發(fā)布時(shí)間：2018-08-29 16:26

【摘要】：研究背景和目的 腦積水是神經(jīng)外科醫(yī)生面臨的最常見(jiàn)和棘手的臨床疾病之一,其發(fā)病機(jī)制復(fù)雜,其根本治療在于外科手術(shù),藥物治療多為臨時(shí)措施。影像學(xué)多表現(xiàn)腦室腦池?cái)U(kuò)張,或單純側(cè)腦室擴(kuò)張,原因有原發(fā)性的中腦導(dǎo)水管梗阻、囊腫或腫瘤壓迫,或顱內(nèi)出血后引起蛛網(wǎng)膜顆粒吸收不良或吸收障礙。部分患者無(wú)明顯臨床癥狀,體檢或外傷檢查發(fā)現(xiàn),大多數(shù)患者出現(xiàn)臨床癥狀后發(fā)現(xiàn),其發(fā)生機(jī)制以及分類(lèi)等目前仍存爭(zhēng)議大,爭(zhēng)議主要有兩點(diǎn)：一是梗阻性腦積水與交通性腦積水的判斷標(biāo)準(zhǔn),二是神經(jīng)內(nèi)鏡對(duì)腦積水治療的適應(yīng)癥。目前診斷腦積水的方式除了結(jié)合臨床癥狀以外主要依靠CT和MR影像學(xué)檢查。CT和MRI檢查方便,損傷較小,所以在腦積水的診斷和隨訪中有重要價(jià)值。但是腦積水病理機(jī)制復(fù)雜,有些時(shí)候很難發(fā)現(xiàn)阻塞性病變,無(wú)法明確診斷,對(duì)手術(shù)的選擇比較困難。有文獻(xiàn)報(bào)道磁共振彌散加權(quán)成像(diffusion。weighted imaging, DWI)及相位對(duì)比電影法能明確鑒別,但本研究預(yù)實(shí)驗(yàn)證實(shí)其準(zhǔn)確率低,可行性需要進(jìn)一步研究。因此,我們提出CT腦池造影檢查(CT cistemography, CTC),并證實(shí)CTC是明確鑒別交通性與非交通性腦積水的有效方法。且對(duì)腦積水的治療能起到一定的指導(dǎo)作用。CT腦池顯像是將無(wú)刺激性的,不參與代謝的水溶性非離子碘劑經(jīng)腰椎穿刺術(shù)注入蛛網(wǎng)膜下腔,然后非離子碘劑沿著腦脊液循環(huán)途徑逆行上行,依次進(jìn)入各個(gè)腦池腦室,最后到達(dá)大腦凸面上矢狀竇吸收入血液,用CT螺旋掃描可顯示蛛網(wǎng)膜下腔的通暢情況,經(jīng)三維重建可見(jiàn)各腦室腦池之間造影劑的成像,以及腦脊液循環(huán)通路的動(dòng)力學(xué)是否發(fā)生改變,明確梗阻部位。神經(jīng)內(nèi)鏡使用之前,分流術(shù)一直是腦積水外科治療的首先方法,但分流術(shù)術(shù)后后存在的問(wèn)題是并發(fā)癥較多多,容易發(fā)生分流管堵塞、感染、分流過(guò)度或者不足等,最終導(dǎo)致手術(shù)失敗。McGirt報(bào)告308例腦積水的分流術(shù)因手術(shù)失敗行分流管調(diào)整術(shù)528次。分流術(shù)后病人體內(nèi)將終身留置異物,低齡病人隨身材長(zhǎng)高還可能須多次換管,因此如何避免行分流術(shù)一直是神經(jīng)外科醫(yī)師關(guān)注的重要問(wèn)題。隨著神經(jīng)內(nèi)鏡的發(fā)展,神經(jīng)內(nèi)鏡下治療梗阻性腦積水已成首選術(shù)式,具有手術(shù)打擊小,術(shù)后恢復(fù)快,并發(fā)癥少,住院周期短等諸多優(yōu)點(diǎn),對(duì)梗阻性腦積水的遠(yuǎn)期療效達(dá)90%以上。國(guó)內(nèi)外有報(bào)道神經(jīng)內(nèi)鏡治療分流術(shù)后腦室腹腔分流管堵塞導(dǎo)致分流失敗的腦積水病例,預(yù)后效果可。 本研究對(duì)48例病例行進(jìn)行CTC檢查并進(jìn)行了前瞻性研究,探討CTC在腦積水疾病的診斷及治療中的運(yùn)用價(jià)值。腦積水的治療原則一直都是國(guó)內(nèi)外爭(zhēng)論的主題。爭(zhēng)議的焦點(diǎn)在于手術(shù)指征把握及手術(shù)方式的選擇,即哪種類(lèi)型的腦積水需要手術(shù)治療,哪種手術(shù)方式最佳,眾多文獻(xiàn)報(bào)道不一,通過(guò)CTC檢查明確腦積水類(lèi)型,選擇正確的手術(shù)方式及減少病人痛苦是本文的研究重點(diǎn)。 方法 1、CT腦池造影在腦積水診斷中的應(yīng)用 通過(guò)分析總結(jié)我院神經(jīng)外科2011年2月-2012年12月48例腦積水患者進(jìn)行CT腦池造影,根據(jù)造影結(jié)果診斷腦積水的類(lèi)型和選擇治療方式。分析CTC檢查與常規(guī)CT/MRI的診斷準(zhǔn)確率。分析造影過(guò)程中顱內(nèi)壓對(duì)造影劑擴(kuò)散的影響。 2、CT腦池造影在腦積水神經(jīng)內(nèi)鏡三腦室底造瘺術(shù)后的應(yīng)用 24例梗阻性腦積水患者行三腦室底造瘺術(shù)后,隨機(jī)抽取8例患者術(shù)后一周進(jìn)行CTC復(fù)查,根據(jù)造影劑的擴(kuò)散情況分析三腦室底造瘺術(shù)后腦脊液通路改善情況；通過(guò)術(shù)前術(shù)后腰穿壓力比較,分析三腦室底造瘺的效果。術(shù)后進(jìn)行常規(guī)的CT或MRI影像資料隨訪。 2、統(tǒng)計(jì)學(xué)處理 所有結(jié)果均應(yīng)用SPSS13.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析,采用T檢驗(yàn)、方差分析和卡方檢驗(yàn)。P≤0.05視為有統(tǒng)計(jì)學(xué)意義。 結(jié)果 1、CT腦室腦池造影在腦積水診斷中的應(yīng)用 1.1、影像檢查結(jié)果本組48例患者術(shù)前均行頭顱CT檢查,40例行頭顱MR檢查,本組48例均行CT腦池造影,其中22例腦室腦池造影劑均顯影,腦室腦池及蛛網(wǎng)膜下腔造影劑填充,證實(shí)交通性腦積水；其中26例造影劑擴(kuò)散的通路上出現(xiàn)不同程度的梗阻現(xiàn)象,診斷為非交通性腦積水。 (1)交通性腦積水：腦池顯像雙側(cè)側(cè)腦室顯影并持續(xù)滯留即診斷為交通性腦積水,影像冠狀位可以看到造影劑擴(kuò)散至側(cè)腦室與三腦室、四腦室,影像矢狀位可以看到造影劑擴(kuò)散從枕大池-四腦室-經(jīng)中腦導(dǎo)水管到達(dá)三腦室-雙側(cè)側(cè)腦室,基底池及幕上蛛網(wǎng)膜下腔均充盈良好。 (2)非交通性腦積水：大多為部位梗阻性腦積水,腦池影像無(wú)固定的特征,因梗阻部位不同可有不同表現(xiàn),側(cè)腦室一般不顯影,部分梗阻性腦積水的患者造影劑長(zhǎng)時(shí)間滯留于枕大池和基底池,CT掃描時(shí)冠狀位無(wú)“Y”型影像。 1.2、CTC與常規(guī)CT/MRI診斷結(jié)果的比較。 本組病例CT腦池影像結(jié)果提示26例為非交通性腦積水,其中有15例在常規(guī)CT/MRI診斷為梗阻性腦積水的患者,符合CTC診斷結(jié)果。其中CTC檢查中有2例因倒位原因造影劑擴(kuò)散不佳,交通性腦積水誤診為梗阻性腦積水,診斷準(zhǔn)確率95.8%；常規(guī)CT/MRI檢查中有2例交通性診斷為梗阻性,5例梗阻性診斷為交通性,診斷準(zhǔn)確率為85.4%。 1.3、顱內(nèi)壓對(duì)造影劑擴(kuò)散的影響 從腰椎穿刺注入造影劑,進(jìn)行逆向擴(kuò)散CT顯影,為了探討顱內(nèi)壓對(duì)造影劑擴(kuò)散的影響,對(duì)41例行腦室腦池造影的病例進(jìn)行回顧性分析,41例病例中的腦室腦池內(nèi)均充盈造影劑。并且采用同樣的造影方式和造影劑擴(kuò)散時(shí)間。根據(jù)腰穿壓力分成兩組,一組腰椎穿刺壓力≥200mmH2O,另一組腰椎穿刺測(cè)壓壓力在正常范圍,即200mmH2O,通過(guò)兩組造影劑在腦室腦池的顯影情況CT值(Hu)進(jìn)行比較。結(jié)果顯示兩組造影劑擴(kuò)散的效果無(wú)明顯的統(tǒng)計(jì)學(xué)差異,P0.05。 2、CTC在腦積水神經(jīng)內(nèi)鏡三腦室底造瘺術(shù)中的應(yīng)用 (1)24例患者術(shù)后6個(gè)月復(fù)查MRI,其中14例患者腦室腦池明顯縮小,術(shù)前頭痛頭暈癥狀消失,其中3例術(shù)前意識(shí)障礙患者,術(shù)后意識(shí)障礙明顯改善；5例腦室腦池稍縮小,臨床癥狀明顯改善；6例患者影像學(xué)無(wú)明顯變化,其中4例臨床癥狀明顯改善,1例因腦積水吸收障礙再次行腦室腹腔分流術(shù)后改善。 (2)24例患者術(shù)后3天行腰椎穿刺檢查,排除行腰穿術(shù)前靜脈使用甘露醇注射液。其中13例腰穿壓力70～100mmH2O,6例腰穿壓力110～150mmH2O,3例為160～180mmH2O,2例≥180mmH2O。術(shù)前術(shù)后腰穿壓力比較結(jié)果顯示P0.05,提示有統(tǒng)計(jì)學(xué)意義,造瘺術(shù)后壓力改善。 (3)術(shù)后一周隨機(jī)抽取8例進(jìn)行CTC復(fù)查,結(jié)果顯示8例病例腦室均充盈造影劑。3例術(shù)前四腦室擴(kuò)張明顯患者,術(shù)后四腦室明顯縮小,術(shù)后1個(gè)月復(fù)查MRI,腦室腦池基本正常。 結(jié)論 1、CT腦池造影在腦積水的診斷中,尤其是對(duì)梗阻性腦積水與交通性腦積水的鑒別診斷中的作用尤為重要,且CTC檢查為腦積水是否手術(shù)治療以及選擇手術(shù)方式提供可靠的依據(jù),CTC較常規(guī)CT/MRI的診斷準(zhǔn)確率高。 2、合理劑量下進(jìn)行CT腦室腦池造影檢查是安全的有效的, CT腦池造影雖為有創(chuàng)性檢查方法,但它是一種簡(jiǎn)便、安全、可靠、快速的能明確診斷腦積水的有效方法。 3、經(jīng)腰椎穿刺途徑進(jìn)行CT腦室腦池造影時(shí),顱內(nèi)壓的大小并不影響造影劑擴(kuò)散的效果。從結(jié)論看進(jìn)行CT腦室腦池時(shí)可以不考慮顱內(nèi)壓的大小來(lái)增加或減少造影劑劑量,進(jìn)一步提高造影的安全性和有效性。 4、術(shù)后CTC檢查可初步評(píng)價(jià)腦積水的手術(shù)效果。對(duì)于CT和MR無(wú)法明確診斷的患者行CTC檢查是有必要的,證實(shí)為梗阻性腦積水的患者且達(dá)到手術(shù)指征應(yīng)考慮神經(jīng)內(nèi)鏡造瘺手術(shù)治療,根據(jù)術(shù)后CTC復(fù)查結(jié)果以及臨床癥狀的改善程度可以綜合評(píng)估手術(shù)效果。 5、神經(jīng)內(nèi)鏡手術(shù)損傷小、手術(shù)時(shí)間短、可直視、成像清晰、視角寬闊、恢復(fù)快、并發(fā)癥少、遠(yuǎn)期療效佳,相對(duì)之前單純的腦室腹腔分流術(shù),神經(jīng)內(nèi)鏡的出現(xiàn)無(wú)疑減少了患者的長(zhǎng)期帶管的痛苦和不便,神經(jīng)內(nèi)鏡造瘺手術(shù)是梗阻性腦積水的有效的治療方法。 本研究創(chuàng)新之處 1、CT腦池造影是腦積水的診斷的可靠標(biāo)準(zhǔn),尤其是對(duì)難以鑒別梗阻性與交通性腦積水的診斷,并且為指導(dǎo)治療及初步療效提供依據(jù)。提出了CTC檢查的指征。 2、通過(guò)CTC檢查,對(duì)腦積水的分類(lèi)有了安全、可靠的診斷方法。 3、CTC是評(píng)估神經(jīng)內(nèi)鏡三腦室底造瘺術(shù)術(shù)后的效果的可靠指標(biāo)。
[Abstract]:Research background and purpose
