Glick P L, Harrison M R, Halks-Miller M, Adzick N S, Nakayama D K, Anderson J H, Nyland T G, Villa R, Edwards M S
J Pediatr Surg. 1984 Dec;19(6):870-81. doi: 10.1016/s0022-3468(84)80387-5.
To study the effect of in utero ventricular decompression of hydrocephalus on brain development and prognosis, and to evaluate the function and possible complications of different shunt designs, we created fetal hydrocephalus in 28 fetal lambs and 17 fetal monkeys by injecting kaolin into the cisterna magna during the third trimester. One fetal lamb had indwelling intracranial subdural and amniotic cavity pressure catheters placed to study serial changes in the relationship of intracranial pressure (ICP) and amniotic fluid pressure (AFP) from the time of injection until term. Twenty hydrocephalic fetal lambs underwent ventricular decompression--ventriculoamniotic (V-A), N = 10; ventriculo-right atrial (V-RA), N = 9; and ventriculo-pleural (V-PL), N = 1--21 to 25 days after the kaolin was injected; seven hydrocephalic fetuses were left unshunted as controls (CON). Eight fetal monkeys underwent V-A decompression 14 to 21 days after kaolin injection; nine were left unshunted as controls. All animals were delivered by cesarean section near term, assessed for viability and their brains examined grossly and microscopically. After kaolin injection in the fetal lamb, ICP (r = 0.94) and ICP minus AFP (r = 0.93) rose in a linear fashion, while AFP showed no trend (r = 0.22). All unshunted newborn lambs and monkeys had split sutures, dilated ventricles, and thinned cortical mantle. Most shunted lambs showed anatomic improvement with decreased head circumference, overriding sutures, normal-sized ventricles, and improved survival. However, histopathology revealed marked white matter destruction. In contrast, most shunted monkeys showed little anatomic improvement. Both shunted and unshunted monkey brains showed a severe inflammatory ventriculitis. In both lambs and monkeys, shunting was associated with a variety of complications including subdural hematoma, subdural hygroma, shunt infection, shunt occlusion, and improper shunt tip placement. In this experimental model, in utero decompression of obstructive hydrocephalus improves overall survival, improves gross ventriculomegaly, does not improve histopathologic brain damage, and is associated with significant complications. The choice of the optimal shunt design and the effect on postnatal neurologic function requires further study. This work emphasizes the need for continuing research in an animal model prior to human application.
为研究宫内脑积水脑室减压对脑发育及预后的影响，并评估不同分流设计的功能及可能的并发症，我们在孕晚期通过向28只胎羊和17只胎猴的枕大池注射高岭土来制造胎儿脑积水。一只胎羊植入了颅内硬膜下和羊膜腔压力导管，以研究从注射时到足月期间颅内压（ICP）与羊水压力（AFP）关系的系列变化。20只脑积水胎羊在注射高岭土后21至25天接受了脑室减压——脑室-羊膜腔（V-A）分流，N = 10；脑室-右心房（V-RA）分流，N = 9；脑室-胸膜腔（V-PL）分流，N = 1；7只脑积水胎儿未行分流作为对照（CON）。8只胎猴在注射高岭土后14至21天接受了V-A减压；9只未行分流作为对照。所有动物在接近足月时行剖宫产，评估其生存能力，并对其大脑进行大体和显微镜检查。在胎羊注射高岭土后，ICP（r = 0.94）和ICP减去AFP（r = 0.93）呈线性上升，而AFP无变化趋势（r = 0.22）。所有未行分流的新生羊和猴均有颅骨缝裂开、脑室扩张和皮质变薄。大多数行分流的羊在解剖学上有改善，头围减小、颅骨缝重叠、脑室大小正常且生存率提高。然而，组织病理学显示有明显的白质破坏。相比之下，大多数行分流的猴在解剖学上改善甚微。行分流和未行分流的猴脑均显示有严重的炎症性脑室炎。在羊和猴中，分流均与多种并发症相关，包括硬膜下血肿、硬膜下积液、分流感染、分流阻塞和分流尖端放置不当。在这个实验模型中，宫内梗阻性脑积水减压可提高总体生存率，改善明显的脑室扩大，但不能改善组织病理学上的脑损伤，且与显著的并发症相关。选择最佳分流设计及其对出生后神经功能的影响需要进一步研究。这项工作强调在应用于人类之前需要在动物模型中继续进行研究。
