摘要
目的;
蛛网膜囊肿是发生在中枢神经系统内的良性囊肿,与蛛网膜关系密切,囊液常无色、清亮,似脑脊液,很少黄染。蛛网膜囊肿有原发性和继发性两种。原发性蛛网膜囊肿常见,又称先天性蛛网膜囊肿,由胚胎发育异常或组织异位发育所致,与蛛网膜下腔和脑池关系密切;继发性蛛网膜囊肿,又称假性蛛网膜囊肿,是由于脑外伤、脑出血或颅内感染等因素引起的蛛网膜下腔炎症反应,导致脑脊液病理性积聚,以炎症细胞和含铁血黄素沉着为特征。本研究观察病例均无明确外伤和颅内感染既往史,主要考虑为先天性IAC。
蛛网膜囊肿的自然病史不详,许多蛛网膜囊肿病人可以终身没有症状,还有部分病人发现后多年才出现症状,甚至还有囊肿自发消失的报道,但也有因出现临床症状而就诊的患者。临床症状的出现主要由于蛛网膜囊肿进行性增大,囊内压大于蛛网膜下腔压力,导致周围脑组织受压或脑脊液循环受阻,表现为如下症状和体征;头痛、恶心、呕吐、抽搐发作、智力发育障碍、记忆力下降,头围增大、局部颅骨外突膨隆、视神经乳头水肿、脑积水以及局灶性神经功能缺失等。
随着神经影像学的发展,颅脑CT、MRI等辅助检查得以广泛使用,临床上IAC的检出率明显增多,但是否影像学确诊的蛛网膜囊肿病人都有手术适应症,都需要行手术治疗?本着解决这一问题的目的,我们将本院2001年1月～2006年4月期间收治的72例蛛网膜囊肿病人,通过临床表现、影像学检查、随访观察对比研究,探讨蛛网膜囊肿病人的手术适应症。
方法;
1.收集IAC病人的临床资料。
2.影像学检查;颅脑CT和CT蛛网膜下腔脑池造影(CTC)检查。
3.对病人进行随访,观察其临床症状以及颅脑CT表现。
4.对收集的资料进行对比研究,探讨手术适应症。
结果;
72例病人均行颅脑CT检查,确诊为蛛网膜囊肿,其中手术病人45例,非手术病人27例;46例行CTC检查,其中交通性蛛网膜囊肿(CIAC)13例,非交通性蛛网膜囊肿(NCIAC)33例。术后病人临床症状都得到一定程度的改善,未有明显并发症发生,41例病人复查颅脑CT示囊肿较前缩小。
结论;
1.颅脑CT平扫及CTC对于IAC的诊断及手术适应症选择有重要意义。
2.IAC的绝对手术适应症;有明确临床症状的NCIAC。
3.IAC的相对手术适应症;临床症状加重或复查CT囊肿增大的CIAC。
目的;
蛛网膜囊肿病人如果具有明确手术适应症,需要行手术治疗,选择合适的手术方式非常重要。IAC发病的病理学基础是压力问题,囊内压大于脑组织搏动压和蛛网膜下腔的压力,造成相邻脑组织受压而出现临床症状,解决压力最好办法是给囊液一条通畅出路,逐渐减小囊内压力。因此手术目的在于切除囊肿壁,消除囊肿的占位效应,解除对脑组织的压迫,以利于脑组织的复位和发育,使囊肿与蛛网膜下腔广泛沟通,囊液参与正常脑脊液循环。
目前的手术方式主要包括直接手术和间接手术两种;直接手术,是指通过开颅手术将囊壁切除或将囊肿与蛛网膜下腔、脑池、脑室交通;间接手术是使用分流装置将囊液引流至脑池、腹腔。囊壁切除术从理论上讲最为合理,但因囊壁与正常神经结构粘连严密,很少能做到完全切除,虽然术后可改善临床症状,复查CT显示囊腔变小,但操作上有一定难度,且创伤及风险较大;分流手术的优点是创伤小、手术易行、风险低,但缺点是感染和分流管堵塞等并发症;现在开展的神经内镜治疗颅内蛛网膜囊肿,既可大部切除囊肿壁,又可打通脑池,避免了对分流管的依赖,值得提倡与推广。
总之,手术方式的选择应根据病人的个体差异和术者的经验能力以及设备条件而定,不宜强求一致。重要的是不断积累治疗病例,加强随访,从长期结果中判定不同术式的疗效,以期达到共识。本着这一目的,我们回顾分析了本院2001年1月～2006年4月期间手术治疗的45例蛛网膜囊肿病人,通过不同手术方式、临床疗效、手术并发症以及术后随访的对比研究,探讨蛛网膜囊肿合适的手术方式。
方法;
1.收集手术病人的临床资料。
2.3种不同手术方式。
3.典型病例分析。
4.对收集的资料进行对比研究,探讨合适的手术方式。
结果;
手术病人共45人,行囊肿—腹腔分流术4例,行开颅囊肿切除+脑池交通术15例,行神经内镜下囊肿切除+脑池交通术26例。术中见囊肿壁为薄膜状,颜色发蓝,组织病理学检查为纤维结缔组织和少量淋巴细胞构成;囊液均呈无色清亮水样,常规化验其成分与脑脊液相似。术后大部分病人临床症状得到控制,复查颅脑CT示囊腔较前缩小。
结论;
1.手术方式的选择应根据囊肿的部位、疾病特殊性和术者手术操作的熟练性等因素综合决定。
2.蛛网膜囊肿并发其他疾病者,首选开颅手术治疗;鞍区、脑室内囊肿首选神经内镜治疗;交通性蛛网膜囊肿及巨大蛛网膜囊肿行囊肿—腹腔分流术效果较好;后颅窝IAC采取开颅囊肿切除+脑池交通术治疗,在这基础上行囊肿—腹腔分流术,效果更好。
3.病变位于半球者,神经内镜的优势大于开颅。
