【作者】 张丕强；

【导师】 张会丰；

【作者基本信息】 河北医科大学 ， 儿科学， 2008， 硕士

【摘要】 目的:利用CT、MRI和B超诊断外部性脑积水,总结小儿头颅B超的影像学特征及外部性脑积水的动态演变过程,结合临床表现与生长发育指标的测定,探讨外部性脑积水颅脑B超的诊断标准、治疗与预后的关系。方法:从2006年3月至2007年10月在河北医科大学第二医院儿科门诊或住院病房中诊断为外部性脑积水患儿78例(男41例,女37例),其中轻度HIE 15例,颅内出血6例,高胆红素血症5例,颅内感染10例,热性惊厥4例,癫痫3例,兴奋、夜惊7例,头围增大8例,前囟隆起14例,呼吸道感染4例,无任何表现者2例。将所有病例按月龄分为6组,采用前瞻性研究方法,利用头颅CT或MRI来确诊外部性脑积水,然后使用B超分别从冠状面、矢状面动态观察外部性脑积水的变化并测量额顶部蛛网膜下腔深度和半球间裂的宽度,由专人测量身高、体重、头围,使用Gesell发育量表进行智力评估,每隔3月复查一次。所有统计学分析应用SPSS 13.0统计软件包进行,计量数据采用均数±标准差( x±s)表示。结果:头颅CT和MRI的典型表现:(1)额部或额顶叶蛛网膜下腔增宽,大脑后半部不宽。(2)前纵裂池增宽,后纵裂池不增宽。(3)大脑外侧裂池增宽。(4)鞍上池稍大。(5)额顶叶脑沟增宽加深,边缘呈“花瓣状”,其余部分脑池不宽。(6)脑室不大或轻度扩大。从B超结果可以看出,双侧额部或额顶部蛛网膜下腔增宽78例(100%),平均值为4.73mm。前纵裂增宽者64例(85%),平均为5.54mm。从年龄分组上看,1月内新生儿的蛛网膜下腔与前纵裂无明显增宽,3月内婴儿,与蛛网膜相比前纵裂增宽最为明显,3~6月组额部或额顶部蛛网膜下腔宽度与前纵裂宽度绝对值最大,合并硬膜下积液2例,6月以后,蛛网膜下腔与前纵裂逐渐缩小,有1例出现脑萎缩,到前囟闭合前54例已消失,其余均明显减少。因此蛛网膜下腔的深度和半球间裂的宽度可以作为评价外部性脑积水的指标,蛛网膜下腔4.17±1.09(mm),半球间裂4.92±0.84(mm),超过该数值可诊断为外部性脑积水。智测结果:6月龄时:≥85分者47例,75~84分者20例,≤74分者11例。评估发育商≥85分者其中颅内感染8例,热性惊厥3例,呼吸道感染4例,癫痫1例,兴奋、夜惊7例,头围增大8例,前囟隆起14例,无任何表现者2例。在75~84分者中新生儿缺血缺氧性脑病11例,颅内出血1例,高胆红素血症4例,颅内感染1例,癫痫1例,热性惊厥1例,在大运动,细动作,个人—社会,语言,适应性行为五个项目中,有11例运动功能均有落后,运动发育落后均>1.8月龄,大运动和细动作落后水平基本相同(平均分数分别为78分和76分)。语言能力落后7例(平均81分)。≤74分者11例,其中大运动,细动作,个人—社会,适应性行为均落后(平均65分)。12月龄时:≥85分者45例,75~84分者18例,≤74分者15例。评估发育商≥85分者其中颅内感染7例,热性惊厥2例,呼吸道感染4例,癫痫1例,兴奋、夜惊7例,头围增大8例,前囟隆起14例,无任何表现者2例。在75~84分者中新生儿缺血缺氧性脑病9例,颅内出血2例,高胆红素血症4例,颅内感染1例,癫痫1例,热性惊厥1例,在大运动,细动作,个人—社会,语言,适应性行为五个项目中,有11例运动功能均有落后,运动发育落后均>2月龄,大运动和细动作落后水平基本相同(平均分数分别为76分和75分)。语言能力落后7例(平均80分)。≤74分者15例,其中大运动,细动作,个人—社会,适应性行为均落后(平均62分)。头围增长情况:出生时头围的平均值为35.2cm,3月龄时头围平均值为42.3cm,6月龄时平均头围为44.5cm,9月龄时平均头围为46.4cm,12月龄平均头围为47.6cm,18月龄时平均头围为48.7cm,在正常生长速度之内。身长增长情况:出生时身长的平均值为51.4cm,3月龄时身长平均值为62.7cm,6月龄时身长平均为68.6cm,9月龄时身长平均为72.7cm,12月龄身长平均为76.2cm,18月龄时身长平均为82.0cm,处于正常增长范围之内。体重增长情况:出生时体重的平均值为3.7kg,3月龄时体重平均值为7.4kg,6月龄时体重平均为9.1kg,9月龄时体重平均为10.2kg,12月龄体重平均为11.5kg,18月龄时体重平均为12.4kg,为正常生长速度。结论:1外部性脑积水作为交通性脑积水的特殊类型,可以存在于正常生长发育小儿中,不应该看作病理情况,绝大多数预后良好,无后遗症。但对于那些继发性外部性脑积水,应该采取积极地治疗措施。2利用B超的灵敏,可靠,无创,价廉,可重复操作等优点,适合动态观测外部性脑积水等小儿颅内病变。3蛛网膜下腔的深度和半球间裂的宽度可以作为评价外部性脑积水的指标,蛛网膜下腔4.17±1.09(mm),半球间裂4.92±0.84(mm),超过该数值可诊断为外部性脑积水。更多还原

【Abstract】 Objectives: Diagnose external hydrocephalus by CT or MRI , then B ultrasound was used to observe the succession and the feature of imageology of external hydrocephalus, we probed diagnostic criteria in B ultrasound, the relation between the treatment and prognostic of external hydrocephalus combining clinical manifestation and the index of growth and development.Methods: All experimental objects weres 78 examples( 41boys, 37girls ) diagnosed external hydrocephalus in paediatric out-patient and inpatient department of the Second Hospital of Hebei Medical University from March in 2006 to Octomber in 2007, including 15 HIE, 6 intracranial hemorrhage, 5 hyperbilirubinemia, 10 intracranial infeion,4 febrile convulsion, 3 epilepsy, 7 angor nocturnes, 8 head circumferenceaugmentation, 14 anterior fontanel, 4 respiratory infection, 2 without any symptom. All experimental objects were divided into six groups every three