Bock Hans C, Dreha-Kulaczewski Steffi F, Alaid Awad, Gärtner Jutta, Ludwig Hans C
Department of Neurosurgery, Section Pediatric Neurosurgery, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
Childs Nerv Syst. 2019 May;35(5):833-841. doi: 10.1007/s00381-019-04119-x. Epub 2019 Mar 27.
The specific pathophysiological processes in many forms of obstructive hydrocephalus (HC) are still unclear. Current concepts of cerebrospinal fluid (CSF) dynamics presume a constant downward flow from the lateral ventricles towards subarachnoid spaces, which are in contrast to neurosurgical observations and findings of MRI flow studies. The aim of our study was to analyze CSF movements in patients with obstructive HC by neuroendoscopic video recordings, X-ray studies, and MRI.
One hundred seventeen pediatric patients with obstructive HC who underwent neuroendoscopy in our center were included. Video recordings were analyzed in 85 patients. Contrast-enhanced X-rays were conducted during surgery prior to intervention in 75 patients, and flow void signals on pre-operative MRI could be evaluated in 110 patients.
In 83.5% of the video recordings, CSF moved upwards synchronous to inspiration superimposed by cardiac pulsation. Application of contrast medium revealed a flow delay in 52% of the X-ray studies prior to neurosurgery, indicating hindered CSF circulation. The appearances and shapes of flow void signals in 88.2% of the pre-operative MRI studies suggested valve-like mechanisms and entrapment of CSF.
Neuroendoscopic observations in patients with obstructive HC revealed upward CSF movements and the corresponding MRI signs of trapped CSF in brain cavities. These observations are in contrast to the current pathophysiological concept of obstructive HC. However, recent real-time flow MRI studies demonstrated upward movement of CSF, hence support our clinical findings. The knowledge of cranial-directed CSF flow expands our understanding of pathophysiological mechanisms in HC and is the key to effective treatment.
多种形式的梗阻性脑积水（HC）的具体病理生理过程仍不清楚。目前关于脑脊液（CSF）动力学的概念假定脑脊液从侧脑室持续向下流入蛛网膜下腔，这与神经外科观察结果和MRI血流研究结果相反。我们研究的目的是通过神经内镜视频记录、X线研究和MRI分析梗阻性HC患者的脑脊液运动情况。
纳入在我们中心接受神经内镜检查的117例小儿梗阻性HC患者。对85例患者的视频记录进行了分析。75例患者在手术干预前术中进行了增强造影X线检查，1ll例患者术前MRI上的流空信号得以评估。
在83.5%的视频记录中，脑脊液在心脏搏动叠加下随吸气同步向上移动。造影剂的应用显示，在神经外科手术前的X线研究中，52%存在血流延迟，提示脑脊液循环受阻。88.2%的术前MRI研究中流空信号的表现和形态提示存在瓣膜样机制和脑脊液潴留。
梗阻性HC患者的神经内镜观察显示脑脊液向上运动以及脑腔内脑脊液潴留的相应MRI征象。这些观察结果与目前梗阻性HC的病理生理概念相反。然而，最近的实时血流MRI研究显示脑脊液向上运动，因此支持我们的临床发现。对脑脊液向颅方向流动的认识扩展了我们对HC病理生理机制的理解，是有效治疗的关键。