4.EAM和ECM技术是微创治疗蛛网膜囊肿的发展方向,适合各部位蛛网膜囊肿。
Objective;
Intracranial arachnoid cyst is a kind of benign cyst,which is closely related with arachnoid.The cystic fluid is usually colorless,transparent,like cerebrospinal fluid and seldom yellow stained.The ICA can be classified into two kinds;primary ICA and secondary ICA.The primary ICA is also called congenital ICA,which is caused by embryogenesis dyspasia.The cyst is formed by arachnoid cleavage or duplication and closely related with subarachnoid cavity and cistern.The secondary ICA is also called fake ICA,which is featured with inflammatory cell and Hemosiderin pigmentation.It is caused by brain trauma,brain hemorrhage or intracranial infection. The inflammatory reaction of subarachnoid cavity made CSF gathered pathologically. All the patients in this study had no history of brain trauma or intracranial infection, so the primary ICA is considered.
The natural case history of ICA is not in detail.Many patients may show no symptom all their lives,and some patients became Symptomatic many years after the cyst was detected.There are also reports of the spontaneous disappear of the cyst. There are also patients who were admitted because of clinical symptoms as follows; regional prominence of cranial skull,headache,vomiting,epileptic attack,blurred vision,distracted attention,hypomnesia,diminished eyesight,papilledema and hydrocephalus.
In recent years,with the development of the radiological techniques,the clinically detectable rate of IAC seemed to have a tendency to increase.But whether all the patients diagnosed by imageology need surgical therapy? For this goal,we collect 72 ICA cases from January 2006 to April 2007,and decide the suitable surgical indications by comparing Clinical symptoms,imaging examination and follow-up.
Methods;
1.Collect clinical data of ICA patients.
2.hnageology examination,including CT and CTC.
3.Follow-up of the patients,detect the change of symptoms and the imaging.
4.Choose the suitable surgical indications by comparing the data.