months. Firstly we can diagnose external hydrocephalus by CT or MRI, Secondly B ultrasound was used to observe the architecture of brain from the coronal section and sagittal section. The brain middle was excentric or not. firstly, we could observe the architecture of brain and the appearance and seize of cerebral ventricle according to routine cross sections, Then the depth of cavitas subarachnoidealis and the width of fissura interhemisphaerica could be measured. Finally we measured the height, the weight, head circumference and evaluate the intelligence by Gesell developmental scale. Recheck every three months. The data was analyzed with SPSS for Windows 13.0 statistic software expressed as mean±standard deviation (mean±SD).Results: typical examples of cerebral CT and MRI in external hydrocephalus:(1)subarachnoid cavities in frontal and frontoparietal parts symmetrically broadened, not in posterior part;(2)frontal interhemispheric cistern widened, not in posterior part;(3)Sylvian fissure cisterns also widened.(4)suprasellar cistern slightly enlarged.(5)cortical sulci in frontal and frontoparietal parts widened and deepened, like petaloid ambulacra in the rim, other cisterns didn’t change.(6)cerebral ventricle didn’t enlarge or slightly enlarge,We can gain the results by B ultrasound: 78 examples(100%) subarachnoid cavities in frontal and frontoparietal parts broadened, the average was 4.73mm.64 examples ( 85% ) frontal interhemispheric cistern widened, the average was 5.54mm. 43 examples(55%)sylvian fissure cisterns widened, 5 examples(6%)basal cistern enlarged, 7 examples (9%) cerebral ventricle slightly enlarged. From age groups, subarachnoid cavities and frontal interhemispheric cistern didn’t widened in neonatal period. Comparing with subarachnoid cavities frontal interhemispheric cistern widened extreme obviously from first month to third month. subarachnoid cavities in frontal or frontoparietal parts and frontal interhemispheric cistern widened largest from third month to sixth month, inclulding 4 examples sylvian fissure cisterns widened and suprasellar cistern slightly enlarged, inclulding 2 examples subdural collection of fluid and cerebral atrophy 1 examples, which reflected obviously in HIE, intracranial hemorrhage. subarachnoid cavities in frontal or frontoparietal parts and frontal interhemispheric cistern gradually diminished after 6 months, 54examples had vanished till anterior fontanelle closed, cerebral atrophy hadn’t changed obviously. So we thought that the width of fissure interhemisphaerica and the depth of cavitas subarachnoidealis could be took as the index estimating external hydrocephalus. The sonogram of external hydrocephalus infants was the depth of cavitas subarachnoidealis(4.17±1.09mm)and the width of fissure interhemisphaerica(4.92±0.84mm).The result of intelligence evaluation: sixth months: there were 47 examples whose score exceed 85, including 8 intracranial infeion, 3 febrile convulsion, 1 epilepsy, 7 angor nocturnes, 8 head circumferenceaugmentation, 