婴儿出血后脑积水的内镜诊断和治疗

Endoscopic diagnosis and treatment of infants with posthemorrhagic hydrocephalus

目的探讨软性神经内镜在婴儿出血后脑积水诊断和治疗中的应用价值。方法自2006年4月至2008年10月，应用电子软性神经内镜对28例婴儿出血后脑积水明确诊断并进行治疗，脑室内出血25例，蛛网膜下腔出血2例，小脑幕下硬膜下血肿1例。除1例硬膜下血肿患者内镜下行血肿腔冲洗外，其余27例均在神经内镜下进行脑室冲洗，其后行第三脑室底造瘘18例，同时行脉络丛烧灼7例，终板造瘘4例，脑室内多发分隔造瘘1例；经额第四脑室正中孔造瘘3例；导水管成形术6例。结果28例婴儿出血后脑积水，术前通过影像学检查结合病史明确诊断17例，通过软性神经内镜对脑室系统进行全面探查后明确诊断11例。术后出现间脑发作6例，远期出现基底池梗阻2例，分别发生在术后80d和7个月，经内镜下二次脑室探查证实后再次行基底池造瘘。随访2—27个月，平均13．5个月效果良好，无脑室感染、硬膜下积液等其他并发症出现。结论软性内镜下脑室系统全面探查是诊断出血后脑积水最可靠的手段，内镜下脑室系统冲洗尽量清除脑室壁上的陈旧血斑，有利于降低术后造瘘口或分流管梗阻概率，二次脑室探查能够明确术后效果不佳的原因，值得提倡。

Objective To study the application of flexible endoscope for diagnosis and treatment of infants with posthemorrhagic hydrocephalus. Method 28 cases of infants with posthemorrhagic hydrocephalus were diagnosed and treated with flexible neuron - endoscope in our hospital, from April 2006 to October 2008. Intraventricular haemorrhage in 25, subarachnoid hemorrhage in 2 and infratentorial subdural hematoma in 1. Ventricle irrigation was performed with flexible neuro - endoscope in all patients except 1 hematoma cavity irrigation in the case of infratentorial subdural hematoma. Followed third ventrieulostomy in 18, simultaneous choroid plexus cauterization in 7,lamina terminalis fenestration in 4 and the multi septum fenestration in the ventricles in 1. Endoscopic opening of the foramen of magendie with transaqueductal approach in 3. Endoscopic aqueduetoplasty in 6. Results Among 28 cases of infants with posthemorrhagic hydrocephalus ,only 17 diagnoses occupied 60. 7% （17/28） were defined preoperatively by neural images and the other 11 were diagnosed by overall exploration to the ventricular system under flexible endoscope. Postoperative diencephalic seizures occurred in 6, obstruction in basal cistern was defined by second ETV in 2 patients on 80 days and 7 months after operation respectively. Good results showed in the follow up of 2 to 35 months（ median 13.5 months） with no complications such as intraventricular infection or subdural effusion. Conclusions Overall exploration to the ventricular system under flexible endoscope is reliable for diagnosis of posthemorrhagie hydrocephalus. Ventricle irrigation to evacuate the blood blot as far as possible is benefit to decrease the opportunity of obstruction of the stoma or shunt catheter. Second ETV is worth to advocate to identify the cause of unsatisfactory operative results.