Iannelli A, Rea G, Di Rocco C
Institute of Neurosurgery, Section of Paediatric Neurosurgery, University of Pisa, Pisa, Italy.
Acta Neurochir (Wien). 2005 May;147(5):503-7; discussion 507. doi: 10.1007/s00701-005-0494-6. Epub 2005 Mar 14.
The possibility to remove a previously inserted CSF shunt device in hydrocephalic children is a well known though rare event for paediatric neurosurgeons. A retrospective analysis of our experience with a series of 850 children affected by non tumoral hydrocephalus shows that obvious shunt independence could be demonstrated in 3.2% of the patients (27 cases). The time interval between the CSF shunt insertion and removal ranged between 8 months and 12 years (mean: 8 years). Parameters analysed to search for any predictive elements were age at surgery, aetiology, type of prosthesis utilised, time interval between insertion and removal of the shunt, number of the possible revisions. The results of the study suggest that the highest incidence of shunt independence is reached in subjects operated on in early infancy, as 24 of 27 removed shunts were in patients operated on under 6 months of age, and the remaining in 2 children treated when less than 2 years old. Such a finding could be explained on the grounds of a delay in maturation of the CSF absorption mechanisms followed by a late normalisation in these patients. As regards to aetiology, 41% of the 27 patients considered in this series were affected by a post-haemorrhagic hydrocephalus, which was progressive, as demonstrated by serial neuroradiological examinations and echo-Doppler cerebral studies at the time of the surgical treatment. In six children the hydrocephalus was associated with myelomeningocele. Five patients had aqueduct stenosis and 2 communicating hydrocephalus. The types of CSF shunting system we utilised did not play any role in determining or facilitating shunt independence. No correlation was observed with the need and the number of shunt revisions. The role of the interval time between the insertion and the removal of the shunt was not analysable, because of the possible acquisition of the shunt independence prior to its demonstration at the moment of the surgical revision of the CSF shunt (elective lengthening because of the physiological body growth) or to the radiological demonstration of CSF shunt device disconnection. The same constraint prevents the evaluation of the actual overall incidence of shunt independence in shunted hydrocephalic children, as some of them could have harboured a non-functioning CSF shunt device, though unnoticed.
对于小儿神经外科医生来说，脑积水患儿移除先前植入的脑脊液分流装置这种可能性虽不常见但广为人知。对我们治疗的850例非肿瘤性脑积水患儿的经验进行回顾性分析表明，3.2%的患者（27例）可证实明显分流独立。脑脊液分流装置植入与移除之间的时间间隔在8个月至12年之间（平均：8年）。为寻找任何预测因素而分析的参数包括手术时年龄、病因、所用假体类型、分流装置植入与移除之间的时间间隔、可能的翻修次数。研究结果表明，分流独立发生率最高的是在婴儿早期接受手术的患者，因为27例移除分流装置的患者中有24例是在6个月以下接受手术的，其余2例是在2岁以下接受治疗的。这一发现可以基于脑脊液吸收机制成熟延迟以及这些患者后期恢复正常来解释。关于病因，本系列中27例患者中有41%患有出血后进行性脑积水，手术治疗时的系列神经放射学检查和脑回波多普勒研究证实了这一点。6例患儿脑积水与脊髓脊膜膨出有关。5例患者有导水管狭窄，2例有交通性脑积水。我们使用的脑脊液分流系统类型在决定或促进分流独立方面没有起到任何作用。未观察到与分流翻修的必要性和次数有相关性。由于在脑脊液分流手术翻修时（因身体生理性生长而进行选择性延长）可能在分流独立得到证实之前就已实现，或者由于脑脊液分流装置断开的放射学表现，所以无法分析分流装置植入与移除之间的间隔时间的作用。同样的限制也妨碍了对分流脑积水患儿分流独立实际总体发生率的评估，因为其中一些患儿可能有一个未被注意到的无功能脑脊液分流装置。
