The fiberoptic endoscope aqueduct angioplasty and stent placement for treatment of internal hydrocephalus
Objective: Neuroendoscopic third ventriculostomy nephrostomy operation has been widely used in treatment of hydrocephalus caused by aqueduct stenosis, and has been turned out effective. In addition, the fiberoptic endoscope aqueduct angioplasty can also attempted for the patient with difficulty of nephrostomy in third ventriculostomy, because the single aqueduct angioplasty is provided with a very high incidence rate of stenosis. We try to use small-caliber fiberoptic endoscope to do third ventriculostomy nephrostomy operation, and have an operation of midbrain aqueduct angioplasty and stent placement to the patient with difficulty of nephrostomy in third ventriculostomy.
Objects and Methods: From Feb 2007 to Aug 2009, there are 13 cases in aqueduct stenosis treated by aqueduct angioplasty in endoscope with stent placement. 7 cases in congenital aqueduct opening membrane obstruction, 4 cases in post hemorrhagic hydrocephalus of newborn, 1 case in hydrocephalus caused by tuberculous meningitis, 1 case in hydrocephalus caused by purulent meningitis. Take Line magnetic resonance imaging of the cerebrospinal fluid film to all patient to examine the dynamics of cerebrospinal fluid, it indicated that aqueduct obstruction. Make the patient general anesthesia, supine position, head 30°high, and employ Rudolph-Fujinon 3.8mm electronic soft lenses. Incision of scalp is generally selected in 1cm to right frontal coronal suture, and break open 3cm approached anteropostorior line. Let 3.8mm electronic soft lenses into ventriculus laterali cerebri, try to expand opening of aqueduct through 2F Foley’s tube to 4~5mm. Machining the shunt valve into 1cm length of stent, slipping into Foley’s tube, and injecting water into tube and fixating the stent to the end of tube, then putting into cerebral aqueduct. Pump the physiological saline injected out, and exit tube duct, then put stent into stenosis of duct.
Result:
Follow-up time of the 13 patients are 24-36 months, 29 months average. 11 patients get a remission after operation. A 5-months male patient in post hemorrhagic hydrocephalus, gets fontanelle tension increased again 2 months later the operation. Endoscope examination indicate that proximal stent membrane obstructed, and pull the stent out towards the third ventriculostomy tower opening of aqueduct 3mm, then the patient get remission. A 7-year female with hydrocephalus caused by tuberculous meningitis, didn’t get an obvious remission when put in a 6mm stent, and PC-cline indicate aqueduct cramped still. Do the operation again, changing stent into 12mm, the symptom of high intracranial pressure get relieved. The 13 patients don’t have infection, cerebrospinal fluid fistula, oculomotor paralysis or any other complications.
Conclusion: Aqueduct angioplasty provides the opportunity that get rid of shunt tube depends for the patients of obstructive hytrocephalus who can’t get the operation of the third ventriculostomy nephrostomy, however, the single aqueduct angioplasty may provide a very high rate of re-obstruction. Stent placement after aqueduct angioplasty can increase the success rate of operation, but the risks of mid-brain or aqueduct injury and complications of stent displacement also exist. Employing   fiberoptic endoscope to place the stent can decease the injury of mid-brain, due to a small number of cases and short time of follow-up, it is rigorous to select patients according to indications.

纖維內鏡導水管成形術(shù)并放置支架治療梗阻性腦積水
 
目的:神經(jīng)內鏡三腦室底造瘺術(shù)已經(jīng)被廣泛用于治療導水管狹窄導致的腦積水，并被證明是安全有效地。而對于三腦室造瘺困難的患者，也可以嘗試內鏡中腦導水管成形術(shù)，單純導水管成形術(shù)具有有非常高的在狹窄發(fā)生率。我們嘗試利用小口徑纖維內鏡進(jìn)行三腦室底造瘺術(shù)，對三腦室底造瘺困難的患者行中腦導水管成形并放置支架。  對象與方法:2007年2月至2009年8月間，內窺鏡下導水管成形術(shù)同時(shí)放置支架治療導水管梗阻性腦積水13例。先天性導水管開(kāi)口膜性梗阻7例，新生兒腦出血后腦積水4例。結核性腦膜炎導致腦積水1例，化膿性腦膜炎后腦積水1例。全部患者行磁共振腦脊液電影成像檢查對導水管中腦脊液流的動(dòng)力學(xué)進(jìn)行檢測，提示導水管梗阻。采用魯道夫-富士能外徑3.8mm電子軟鏡。全麻，仰臥，頭高30°，頭皮切口一般選擇右額部冠狀縫前1cm，中線(xiàn)旁開(kāi)3cm。電視監視下以3.8mm直徑電子軟鏡進(jìn)入側腦室,首先嘗試通過(guò)2F球囊導管擴張導水管開(kāi)口，擴張至4~5mm。將分流管加工成長(cháng)度1cm支架，套入球囊導管，將球囊注水后將支架固定于球囊末端，送入中腦導水管，將注入生理鹽水抽出，退出球囊導管，支架放置于導水管狹窄位置。 結果:13例患者隨訪(fǎng)時(shí)間隨訪(fǎng)24-36個(gè)月，平均29個(gè)月。11例患者術(shù)后癥狀緩解。一名年齡5個(gè)月的男性患者，新生兒出血后腦積水，手術(shù)后2個(gè)月，再次出現囟門(mén)張力增高，內鏡探查支架近端膜性閉塞，將支架向三腦室方向拔出，高于導水管開(kāi)口水平3mm，臨床癥狀緩解。1名女性，7歲結核性腦膜炎導致腦積水患者放入6mm支架后癥狀無(wú)明顯緩解，PC-cine提示導水管未通暢，再次手術(shù)，更換12mm支架后，高顱壓癥狀緩解。13例患者無(wú)感染，腦脊液瘺，動(dòng)眼神經(jīng)麻痹等并發(fā)癥。結論:導水管成形術(shù)為這無(wú)法行三腦室底造瘺術(shù)的梗阻性腦積水患者提供了擺脫分流管依賴(lài)的機會(huì )，但是簡(jiǎn)單的導水管成形術(shù)再次梗阻的率非常高，在導水管成形之后放置支架可以提高手術(shù)的成功率，但是存在術(shù)中損傷導水管或中腦，術(shù)后支架移位的并發(fā)癥，利用纖維內鏡放置支架可以減少中腦損傷，但是由于病例少，隨訪(fǎng)時(shí)間短，選則患者要嚴格選擇適應癥。世聯(lián)翻譯公司完成纖維內鏡導水管成形術(shù)中文翻譯

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