冯书彬 芦山 齐林

[摘要] 目的 分析脑室-腹腔分流术（VPS）治疗儿童结核性脑膜炎脑积水（TBMH）的临床疗效。 方法 选取TBMH患儿45例，所有患儿均行VPS治疗。记录患儿年龄、手术前后GCS评分、TBM分级、脑积水的类型和程度、术前抗结核治疗时间、术后恢复情况和术后并发症情况。分析患儿术后的疗效，同时比较疗效好和疗效差患儿参数差异。 结果 治疗效果好27例（60%），效果较差18例（40%）；术后近期出现并发症7例，发生率为15.6%。与疗效差患儿相比，疗效好患儿术前GCS评分较高、抗结核治疗时间较长、TBM分级较低，差异有统计学意义（P < 0.05）。 结论 VPS是一种有效治疗儿童TBMH的方法，其疗效可能与术前GCS评分、抗结核治疗时间、TBM分级有关。

[关键词] 脑室-腹腔分流术；结核性；脑膜炎；脑积水；儿童

[中图分类号] R529.3[文献标识码] A[文章编号] 1674-4721（2012）07（c）-0051-02

Analysis of curative effect on ventriculo-peritoneal shunt in the treatment of childhood tuberculous meningitis hydrocephalus

FENG Shubin LU Shan QI Lin

Department of Neurosurgery, Zhengzhou Children's Hospital in He'nan Province, Zhengzhou 450053, China

[Abstract] Objective To analyze the clinical effect of ventriculo-peritoneal shunt (VPS) in the treatment of childhood tuberculous meningitis hydrocephalus (TBMH). Methods Forty five cases of children with TBMH were chosen. All the children were given the treatment of VPS. The children's age, GCS scores before and after the operation, TBM classifications, the types and levels of hydrocephalus, the preoperative treatment time of anti-tuberculosis, the recovery conditions after operation and the complications after operation were recorded. The postoperative effects of children were analyzed, at the same time, the parametric differences among better effects and worse effects in children were compared. Results There were 27 cases (60%) of good curative effects and 18 cases (40%) of worse effects; the postoperative short-term complications occurred in 7 cases, with the incidence of 15.6%. Compared with the children with worse effects, the preoperative GCS scores of children with better effects were higher, the treatment time of anti-tuberculosis was longer, TBM classifications were lower, the differences were statistically significant (P ＜ 0.05). Conclusion VPS is an effective way in the treatment of childhood TBMH, its effects may be connected with preoperative GCS scores, the treatment time of anti-tuberculosis and TBM classifications.

[Key words] Ventriculo-peritoneal shunt; Tuberculous; Meningitis; Hydrocephalus; Children

腦积水是指由于脑脊液循环通路阻塞使脑脊液在颅内大量积聚，而导致脑室进行性扩大的一种疾病，根据阻塞原因分为梗阻性脑积水和交通性脑积水。结核性脑膜炎脑积水（tuberculous meningitis hydrocephalus，TBMH）是小儿结核性脑膜炎常见的并发症，发生率可达48%，多为梗阻性脑积水[1]。解除梗阻原因是TBMH最理想的治疗方法，但成功率不高，如何有效治疗TBMH一直是儿科临床医生十分头疼的问题。目前，脑室-腹腔分流术（ventriculoperitoneal shunting，VPS）是儿童脑积水的最常用治疗方法之一，其可以解除脑脊液循环障碍，使脑脊液的分泌与吸收得到平衡，降低颅内高压，达到治疗脑积水的目的[2]，但应用VPS治疗儿童TBMH的时机和疗效仍存在争议。本研究通过分析VPS治疗45例儿童TBMH的临床资料，来探讨VPS治疗儿童TBMH的疗效。

1 资料与方法

1.1 一般资料

选取2006年12月～2011年2月本院神经外科诊治的TBMH患儿45例，男27例，女18例，年龄3～14岁，平均（8.3±2.1）岁，包括梗阻性脑积水28例，交通性脑积水17例。主要临床表现：头痛、恶心、呕吐、意识障碍和癫痫发作等。TBMH诊断标准符合如下标准：（1）有结核接触史；（2）结核菌素试验阳性；（3）典型的结核性脑膜炎脑脊液变化（低糖和高蛋白）；（4）经头部CT和（或）MRI检查确诊为脑积水，脑室系统呈对称性扩大，并以侧脑室扩大为主。

1.2 方法

1.2.1 手术方法所有TBMH患儿均行VPS治疗，部分患者行VPS之前先行脑室外引流。术前测定颅内压，根据颅内压的情况选择合适的分流管，术前抗生素溶液浸泡；選取右侧额角为穿刺点，硬脑膜切开1个容分流管穿过的小孔，连接分流管，分流管脑室端置于室间孔附近，分流管腹腔端经胸壁前皮下隧道达上腹部，于上腹部剑突下2～3 cm旁正中入腹腔，腹腔游离段保留30～40 cm；充分止血，包扎。患儿手术前后均经抗结核治疗，术后常规抗感染等治疗。所有患者随访1年。

1.2.2 疗效评价所有患者术前均行腰椎穿刺或脑室外引流脑脊液行脑脊液检查；按英国医学研究协会的标准对结核性脑膜炎进行分级；采用Vassilouthis法，根据患者头颅CT和（或）MRI片子进行脑室-颅比测定，判断脑积水程度。手术前后行GCS评分，根据随访1年GCS评分，将恢复良好和中度致残归纳为效果好，重度致残、植物生存和死亡归纳为效果较差。

1.2.3 参数记录和比较记录患儿年龄、手术前后GCS评分、TBM分级、脑积水的类型和程度、术前抗结核药物治疗时间、术后恢复情况和术后并发症发生情况等。分析患儿术后的疗效，同时比较疗效好和疗效差患儿参数差异。

1.3 统计学方法

应用SPSS 13.0进行统计学分析，计量数据以x±s表示，采用t检验，计数数据进行χ²