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

【目的】本研究的目的是通过对未成熟大脑特定脑脊液（CSF）动力学的分析，探讨神经内窥镜脑室造瘘术治疗“非交通性脑积水”失败的潜在病理生理学。【材料与方法】前瞻性分析12例脑积水新生儿及疑似非交通性脑积水患儿作为磁共振成像（MRI）初印痕，采用电影模式MRI和计算机断层扫描（CT）脑室-脑池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-脑池造影模式均显示脑脊液动力学中实质内占优势的脑脊液流动（次要途径），而不是主要途径的通道。选择4例患者作为神经内窥镜脑室切开术的明确适应症。术后4例患者颅内压均稳定，与“内镜脑室造瘘后脑积水”情况一致。然而，所有4例患者在平均5.5周（范围4-9周）时均出现颅内压升高症状。12例患者均行脑室-腹膜（V-P）分流术，除一例因囊肿切除而开颅的患者外，其余患者均有改善。【讨论与结论】新生儿和婴幼儿期脑积水治疗中“神经内窥镜脑室造口术失败”的高发可能与脑脊液的具体动态有关，其中脑脊液主要通路尚未发育，次要通路在个体成熟过程中起重要作用。这一临床证据可能得到以下假设的支持：脑脊液动力学根据进化理论发展，从具有次要脑脊液通路优势的动物的未成熟大脑，即“次要脑脊液通路脑积水”，到成熟的成人大脑，并完成主要脑脊液通路，即“脑脊液动力学的进化理论”。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