Chamiraju Parthasarathi, Bhatia Sanjiv, Sandberg David I, Ragheb John
Division of Pediatric Neurosurgery, University of Miami Miller School of Medicine and Miami Children's Hospital, Miami, Florida; and.
J Neurosurg Pediatr. 2014 Apr;13(4):433-9. doi: 10.3171/2013.12.PEDS13219. Epub 2014 Feb 14.
The aim of this study was to determine the role of endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) in the management of posthemorrhagic hydrocephalus of prematurity (PHHP) and to analyze which factors affect patient outcomes.
This study retrospectively reviewed medical records of 27 premature infants with intraventricular hemorrhage (IVH) and hydrocephalus treated with ETV and CPC from 2008 to 2011. All patients were evaluated using MRI before the procedure to verify the anatomical feasibility of ETV/CPC. Endoscopic treatment included third ventriculostomy, septostomy, and bilateral CPC. After ETV/CPC, all patients underwent follow-up for a period of 6-40 months (mean 16.2 months). The procedure was considered a failure if the patient subsequently required a shunt. The following factors were analyzed to determine a relationship to patient outcomes: gestational age at birth, corrected age and weight at surgery, timing of surgery after birth, grade of IVH, the status of the prepontine cistern and cerebral aqueduct on MRI, need for a ventricular access device prior to the endoscopic procedure, and scarring of the prepontine cistern noted at surgery.
Seventeen (63%) of 27 patients required a shunt after ETV/CPC, and 10 patients did not require further CSF diversion. Several factors studied were associated with a higher rate of ETV/CPC failure: Grade IV hemorrhage, weight 3 kg or less and age younger than 3 months at the time of surgery, need for reservoir placement, and presence of a normal cerebral aqueduct. Two factors were found to be statistically significant: the patient's corrected gestational age of less than 0 weeks at surgery and a narrow prepontine cistern on MRI. The majority (83%) of ETV/CPC failures occurred in the first 3 months after the procedure. None of the patients had a complication directly related to the procedure.
Endoscopic third ventriculostomy/CPC is a safe initial procedure for hydrocephalus in premature infants with IVH and hydrocephalus, obviating the need for a shunt in selected patients. Even though the success rate is low (37%), the lower rate of complications in comparison with shunt treatment may justify this procedure in the initial management of hydrocephalus. As several of the studied factors have shown influence on the outcome, patient selection based on these observations might increase the success rate.
本研究旨在确定内镜下第三脑室造瘘术和脉络丛烧灼术（ETV/CPC）在早产儿出血后脑积水（PHHP）治疗中的作用，并分析哪些因素会影响患者的预后。
本研究回顾性分析了2008年至2011年间27例接受ETV和CPC治疗的脑室出血（IVH）并伴有脑积水的早产儿的病历。所有患者在手术前均接受MRI评估，以验证ETV/CPC的解剖学可行性。内镜治疗包括第三脑室造瘘术、中隔造瘘术和双侧脉络丛烧灼术。ETV/CPC术后，所有患者接受了6至40个月（平均16.2个月）的随访。如果患者随后需要进行分流术，则认为该手术失败。分析以下因素以确定其与患者预后的关系：出生时的胎龄、手术时的矫正年龄和体重、出生后手术时机、IVH分级、MRI上脑桥前池和大脑导水管的状态、内镜手术前是否需要脑室引流装置，以及手术时脑桥前池的瘢痕情况。
27例患者中有17例（63%）在ETV/CPC术后需要进行分流术，10例患者不需要进一步的脑脊液分流。所研究的几个因素与ETV/CPC失败率较高相关：IV级出血、手术时体重3kg或更低且年龄小于3个月、需要放置储液囊，以及大脑导水管正常。发现两个因素具有统计学意义：手术时患者的矫正胎龄小于0周以及MRI上脑桥前池狭窄。大多数（83%）ETV/CPC失败发生在术后的前3个月。没有患者出现与手术直接相关的并发症。
内镜下第三脑室造瘘术/CPC是治疗IVH和脑积水的早产儿脑积水的一种安全的初始手术，可避免部分患者进行分流术。尽管成功率较低（37%），但与分流治疗相比并发症发生率较低，这可能使该手术在脑积水的初始治疗中具有合理性。由于所研究的几个因素已显示出对预后有影响，基于这些观察结果进行患者选择可能会提高成功率。
