颅内感染后孤立性第四脑室4例并文献复习

目的探讨颅内感染后孤立性第四脑室的诊断和治疗。方法回顾性分析航空总医院神经外七科2018年2月—2020年1月收治的4例孤立性第四脑室患者的临床资料，并对相关文献进行复习。结果4例孤立四脑室病例均继发于颅内感染后，均已行侧脑室外引流术，临床表现为神志昏迷，瞳孔对光反射迟钝，呼吸浅快，心率血压波动，吞咽障碍，流涎，肌张力增高并有去脑强直，2例需要呼吸机辅助呼吸，并使用去甲肾上腺素维持血压。其中2例使用内镜探查可见第四脑室内脓苔、假膜分隔形成，4例患者均行四脑室-腹壁外引流术，其中1例患者同时行环池囊肿-腹壁外引流术，1例合并脊髓蛛网膜下腔积脓、开颅术区软组织化脓性感染的患者同时行脓腔、硬膜外引流及腰大池引流。体外引流期间通过引流冲洗治疗颅内感染，术后患者的瞳孔对光反射、呼吸、血压、流涎、胃瘫、肌张力及去脑强直均明显好转，均停用升压药、停用呼吸机治疗，1例患者术后清醒，3例仍处于昏迷状态（其中2例双侧大脑半球、中脑损伤严重）。颅内感染治愈后行脑室腹腔分流术，2例使用分流泵（30 mmH2O），2例未使用分流泵，以直通管分流。结论对于颅内感染并孤立性第四脑室积水的患者，通过影像学确诊且伴有相应临床症状的情况下，应早期手术解除四脑室对脑干的压迫，对改善患者的预后至关重要。

ObjectiveTo investigate the diagnosis and treatment of isolated fourth ventricle after intracranial infection. MethodsThe clinical data of 4 patients with isolated fourth ventricle admitted to the Department of Neurosurgery, General Aviation Hospital from February 2018 to January 2020 were retrospectively analyzed, and the relevant literature was reviewed. ResultsFour cases of isolated fourth ventricle were all secondary to intracranial infection, and all had undergone lateral ventricular drainage. The clinical manifestations were coma, delayed pupillary light reflex, shallow and rapid respiration, fluctuating heart rate and blood pressure, dysphagia, salivation, increased muscle tone, and presence of denervation and rigidity. Two cases needed a breathing machine to assist with respiration, and norepinephrine was used to maintain blood pressure. Among them, 2 patients underwent endoscopic exploration and showed the formation of pus coating and pseudomembranous separation in the fourth ventricle. All 4 patients underwent external drainage from the fourth ventricle to the abdominal wall. Among them, 1 patient underwent simultaneous drainage from the annular cistern cyst to the abdominal wall, and 1 patient complicated with spinal cord subarachnoid abscess and soft tissue suppurative infection in the craniotomy area underwent simultaneous drainage from the pus cavity, epidural drainage, and lumbar cistern drainage. During extracorporeal drainage, intracranial infection was treated with drainage and irrigation. After surgery, the pupil reflex, respiration, blood pressure, salivation, gastroparesis, muscle tone, and denervation rigidity of the patient were significantly improved. Both vasopressor drugs and ventilator therapy were discontinued. One patient was awake after surgery, and three patients were still in a coma state(including two patients with severe bilateral cerebral hemisphere and midbrain injury). After the intracranial infection was cured, a ventriculoperitoneal shunt was performed, with 2 patients using a shunt pump(30 mmH2O) and 2 patients not using a shunt pump, using a straight tube for shunt. ConclusionsFor patients with intracranial infection and isolated hydrocephalus of the fourth ventricle, if diagnosed by imaging and accompanied by corresponding clinical symptoms, early surgery should be performed to relieve the compression of the fourth ventricle on the brainstem, which is very important to improve the prognosis of patients.