Neurosurgery:静脉窦支架治疗自发性脑脊液鼻漏

2019-10-29 杨中华 脑血管病及重症文献导读

72岁,女性。既往否认内科和外科病史,否认创伤病史。

72岁,女性。

既往否认内科和外科病史,否认创伤病史。

因为自发性高流量鼻漏,后鼻滴液(drip),右耳发胀就诊。常规检查没有发现异常,BMI 正常,鼻漏液体检测β-2转铁蛋白提示为脑脊液。

脑 MRI 显示硬脑膜增厚伴强化。另外,可见空蝶鞍,双侧岩尖脑膜膨出,眼球运动神经周围 CSF 间隙扩大,颅中窝蛛网膜凹陷,视神经轻度迂曲,双侧横窦和右侧乙状窦狭窄(由蛛网膜颗粒引起)。

CT 脑池造影(鞘内注射碘造影剂)显示右侧鼻沟内和右侧岩骨气房内造影剂显影。

下图:a 图,低脑脊液容量的表现,包括硬脑膜增厚和强化(箭头),直窦扩张(长箭头);图 b 和 c 显示空蝶鞍(箭头),双侧动眼神经鞘扩张(图 c,箭头);图 d,动态 CT 显示右侧鼻腔内脑脊液漏(箭头):





腰穿测压6 cmH2O。

8天后鼻漏和后鼻滴液消失。

作者推测自发性脑脊液漏可能继发于静脉回流受阻引起的假瘤脑综合征。因为症状自行缓解,暂时无手术的计划。

4个月后,自发性脑脊液漏的症状复发。复查 CT 和 MRI 脑池造影显示相同部位脑脊液漏。

经过4周保守治疗,失败。计划急性外科瘘管修复术和/或纠正假瘤脑综合征的手术。因为无脑膨出(absence of encephaloceles),没有必要进行外科瘘管修复术,最终决定进行假瘤脑综合征纠正术比如静脉窦支架手术。

导管静脉窦狭窄部位测压梯度为2-3 mmHg(无临床意义),判断和脑脊液减少无关。经过多学科讨论后,患者开始服用阿司匹林和氯吡格雷,随后在右侧横窦和乙状窦狭窄处置入了两枚6*40 mm 自膨支架。手术后3天鼻漏和鼻后滴液消失,4周时耳胀缓解。

下图,a、b 和 c 为 DSA,显示双侧横窦和右侧乙状窦狭窄(箭头),并置入支架;d 图为支架术后6个月复查 MRI 显示硬脑膜恢复正常,Galen 静脉大小正常(箭头):





手术后6个月复查增强 MRI 和 CT 显示支架通畅无狭窄,脑脊液容量下降的征象消失。9个月时,一过性轻微可疑鼻漏,几天后缓解;MRI 未见明显异常。随访39个月,患者症状无复发。

讨论:

高颅压会导致颅底一处或多处骨硬膜缺损,形成自发性脑脊液漏。当前文献提示自发性脑脊液漏患者单纯修复瘘管,而未对潜在假瘤脑综合征进行治疗,这会增加脑脊液漏复发的风险。自发性脑脊液漏治疗的策略包括外科修复,以及治疗假瘤脑综合征包括减肥、乙酰唑胺和脑脊液分流。外科修复往往优先假瘤脑综合征的治疗,因为往往忽视了假瘤脑综合征的存在。

静脉窦狭窄部位压力梯度仅为2-3 mmHg,无显着意义,作为认为脑脊液容量下降会引起静脉扩张,这样就会导致狭窄部位压力梯度变小。

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encodeId=df403e45532a, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Oct 29 07:30:14 CST 2019, time=2019-10-29, status=1, ipAttribution=)]
    2020-10-01 chg121
  4. 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encodeId=df403e45532a, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Oct 29 07:30:14 CST 2019, time=2019-10-29, status=1, ipAttribution=)]
    2019-10-30 lsndxfj
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encodeId=df403e45532a, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Oct 29 07:30:14 CST 2019, time=2019-10-29, status=1, ipAttribution=)]
    2019-10-30 sodoo
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encodeId=df403e45532a, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Oct 29 07:30:14 CST 2019, time=2019-10-29, status=1, ipAttribution=)]
    2019-10-29 1209e435m98(暂无昵称)

    学习了,谢谢分享

    0

  10. 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encodeId=df403e45532a, content=学习了很有用不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Tue Oct 29 07:30:14 CST 2019, time=2019-10-29, status=1, ipAttribution=)]
    2019-10-29 飛歌

    学习了很有用不错

    0

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