Hydrocephalus is one of the most common and intractable clinical diseases facing neurosurgeons. Its pathogenesis is complex. Its fundamental treatment is surgery. Medication is mostly temporary. Imaging manifestations include ventricular cistern dilatation, or simple lateral ventricle dilatation. The causes include primary mesencephalic aqueduct obstruction, cyst or tumor compression, or cranium. Some patients have no obvious clinical symptoms. Physical examination or trauma examination found that most patients have clinical symptoms. The mechanism and classification of the occurrence of arachnoid granules are still controversial. There are two main controversies: one is the criteria of obstructive hydrocephalus and communicating hydrocephalus. At present, the diagnosis of hydrocephalus mainly relies on CT and MR imaging besides clinical symptoms. CT and MRI are convenient and less invasive, so they have important value in the diagnosis and follow-up of hydrocephalus. It is reported that diffusion. weighted imaging (DWI) and phase contrast cine can clearly differentiate the obstructive lesions, but this preliminary study confirms that the accuracy is low and the feasibility needs further study. CT cistern imaging injects non-irritating, non-metabolic water-soluble nonionic iodine into the subarachnoid space through lumbar puncture, and then nonionic iodine is injected along the cerebrospinal spine. The fluid circulatory pathway ascends retrogradely and enters the ventricles of each cistern in turn, then reaches the sagittal sinus on the convex surface of the brain to absorb blood. CT spiral scanning can show the patency of the subarachnoid space. The imaging of contrast agents between the cisterns of each ventricle can be seen by three-dimensional reconstruction, and whether the dynamics of the cerebrospinal fluid circulatory pathway has changed to determine the obstruction. Location. Before neuroendoscopy, shunting was always the first method of surgical treatment for hydrocephalus, but the problems after shunting were more complications, prone to blockage of shunt, infection, excessive or insufficient shunting, which eventually led to failure of surgery. McGirt reported 308 cases of hydrocephalus who underwent shunting because of surgical failure. Adjustments were performed 528 times. Foreign bodies were retained in patients after shunting, and the long and tall personal belongings of younger patients may need to be replaced many times. Therefore, how to avoid shunting has always been an important issue for neurosurgeons. With the development of neuroendoscopy, endoscopic treatment of obstructive hydrocephalus has become the preferred operation with surgical strikes. The long-term effect of endoscopic neurosurgery on obstructive hydrocephalus is more than 90%. It has been reported that endoscopic neurosurgery for hydrocephalus caused by ventriculoperitoneal shunt obstruction after shunt surgery has a good prognosis.
