对伴有脑脊液道室外顺行性梗阻的特发性脑积水患者进行内窥镜治疗

K. V. Shevchenko, V. Shimanskiy, S. V. Tanyashin, V. K. Poshataev, V. V. Karnaukhov, K. Solozhentseva, I. Pronin, Y. Strunina, L. R. Gabrielyan, I. O. Kugushev
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摘要

20 世纪中叶,脑室外 CSF 通路阻塞的可能性被证实。神经影像学(主要是核磁共振成像)和内窥镜技术的发展使得在狭窄的解剖走廊中计划和实施微创手术成为可能,并实现了神经症状的消退。研究目的:确定内窥镜手术治疗特发性室外脑脊液通路阻塞所致脑积水的有效性。材料和方法。2007年至2020年期间,65名有室外梗阻症状的患者在神经外科中心接受了检查和手术治疗。术前Kiefer量表评分为6.8±3.3(0-15)分,Rankin量表评分为2.2±1(0-5)分。42例(64.6%)患者的首次手术为内镜下第三脑室造口术。17例(26.1%)患者进行了脑室腹腔分流术。6例(9.2%)患者未进行手术。手术结果内窥镜手术后,患者的病情在 2 个月和 12 个月后明显好转(P < 0.001)。手术 1 年后,85% 的患者症状完全或部分消失。分流手术后的趋势与之相当。唯一会发生变化并与患者病情相关的放射学参数是绒毛膜前的位置和血流空隙。大脑 CSF 系统的其余指标实际上没有变化。在所有内窥镜手术病例中,都在绒毛膜下发现了与术前断层扫描结果相符的额外膜团。结论。内镜下第三脑室蝶窦造口术效率高,因此推荐将此技术作为室外CSF通路阻塞患者的主要治疗方法,但第三脑室底区解剖异常(绒毛膜前膜短且基底分叉高)和后颅窝基底蝶窦(蝶窦狭窄,其尺寸不允许将内镜插入绒毛膜前膜下)的病例除外。
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Endoscopic treatment of patients with idiopathic hydrocephalus with extraventricular cisternal obstruction of the cerebrospinal tract
The possibility of developing extraventricular CSF pathways obstruction was demonstrated in the mid-20th century. The development of neuroimaging (mainly MRI) and endoscopic techniques made it possible to plan and perform minimally invasive surgeries in a narrow anatomical corridor and achieve the regression of neurological symptoms. Purpose of the study: to determine the effectiveness of endoscopic surgery for hydrocephalus due to idiopathic extraventricular CSF pathways obstruction. Materials and methods. Sixty-five patients with signs of extraventricular obstruction underwent examination and surgical treatment at the Center of Neurosurgery from 2007 to 2020. The preoperative Kiefer Scale score was 6.8±3.3 (0-15) points, and the Rankin Scale score — 2.2±1 (0-5) points. Endoscopic third ventriculocisternostomy was performed as the first operation in 42 (64.6 %) patients. Ventriculoperitoneal shunting was performed in 17 (26.1 %) patients. Six (9.2 %) patients were not operated on. Results. After endoscopic surgery, the condition of the patients significantly improved (p < 0.001) after 2 and 12 months. Complete or partial regression of symptoms was noted in 85 % of the patients 1 year after surgery. After shunt surgery, the trend was comparable. The only radiological parameter that changes and correlates with the patients’ condition is the position of the premammillary membrane and the flow void. The remaining indicators of the CSF system of the brain did not actually change. In all cases of the endoscopic surgery, an additional membrane conglomerate that corresponded to preoperative tomograms was found under the premammillary membrane. Conclusion. The high efficiency of endoscopic third ventriculocisternostomy allows recommending this technique as the primary one in patients with extraventricular CSF pathways obstruction, with the exception of cases of anatomy abnormalities of the third ventricular fundus area (short premammillary membrane in combination with a high-lying basilar bifurcation) and cisterns of the posterior cranial fossa base (narrow cisterns, whose dimensions do not allow inserting an endoscope under the premamillary membrane).
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