonsillar hernia. Methods A retrospective analysis was conducted for 24 patients of hydrocephalus associated with cerebellar tonsillar hernia All subjects received both preoperative and post-operative Cine MRI examinations to detect the velocity and quantity of cerebrospinal fluid (CSF) at the important sites in ventricular system. A majority of cases had endoscopic third ventriculostomy (ETV) while others underwent both ETV and endoscopic posterior cranial fossa decompression. Results The pre-operative CSF hydrodynamics of all cases were abnormal at foramen magnum. A post-operative CSF flow through stoma might be detected by Cine MRI in all cases. The clinical symptoms improved to different extents in 21 cases while another two cases showed no improvement. Later these two patients underwent endoscopic posterior cranial fossa decompression. Cerebellar tonsillar hernia improved in 14 cases. Conclusion Cine MRI can detect the CSF hydrodynamics at craniocervical junction so as to help a surgeon determine the time and the plan of operation. Most cases of hydrocephalus associated with cerebral tonsillar hernia are of obstructive hydrocephalus. The efficacy of ETV for hydrocephalus has been confirmed. Also ETV has a therapeutic effect for cerebellar tonsillar hernia and syringomyelia.