14 anterior fontanel, 4 respiratory infection, 2 without any symptom. there were 20 examples, whose score varied from 75 to 84, including 11 HIE, 1 intracranial hemorrhage, 4 hyperbilirubinemia, 1 intracranial infeion, 1 febrile convulsion, 1 epilepsy, coarse action, fine action, individual-society, language and adaptive behavior had been fell behind in 11 examples, motor development fell behind over 1.8 months, the level of coarse action and fine action were identical, the average score were 78 and 76. There were 7 examples whose language ablity fell behind and the score were 81. there were 11 examples whose score below 74, coarse action, fine action, individual-society, language and adaptive behavior had been fell behind. Twelfth months: there were 45 examples whose score exceed 85, including 7 intracranial infeion, 2 febrile convulsion, 1 epilepsy, 7 angor nocturnes, 8 head circumferenceaugmentation, 14 anterior fontanel, 4 respiratory infection, 2 without any symptom. there were 18 examples, whose score varied from 75 to 84, including 9 HIE , 1 intracranial hemorrhage, 4 hyperbilirubinemia, 1 intracranial infeion, 1 febrile convulsion, 1 epilepsy, coarse action, fine action, individual-society, language and adaptive behavior had been fell behind in 10 examples, motor development fell behind over 2 months, the level of coarse action and fine action were identical, the average score were 76 and 75. There were 7 examples whose language ablity fell behind and the score were 81. there were 15 examples whose score was below 74, coarse action, fine action, individual-society, language and adaptive behavior had been fell behind, including 7 HIE, 5 intracranial hemorrhage, 2 hyperbilirubinemia, 1 intracranial infeion.The result of head circumference: the average head circumference of new-born infant was 35.4 cm, Among postnatal three months, the average of head circumference was 42.3 cm, there was 44.5cm, 46.4cm, 47.6cm, 48.7cm in the sixth, nineth, twelfth, eighteenth month, which was almost equal between the objects and the normal children.The result of body length and body weight: not only body length and body weight of new-born infant but also velocity of increase, both the objects and the normal children hadn’t significant difference.Conclusions: 1 As a special sort of communicating hydrocephalus, external hydrocephalus which existed normal infant with growth and development, shouldn’t regard as sick and eusemia. but effective therapeutic measures should be taken positively with regurd to acquired external hydrocephalus.2 B ultrasound which had some merits such as sensitiveness, reliability, no radiation,low expense, reproducibility,had used to observe external hydrocephalus dynamic.3 The width of fissure interhemisphaerica and the depth of cavitas subarachnoidealis could be taken as the index estimating external hydrocephalus.The sonogramof external hydrocephalus infants was the depth of cavitas subarachnoidealis(4.17±1.09mm)and the width of fissure interhemisphaerica (4.92±0.84mm).更多还原