Result;
All the 72 patients were diagnosed of ICA after brain CT scan.45 patients underwent surgery,while the other 36 patients did not undergo operation.CTC was taken in 46 cases,out of which 13 cases were CIAC and 33 cases were NCIAC.After surgery,all the patient's clinical symptoms improved to different degrees,and there were no serious complications.The CT scans indicated the cyst decreased in 41 cases. Conclusion;
1.Brain CT scans and CTC are of great importance for the diagnosis and choose of surgical indication.
2.The absolute surgical indication is the NCIAC patients with definite clinical symptoms.
3.The relative surgical indication is CIAC patients whose clinical symptom keep on aggravating or CT scans show tendency of the cyst to increase.
Objective;
If the ICA patients have definite surgical indications,the surgery will be needed. It is very important to choose the proper modus operandi.The pathological cause of ICA is the pressure difference.The intracystal pressure is higher than the pulsation pressure of brain tissue and subarachnoid cavity,so the surrounding brain tissue will be compressed and clinical symptoms appear.The best way to resolve the pressure is to make a pathway of the cyst fluid to release the intracystal pressure.The goal of surgery is to relieve the compression to normal brain tissue,improve the surrounding blood circulation,promote brain development,release clinic symptom and avoid recurrence of the cyst.The existing modus operandi contains direct surgery and indirect surgery.The direct surgery is to remove the cyst wall or make the cyst communicating with subarachnoid cavity,cistern or ventricle through craniotomy or under neroendoscope.The indirect surgery is to drain the cyst fluid into cistern or abdominal cavity by shunt equipment.Theoretically,the cyst wall excision is the most reasonable.It can release clinic symptom and following CT scans demonstrate the cyst decreased.But the cyst wall can seldom be removed completely,because it sticks to normal nervous structures very tightly.It is very difficult to operate and the wounds and risk may be a little bigger.The advantages of shunt surgery are minimally Invasive,easy to operate and save,but the disadvantages are infection and the obstruction of shunt tube.The neroendoscope therapy can not only remove most of the cyst wall,but also open the cistern.So it avoids the dependence on shunt tube,and worth for recommendation.The final goal of ICA therapy is not only to release the compression and reform the anatomic structure,but also to recover and.retain the neurophysiologic function.
On the whole,how to chose modus operandi depends on the individual difference of patients,the doctor's experience and the operational equipment,so there should not be rigid criterion.What's important is to accumulate cases and reinforce follow-up,then assess the therapeutic effect of different modus operandi and come to a common conclusion.For this sake,we collected 45 ICA cases who have underwent surgical therapy from January 2001 to April 2006,and decided the most proper different modus operandi by comparing different modus operandi,clinical effect, complications and follow-up.
Methods;
1.Collect the clinic data of surgical patients.
2.Introduce 3 different modus operandi respectively.
3.Introduce the typical cases.
4.Decide the most proper different modus operandi by comparing the data collected.
Result;
45 patients underwent surgery,out of which 4 cases underwent cystoperitoneal shunt,15 cases underwent craniotomy cyst excision and cistern communication,26 cases underwent neuroendoscopic cyst excision and cistern communication.During surgery,we can find that the cyst wall was membraneous and a little pale.The contents of cyst are colorless,transparent and CSF-like.The tissue pathological examination of the cysts walls revealed fibrous connective tissue and small amount of lymphocytes infiltration.The chemical examination of the cyst fluid was like CSF.
Conclusion;
1.The modus operandi should be confirmed according to the location of cyst, the characteristic of the disease and the surgeon's erperience.
2.For the patients with ICA complicated with other.diseases,the craniotomy is firstly considered;For the patients with cystslocated-in saddle area or ventricle,the ventriculoscope should be firstly chosen;For the CICA and huge ICV,the cyst-peritoneal shunt is the best;For the ICA in posterior cranial fossa,it's better to take craniotomy cyst excision and cistern communication,then make the cyst-peritoneal shunt.
3.For the ICA located in hemisphere,ventriculoscope is better than craniotomy.
4.EMA and ECM indicate the direction of microinvasive therapy of ICA,and can be used in ICA in different locations.
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