Di Vincenzo Jana, Keiner Doerthe, Gaab Michael R, Schroeder Henry W S, Oertel Joachim M K
Neurochirurgische Klinik, Universitaetsklinikum des Saarlandes, Homburg, Saar, Germany.
Neurochirurgische Klinik, Nordstadtkrankenhaus Hannover, Klinikum Hannover, Germany.
J Neurol Surg A Cent Eur Neurosurg. 2014 Jan;75(1):20-30. doi: 10.1055/s-0032-1328953. Epub 2013 Jun 3.
Although successful endoscopic third ventriculostomy (ETV) has been reported for many indications, peculiarities of the surgical technique in each separate indication require particular respect.
A detailed account of the authors' surgical technique, their presurgical considerations, and their intraoperative strategies to perform ETV is presented. Surgery of representative obstructive hydrocephalus cases in posterior fossa lesions (cerebellar infarction, posterior fossa tumor), in distortion of the ventricular system (intracranial hemorrhage, basilar artery aneurysm) and in membranous obstruction (aqueductal stenosis, posterior fossa malformation), is illustrated in detail.
In posterior fossa lesions, careful evaluation of the prepontine space and localization of the basilar artery is mandatory. Recognition of mammillary bodies and infundibular recess is of particular importance since the third ventricle floor is rather thick and nontranslucent. In distortion of the ventricular system, careful analysis of the preoperative imaging allows the selection of the optimal approach. Sometimes, blood clot removal and vigorous irrigation is required. Frequently, the landmarks are difficult to identify. These are cases for experienced endoscopic neurosurgeons. In aqueductal stenosis and posterior fossa malformation, perforation of the often thin and translucent ventricular floor is easy because of clear anatomical landmarks. Those are ideal candidates for ETV. For experienced neuroendoscopists, the authors advocate inspection of the fourth ventricle with a flexible scope to ensure cerebrospinal fluid (CSF) circulation obstruction.
ETV is a frequent and well-established endoscopic technique. Based on the underlying pathology, the technique has to be modified to obtain good results with minimal complications.
尽管已有报道成功的内镜下第三脑室造瘘术（ETV）可用于多种适应证，但每种单独适应证的手术技术特点都需要特别关注。
本文详细介绍了作者进行ETV的手术技术、术前考虑因素及术中策略。详细阐述了后颅窝病变（小脑梗死、后颅窝肿瘤）、脑室系统变形（颅内出血、基底动脉动脉瘤）和膜性梗阻（导水管狭窄、后颅窝畸形）等典型梗阻性脑积水病例的手术过程。
在后颅窝病变中，必须仔细评估脑桥前间隙并定位基底动脉。识别乳头体和漏斗隐窝尤为重要，因为第三脑室底部较厚且不透明。在脑室系统变形的情况下，仔细分析术前影像学检查有助于选择最佳手术入路。有时需要清除血凝块并进行强力冲洗。通常，解剖标志难以识别。这些情况适合经验丰富的内镜神经外科医生处理。在导水管狭窄和后颅窝畸形中，由于解剖标志清晰，通常较薄且透明的脑室底部穿孔很容易。这些是ETV的理想适应证。对于经验丰富的神经内镜医生，作者主张用软性内镜检查第四脑室，以确保脑脊液（CSF）循环梗阻。
ETV是一种常用且成熟的内镜技术。基于潜在的病理情况，必须对技术进行调整，以在并发症最少的情况下获得良好效果。
