Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes
Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes
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DOI：
10.3171/2012.4.focus1265
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发表时间：
2012-06-01
影响因子：
4.1
通讯作者：
Evans, James J.
中科院分区：
文献类型：
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作者：
Kenning, Tyler J.;Willcox, Thomas O.;Evans, James J.
Object.颞骨的鼓室盖和乳突部分变薄可能易发生脑膜脑膨出和自发性脑脊液漏。手术修复这些骨缺损和相关的脑膜脑膨出有助于预防进展和脑膜炎。颅内高压可能是这种疾病的一个促成因素，必须充分评估和治疗。本研究的目的是建立一个治疗模式的被盖缺陷和阐明致病因素。作者回顾性分析了23例接受乳突切除联合中颅窝开颅术治疗被盖缺损的患者。所有患者的平均体重指数（BMI）为33.2 +/- 7.2 kg/m2。65%的患者（15/23）肥胖（BMI > 30 kg/m2）。术前颅内压（ICP）平均为21.8 +/- 6.0 cm H2O，10例患者（43%）显示ICP > 20 cm H2O。22例患者（96%）有相关脑膨出。5例患者接受了术后脑室腹腔分流术。22例脑脊液漏（96%）在首次尝试时成功修复（平均随访10.4个月）。在脑脊液漏的所有病因中，自发发生的脑脊液漏复发率最高。颞骨缺损的手术治疗，以及伴随的颅内高压的识别和治疗，提供了最大的成功率，在防止复发。在被盖裂开修补术后，对于具有以下复发高危因素的患者，应考虑进行脑室腹膜分流术：自发性脑脊液漏不是由其他诱发条件引起的（即创伤、慢性感染或既往手术）、大量渗漏、CSF开放压> 20 cm H2O、BMI > 30 kg/m（2），术前影像学显示额外的颅底皮质缺损（即，对侧被盖或前颅底）和/或空蝶鞍，以及导致蛛网膜颗粒炎症和CSF吸收受损的任何事件史（即脑膜炎、颅内出血、严重闭合性头部损伤等）。(http：//thejns.org/doi/abs/10.3171/2012.4.FOC1265）
Object. Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors.Methods. The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect.Results. The average body mass index (BMI) among all patients was 33.2 +/- 7.2 kg/m(2). Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m(2)). Preoperative intracranial pressures (ICPs) averaged 21.8 +/- 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months).Conclusions. Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m(2), preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth). (http://thejns.org/doi/abs/10.3171/2012.4.FOCUS1265)