Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia
Herniation secondary to critical postcraniotomy cerebrospinal fluid hypovolemia
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DOI：
10.1227/01.neu.0000166661.96546.33
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发表时间：
2005-08-01
期刊：
影响因子：
4.8
通讯作者：
Connolly, ES
中科院分区：
文献类型：
--
作者：
Komotar, RJ;Mocco, J;Connolly, ES
目的：脑脊液低容量导致体位性头痛是一个众所周知的临床现象，但严重形式的脑脊液低容量导致精神状态改变和脑幕后疝（“脑凹陷”）的症状很少被报道。本文描述了开颅后脑凹陷的临床特征，试图增加对这种综合征的认识。方法：2001年4月至2003年1月，连续220例蛛网膜下腔出血患者前瞻性纳入哥伦比亚蛛网膜下腔出血结局项目；137例因动脉瘤夹闭而开颅。在这些患者中，当出现以下三个标准时，诊断为脑凹陷：经幕幕疝的临床体征，头部计算机断层扫描显示基底池消失，脑干呈椭圆形，患者放置在Trendelenburg体位（-15至-30度）后症状改善。对每位患者的症状、临床病程和随后的治疗反应进行了描述。此外，在脑凹陷解决之前，期间和之后，通过计算机断层扫描测量脑干尺寸。通过将最大前后距离除以最大双足距离，生成这些时间点的“凹陷比”。结果：137例动脉瘤性蛛网膜下腔出血患者中11例（8.0%）经开颅加术中脊髓引流符合脑凹陷标准。幕下疝的症状最常见于术后2至4天。11例患者中有10例（91.0%）瞳孔不对称，而另1例患者表现为伸肌位姿。Trendelenburg体位逆转了所有患者的症状。脑凹陷消退前、消退中、消退后的平均凹陷比分别为0.91 +/- 0.03（平均标准误差）、1.18 +/- 0.03和0.91 +/- 0.03。这表示在下垂期间脑干延伸了30.9% (P
Objective: Cerebrospinal fluid hypovolemia resulting in postural headaches is a well-known clinical entity, but severe forms of cerebrospinal fluid hypovolemia with altered mental status and signs of transtentorial herniation ("brain sag") have rarely been reported. This article describes the clinical features of brain sag after craniotomy in an attempt to increase recognition of this syndrome.Methods: Between April 2001 and January 2003, 220 consecutive patients with subarachnoid hemorrhage were prospectively enrolled in the Columbia Subarachnoid Hemorrhage Outcomes Project; 137 underwent craniotomy for aneurysm clipping. Among these patients, the diagnosis of brain sag was made when all three of the following criteria were present: clinical signs of transtentorial herniation, head computed tomographic scans revealing effacement of the basal cisterns with an oblong brainstem, and improvement of symptoms after placement of the patient in the Trendelenburg position (-15 to -30 degrees). For each patient, the symptoms, clinical course, and subsequent response to treatment were characterized. In addition, brainstem dimensions were measured on computed tomographic scans taken before, during, and after resolution of brain sag. A "sag ratio" was generated for these time points by dividing the maximum anteroposterior distance by the maximum bipeduncular distance.Results: Eleven (8.0%) of 137 aneurysmal subarachnoid hemorrhage patients treated by craniotomy and an intraoperative spinal drain met the criteria for brain sag. Signs of transtentorial herniation developed most commonly between 2 and 4 days postoperatively. Pupillary asymmetry was noted in 10 (91.0%) of 11 patients, whereas the other patient demonstrated extensor posturing. The Trendelenburg position reversed the symptoms in all patients. The mean sag ratios before, during, and after resolution of brain sag were 0.91 +/- 0.03 (mean standard error), 1.18 +/- 0.03, and 0.91 +/- 0.03, respectively. This represented a 30.9% elongation of the brainstem during sag (P