In this study, 48 cases of hydrocephalus were examined by CTC and prospectively studied to explore the value of CTC in the diagnosis and treatment of hydrocephalus. There are many different reports about which operation method is the best for the treatment of hydrocephalus. The focus of this paper is to ascertain the type of hydrocephalus by CTC, choose the correct operation method and reduce the pain of patients.
Method
1, CT cisterography in the diagnosis of hydrocephalus
CT cisternography was performed in 48 patients with hydrocephalus from February 2011 to December 2012 in neurosurgery department of our hospital. The types of hydrocephalus were diagnosed and the treatment methods were selected according to the results of CT cisternography.
2, CT cisterography in hydrocephalus after endoscopic three ventriculostomy.
Twenty-four patients with obstructive hydrocephalus underwent three-ventricular floor fistula. Eight patients were randomly selected for a one-week follow-up of CTC. The improvement of cerebrospinal fluid pathway after three-ventricular floor fistula was analyzed according to the diffusion of contrast media. Follow up of imaging data.
2, statistical processing
All the results were analyzed by SPSS13.0 software. T test, variance analysis and chi-square test were used. P < 0.05 was regarded as statistically significant.
Result
1. The application of CT ventriculography in the diagnosis of hydrocephalus.
1.1. Imaging findings: All 48 patients underwent cranial CT examination before operation, 40 patients underwent cranial MR examination, 48 patients underwent CT cisternography, of which 22 patients underwent ventricular cisternography, ventricular cisternography and subarachnoid cavity contrast medium filling, which confirmed communicating hydrocephalus; 26 patients had different degrees of infarction in the diffusion pathway of contrast medium. Obstruction is diagnosed as non communicating hydrocephalus.
(1) communicating hydrocephalus: bilateral ventricles of cistern imaging with persistent detention were diagnosed as communicating hydrocephalus. Contrast agent diffused to lateral ventricle and third ventricle, fourth ventricle and fourth ventricle were seen in coronal image. Contrast agent diffused from occipital cistern to fourth ventricle to third ventricle and bilateral ventricle through midbrain aqueduct. The cistern and supratentorial subarachnoid space were well filled.
