Guida Lelio, Beccaria Kevin, Benichi Sandro, Chivet Anaïs, de Saint Denis Timothée, James Syril, Paternoster Giovanna, Zerah Michel, Puget Stéphanie, Blauwblomme Thomas
1Department of Pediatric Neurosurgery, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Université de Paris, France; and.
2Department of Neurosurgery, University of Milan, Italy.
J Neurosurg Pediatr. 2020 Jul 3;26(4):346-352. doi: 10.3171/2020.4.PEDS20144. Print 2020 Oct 1.
Pediatric patients with long-term shunts may experience specific complications related to the segregation of the supra- and infratentorial spaces along with different pressure regimens, leading to either mesencephalic syndromes during shunt dysfunction or isolated fourth ventricle (IFV). An accepted treatment to reestablish normal CSF pathways and reequilibrate the transtentorial pressures is endoscopic aqueductal stenting (EAS) to avoid restenosis. In the present paper, the authors studied children treated with EAS during the last decade for both IFV and obstructive hydrocephalus, evaluated its impact on the course of the disease, and identified prognostic factors for EAS success.
A noninterventional retrospective study of routinely acquired data was performed, including all hydrocephalic children undergoing EAS between 2011 and 2019 at Hôpital Necker, Paris, France. The following variables were analyzed: etiology of hydrocephalus; number of surgeries before and after stent placement; indication for EAS; type of stent connection (i.e., connected or not to a ventriculoperitoneal shunt); and the stent position. Stent failure was defined as the need to perform further shunt revision. Univariate and multivariate analyses were run to identify factors associated with stent failure.
Seventeen patients with a mean age at stent placement of 6 years (SD 6.5 years, range 1 month-18 years) and with a mean follow-up after EAS of 47.5 months (SD 33.7 months, range 5-120 months) were included in the analysis. The etiology of hydrocephalus was as follows: obstructive tumoral (41%), posthemorrhagic (35%), postinfectious (12%), and dysraphism related (12%). The indication for EAS was IFV (47%), rostral midbrain dysfunction syndrome (35%), prevention of secondary aqueductal stenosis after debulking surgery (12%), or primary aqueductal stenosis (6%). No transient or permanent neurological deficits related to the procedure were observed. After EAS, 10 patients did not require further surgeries (59%), and for the others the number of hydrocephalus-related surgeries significantly decreased after stenting. In univariate analysis posthemorrhagic etiology and prevention of aqueductal stenosis were identified as predictors of a good outcome, whereas in multivariate analysis posthemorrhagic hydrocephalus was found to predict a favorable outcome.
The results confirm EAS as a first-line treatment for IFV and suggest its efficacy in changing the history of hydrocephalic patients who have undergone multiple operations and who experience rostral midbrain dysfunction syndrome, as well as efficacy in the prevention of aqueductal stenosis in selected cases of obstructive tumoral hydrocephalus.
长期使用分流管的儿科患者可能会经历与幕上和幕下空间分隔以及不同压力状态相关的特定并发症，这会导致分流功能障碍时出现中脑综合征或孤立性第四脑室（IFV）。一种公认的重建正常脑脊液通路和重新平衡幕间压力的治疗方法是内镜下导水管支架置入术（EAS），以避免再狭窄。在本文中，作者研究了过去十年中接受EAS治疗的IFV和梗阻性脑积水患儿，评估了其对疾病进程的影响，并确定了EAS成功的预后因素。
对常规获取的数据进行非干预性回顾性研究，纳入2011年至2019年在法国巴黎内克尔医院接受EAS治疗的所有脑积水患儿。分析了以下变量：脑积水的病因；支架置入前后的手术次数；EAS的适应证；支架连接类型（即是否与脑室腹腔分流管连接）；以及支架位置。支架失败定义为需要进行进一步的分流管修复手术。进行单因素和多因素分析以确定与支架失败相关的因素。
17例患者纳入分析，支架置入时的平均年龄为6岁（标准差6.5岁，范围1个月至18岁），EAS后的平均随访时间为47.5个月（标准差33.7个月，范围5至120个月）。脑积水的病因如下：梗阻性肿瘤（41%）、出血后（35%）、感染后（12%）和神经管闭合不全相关（12%）。EAS的适应证为IFV（47%）、中脑嘴端功能障碍综合征（35%）、肿瘤切除术后预防继发性导水管狭窄（12%）或原发性导水管狭窄（6%）。未观察到与该手术相关的短暂或永久性神经功能缺损。EAS后，10例患者无需进一步手术（59%），其他患者在置入支架后脑积水相关手术次数显著减少。单因素分析中，出血后病因和预防导水管狭窄被确定为良好预后的预测因素，而多因素分析中发现出血后脑积水可预测良好预后。
结果证实EAS是IFV的一线治疗方法，并表明其在改变接受过多次手术且患有中脑嘴端功能障碍综合征的脑积水患者病程方面的有效性，以及在特定梗阻性肿瘤性脑积水病例中预防导水管狭窄的有效性。
