[NEJM临床医学影像]:颅压正常脑积水的脑室腹腔分流 | 中国病理生理学会危重病医学专业委员会
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2018年01月21日 临床影像, 临床话题 暂无评论

Images in Clinical Medicine

Ventriculoperitoneal-Shunt Placement for Normal-Pressure Hydrocephalus

Mahmoud A. AbdelRazek, Nagagopal Venna

N Engl J Med 2017; 377: e35


A 70-year-old woman presented to the neurology clinic with a 2-year history of gait disturbance, cognitive impairment, and urinary incontinence. Examination revealed a Mini–Mental State Examination (MMSE) score of 12 (on a scale of 0 to 30, with higher scores representing better performance) and a short-stepped, narrow-based, nonataxic gait. The patient walked 7.6 m in 31 seconds (Video 1). Magnetic resonance imaging revealed ballooning of the ventricles, with an Evan’s ratio (the ratio of the width of the frontal horns of the lateral ventricles [45 mm in this patient] to the internal diameter of the skull [122 mm]) of 0.37 (upper limit of the normal range, 0.31) (Panel A). The callosal angle (Panel B, white arrow) — the angle (outlined in white) between the lateral ventricles measured at the level of the posterior commissure (black arrow) on a coronal plane perpendicular to a line between the anterior and posterior commissures — was less than 90 degrees (reference range, 100 to 120). A lumbar puncture revealed a normal opening pressure, a finding consistent with normal-pressure hydrocephalus. Normal-pressure hydrocephalus classically manifests with urinary incontinence, gait disturbance, and dementia. Surgical shunting of cerebrospinal fluid is the main treatment method. A ventriculoperitoneal shunt was placed, which led to a marked improvement in the patient’s gait (Video 2 at 1 month and Video 3 at 6 months); 6 months after shunt placement, she walked 7.6 m in 6 seconds. The MMSE score increased to 20 points at 1 month, with resolution of urinary incontinence, and increased to 28 points at 6 months.

一名70岁女性患者因步态异常、认知障碍及尿失禁2年就诊于神经内科门诊。检查显示简易精神状态检查表(MMSE)评分12分(评分范围0-30,分值越高行为越正常),呈小跨步步态。31秒钟患者仅行走7.6米。核磁共振显示脑室扩张,Evan比值(侧脑室前角宽度[45 mm]与颅骨内径[122 mm]比值)为0.37(正常范围上限0.31)(图A)。胼胝体角度(图B,白色箭头)即与前后联合连线垂直的冠状面上后联合水平(黑色箭头)侧脑室之间的角度(白线),这一角度不足90度(参考范围100-120)。腰穿显示初压正常,符合颅压正常脑积水。颅压正常脑积水典型表现包括尿失禁,步态异常及痴呆。脑脊液手术分流是主要治疗手段。此患者接受了脑室腹腔分流,步态有显著改善;分流术后6个月时,患者6秒钟即可行走7.6米。术后1个月时MMSE评分升高到20分,尿失禁缓解,6个月时MMSE评分升高到28分。



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