(2) Non-communicating hydrocephalus: most of them are obstructive hydrocephalus. The images of cistern have no fixed features, and there are different manifestations because of different obstructive sites. The lateral ventricle is not usually developed. Contrast media of some patients with obstructive hydrocephalus remain in the occipital cistern and basal cistern for a long time.
1.2, the comparison between CTC and routine CT/MRI diagnosis.
The results of CT cistern imaging showed that 26 cases were non-communicating hydrocephalus, of which 15 cases were diagnosed as obstructive hydrocephalus by routine CT/MRI, which accorded with the results of CTC. In the examination, 2 cases were diagnosed as obstructive by traffic diagnosis, 5 cases were diagnosed as communicating by obstruction, and the diagnostic accuracy was 85.4%.
1.3, the effect of intracranial pressure on the diffusion of contrast agents.
In order to investigate the effect of intracranial pressure on the diffusion of contrast media, 41 cases of ventriculo-cisternography were retrospectively analyzed. The ventriculo-cisternography in 41 cases was filled with contrast media, and the same contrast mode and diffusion time were used. Two groups, one group of lumbar puncture pressure (> 200 mm H2O) and the other group of lumbar puncture pressure in the normal range, that is, 200 mm H2O, were compared by two groups of contrast media in the ventricular cistern CT value (Hu).
2. Application of CTC in hydrocephalus endoscopic three Ventriculostomy
(1) MRI was performed in 24 patients 6 months after operation. The ventricular cistern was significantly reduced in 14 of them, and the symptoms of headache and dizziness disappeared before operation. Among them, 3 patients with preoperative disturbance of consciousness were significantly improved after operation; 5 patients with slight reduction of ventricular cistern and obvious improvement of clinical symptoms; 6 patients with no significant changes in imaging, 4 of them were significantly improved in clinical symptoms. 1 cases were improved after ventriculoperitoneal shunt for hydrocephalus.
(2) 24 patients were examined by lumbar puncture 3 days after operation, and mannitol injection was used intravenously before lumbar puncture excluding lumbar puncture. Among them, 13 cases had lumbar puncture pressure of 70-100 mm H2O, 6 cases had lumbar puncture pressure of 110-150 mm H2O, 3 cases had lumbar puncture pressure of 160-180 mm H2O, and 2 cases had lumbar puncture pressure of more than 180 mm H2O. Good.
(3) Eight cases were randomly selected one week after operation for CTC reexamination. The results showed that the ventricles of 8 cases were filled with contrast media. Three cases had evident dilatation of the fourth ventricle before operation, and the fourth ventricle was significantly reduced after operation.
conclusion
1. CT cisternography plays an important role in the diagnosis of hydrocephalus, especially in the differential diagnosis between obstructive hydrocephalus and communicating hydrocephalus. CTC provides a reliable basis for the surgical treatment of hydrocephalus and the choice of surgical methods. CTC has a higher diagnostic accuracy than conventional CT/MRI.
2. It is safe and effective to perform CT cisternography at a reasonable dose. Although CT cisternography is a invasive method, it is a simple, safe, reliable and rapid method for definite diagnosis of hydrocephalus.
3. Intracranial pressure does not affect the effect of contrast media diffusion in CT ventriculo cisternography via lumbar puncture. ConclusionIntracranial pressure can be neglected to increase or decrease the dose of contrast media in CT ventriculo cisternography to further improve the safety and effectiveness of contrast media.
4. Postoperative CTC can evaluate the effect of hydrocephalus. It is necessary for patients with obstructive hydrocephalus who can not be diagnosed clearly by CT and MR to have CTC. Neuroscopic fistula should be considered when the operation indication is reached. Evaluate the effect of operation.
5. Neuroendoscopic surgery has the advantages of small injury, short operation time, direct vision, clear imaging, wide visual angle, quick recovery, fewer complications, and good long-term effect. Compared with the previous simple ventriculoperitoneal shunt, the emergence of neuroendoscopy undoubtedly reduces the patient's long-term pain and inconvenience with the tube. Neuroendoscopic fistula surgery is effective for obstructive hydrocephalus. Treatment.
The innovation of this research
1. CT cisternography is a reliable criterion for the diagnosis of hydrocephalus, especially for the diagnosis of obstructive and communicating hydrocephalus which is difficult to differentiate, and provides a basis for guiding treatment and preliminary curative effect.
2, through CTC examination, there is a safe and reliable diagnostic method for hydrocephalus classification.
3, CTC is a reliable index to evaluate the effect of endoscopic three ventriculostomy.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類(lèi)號(hào)】：R816.1;R742.7

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