Peretta Paola, Cinalli Giuseppe, Spennato Pietro, Ragazzi Paola, Ruggiero Claudio, Aliberti Ferdinando, Carlino Christian, Cianciulli Emilio
Department of Pediatric Neurosurgery, Regina Margherita Children's Hospital, Turin, Italy.
Neurosurgery. 2009 Sep;65(3):539-47; discussion 547. doi: 10.1227/01.NEU.0000350228.08523.D1.
To evaluate retrospectively the operative findings and long-term results of a repeat endoscopic third ventriculostomy (ETV) in pediatric hydrocephalic patients readmitted after the first procedure with symptoms and/or signs of intracranial hypertension and/or radiological evidence of increased ventricular dilation and/or occluded stoma on follow-up radiological examinations.
We analyzed a series of 482 ETVs in pediatric patients from 2 Italian departments of pediatric neurosurgery. The clinical charts of 40 patients undergoing a second ETV were selected and reviewed retrospectively. The pre- and postoperative radiological findings and operative films were analyzed retrospectively.
Forty patients underwent a total of 82 ETVs. Thirty-eight patients were operated on twice and 2 were operated on 3 times. During the second procedure, the stoma was found to be closed in 28 patients without underlying adhesions, to be open but with significant arachnoid adhesions in the prepontine cistern in 8 patients, to be open without adhesions in 2 patients, to have a pinhole orifice in 1 patient, and to be closed with underlying adhesions in 1 patient. The second procedure allowed reopening of the stoma or lysis of the arachnoid adhesions in 35 patients and was abandoned in 3 patients because of extensive arachnoid adhesions or because the stoma was found to be wide open (2 patients). In 30 patients (75%), the second ETV was effective, and the 2 patients who underwent a third ETV remained shunt free. In 10 patients (25%), a ventriculoperitoneal shunt was eventually placed. Age younger than 2 years at the time of the first procedure and arachnoid adhesions in the subarachnoid cisterns observed during the second procedure are the main negative prognostic factors for the success of a second ETV.
A second ETV can be performed with a reasonable chance of restoring patency of the stoma and avoiding placement of an extrathecal shunt. Every effort should be made to detect subarachnoid adhesions in the cistern on preoperative imaging study to select potential candidates and avoid unnecessary procedures.
回顾性评估小儿脑积水患者首次内镜下第三脑室造瘘术（ETV）后因颅内高压症状和/或体征及/或随访影像学检查发现脑室扩张增加和/或造瘘口闭塞而再次入院时的手术发现及长期结果。
我们分析了来自意大利两个小儿神经外科科室的一系列482例小儿患者的ETV手术。选择并回顾性分析了40例行二次ETV手术患者的临床病历。对术前和术后的影像学检查结果及手术影像进行回顾性分析。
40例患者共接受了82次ETV手术。38例患者接受了两次手术，2例患者接受了三次手术。在第二次手术中，发现28例患者的造瘘口闭合且无潜在粘连，8例患者的造瘘口开放但脑桥前池有明显蛛网膜粘连，2例患者的造瘘口开放且无粘连，1例患者的造瘘口有针孔样开口，1例患者的造瘘口因潜在粘连而闭合。第二次手术使35例患者的造瘘口重新开放或蛛网膜粘连松解，3例患者因广泛蛛网膜粘连或造瘘口发现已完全开放（2例）而放弃手术。30例患者（75%）二次ETV手术有效，2例接受第三次ETV手术的患者无需分流。10例患者（25%）最终放置了脑室腹腔分流管。首次手术时年龄小于2岁以及第二次手术时观察到蛛网膜下池有蛛网膜粘连是二次ETV手术成功的主要负面预后因素。
二次ETV手术有合理机会恢复造瘘口通畅并避免放置鞘外分流管。应尽一切努力在术前影像学检查中检测脑池内的蛛网膜粘连，以选择潜在的合适患者并避免不必要的手术。
