儿童颅后窝囊肿合并脑积水的内镜治疗

Strategy of endoscopic surgery for posterior cranial fossa cysts with hydrocephalus in children

目的探讨神经内镜手术治疗不同类型颅后窝囊肿的手术入路、技巧及疗效。方法回顾性分析26例颅后窝囊肿合并脑积水病人的临床资料。术前均行脑脊液磁共振电影成像(Cine MRI)和同位素脑池显像检查。采用幕下后正中入路内镜辅助显微手术3例,幕上经额皮质入路单纯神经内镜手术23例。结果术后颅高压症状均不同程度改善;肢体活动障碍好转1例,无明显变化2例;经腰椎穿刺释放脑脊液后,术后所有病人颅内压均降至正常水平。术后出现皮下脑脊液漏1例,无其他严重并发症。幕上入路手术病人中,术后1周复查Cine MRI显示造瘘口均有脑脊液通过。术后6个月,复查MRI显示囊肿缩小18例,无明显变化8例;脑室缩小11例,无明显变化15例。结论幕上经额皮质入路单纯内镜手术对侵及小脑幕的颅后窝巨大囊肿,及伴中脑导水管扩张的Dandy-Walker畸形疗效确切,可同期解决脑积水和囊肿的占位效应。

Objective To explore the surgical approach,techniques and efficacy for different types of posterior cranial fossa cysts treated by endoscopic surgery.Methods Clinical data of 26 patients with posterior cranial fossa cysts complicated by hydrocephalus were analyzed retrospectively.Cerebrospinal fluid（CSF） Cine MRI and radionuclide cisternography were performed in all the patients preoperatively.The endoscope-assisted microsurgery through infratentorial posterior median approach was performed in 3 cases,and endoscopic surgery alone via supratentorial transfrontal cortical approach in 23.Results High intracranial pressure improved to different degrees in all the patients postoperatively,limb dyskinesia improved in 1 case and was not obviously changed in 2.Postoperatively intracranial pressure declined to normal level after releasing CSF by lumbar puncture.CSF leaked into the hypoderma in 1 case and no other serious complications occurred postoperatively.Cine MRI 1 week after operation showed CSF flowed through the ostomy of third ventricle floor in all patients undergoing surgery via supratentorial approach.MRI reexamination was performed in all the patients 6 months after operation,the cysts shrank in 18 cases and was not obviously changed in 8,and the size of ventricles diminished in 11 cases and was not obviously changed in 15.Conclusions Endoscopic surgery through supratentorial transfrontal cortical approach has obvious therapeutic efficacy for huge posterior cranial fossa cysts encroached on the tentorium cerebelli and Dandy-Walker malformation with expanded midbrain aqueduct,which can solve the mass effect caused by hydrocephalus and cysts at the same time.