Dynamic Analysis of minor cerebrospinal fluid circulation and a proposal of "Minor pathway Hydrocephalus" based on the indication for endoscopic surgery.

[目的]通过对未成熟脑内特定脑脊液(CSF)动力学的分析，探讨神经内窥镜脑室吻合术治疗“非交通性脑积水”失败的病理生理学基础。[材料与方法]对12例怀疑为非交通性脑积水的新生儿和婴儿进行前瞻性分析，以磁共振成像(MRI)为首发表现，采用电影模式MRI和CT脑室造影进行术前脑脊液动态研究。[结果]在12例脑脊液动力学前瞻性研究中，9例(75%)误诊为“交通性脑积水”。所有病例的脑室-脑池造影术均显示脑脊液动力学以实质内血流为主(次要通路)，而不是主要通路。选择4例显示De…的患者神经内窥镜脑室造口术的更多最终适应症。术后4例患者的颅内压均稳定，如“内窥镜下脑室造瘘术后脑积水停止”。然而，4例患者的颅内压升高症状均复发，平均5.5周(4-9周)。所有12例患者随后均行脑室-腹膜(V-P)分流术，除1例患者行开颅手术摘除囊肿外，其余患者均有明显改善。[讨论与结论]神经内窥镜脑室造瘘术治疗新生儿和婴儿期脑积水的失败率较高，可能与特定的脑脊液动力学有关，其中脑脊液的主要通路尚未发育，而次要通路在个体成熟过程中起着重要作用。这一临床证据可能得到以下假设的支持：脑脊液动力学是根据进化理论发展的，从具有次要脑脊液通路优势的动物的未成熟脑，即“次要通路脑积水”到成熟的人脑，并完成了主要脑脊液通路，即“脑脊液动力学进化论”。较少

[Object] The aim of this study was to discuss the underlying pathophysiology in failure of neuroendoscopic ventriculostomy during treatment of "non-communicating hydrocephalus" with reference to findings from analyses of specific cerebrospinal fluid (CSF) dynamics in the immature brain. [Materials and Method] Prospective analysis was performed for 12 hydrocephalic neonates and infants suspected as non-communicating hydrocephalus as the initial impressions on magnetic resonance imaging (MRI) to undergo the preoperative CSF dynamic studies using cine-mode MRI and computed tomography (CT) ventriculo-cisternography. [Results] Of the 12 cases, 9 (75%) in the prospective study of CSF dynamics revealed misdiagnosis compatible with "communicating hydrocephalus". The pattern in the ventriculo-cisternography in all these cases revealed intra-parenchymal predominant CSF flow (minor pathway) in the CSF dynamics, rather than passage in the major pathway. Four patients were selected as displaying de … More finitive indications for neuroendoscopic ventriculostomy. Postoperatively, all 4 patients were improved with stabilized intracranial pressure (ICP), as in the condition of "post-endoscopic ventriculostomy arrested hydrocephalus". However, symptoms of increased ICP recurred in all 4 patients at a mean of 5.5 weeks (range, 4-9 weeks). Ventriculo-peritoneal (V-P) shunt was subsequently performed in all 12 patients except one who underwent craniotomy for cyst removal, with improvements noted in each case. [Discussion and Conclusion] The high incidence of "failure of neuroendoscopic ventriculostomy" in treatment for hydrocephalus in the neonatal and infantile periods may depend on the specific CSF dynamics, in which the major CSF pathway has not developed and the minor pathway plays a significant role in the individual maturation process. This clinical evidence may be supported by the hypothesis that CSF dynamics develops according to evolutionary theory, from an immature brain as seen in animals with minor CSF pathway predominance, i.e., "Minor Pathway Hydrocephalus" towards a mature adult human brain together with completion of the major CSF pathway, i.e., "Evolution Theory in CSF Dynamics". Less