RU2279295C2 - Method for draining intracerebral isolated liquor cysts - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: one should form a cutting foramen, make a drainage into cystic cavity, fix it and withdraw its distal end beyond cystic limits. Moreover, on installing proximal end of drainage in cystic cavity its distal end should be curved, closed to perform longitudinal incision of a wall and direct it into subarachnoidal space. Drainage should be fixed with a coupling installed at a drainage at the level of a cutting foramen, and a clamp made out of shape-memory metal. A clamp should be installed so, that one of its pedicle be between coupling wall and drainage, and the second - between the bone and external surface of dura mater. The innovation enables to decrease traumatism of surgical access due to excluding liquor flow and reliable drainage fixation.

EFFECT: higher efficiency of draining.

1 cl, 3 dwg, 1 ex

Description

The method relates to medicine, namely to neurosurgery.

The need to further study the problem of the consequences of traumatic brain injury (TBI) is not in doubt. The frequency, severity of the consequences of the injury, the difficulties of diagnosis and the complexity of tactical approaches in treating victims make this problem not only important socially and preventively, but also a difficult scientific task (Arbatskaya Yu.D., 1986; Zotov Yu.V., 1994 ; Bersnev V.P., 1998; Konovalov A.N., 1998; Likhterman L.B., 2000).

After a severe head injury, in the area of brain bruises, in 40-60% of cases, post-traumatic cysts of the brain are formed - subarachnoid, intracerebral, porencephalic (Rostotskaya V.I., 1986; Zotov Yu.V., 1988; Ryabukha N.P. ., 1996).

The detection rate of intracranial cysts of the brain is from 0.5-10% (Starmal S.P., 1958; Robinson R.S., 1971; Mukhametzhanov H., Ivakina N.I., 1996; Sufianov A.A., 2000). Various aspects of this problem are dealt with by a large number of scientific publications by both domestic and foreign authors. However, questions regarding the indications and methods of surgical interventions for this pathology are contradictory and require further development (Shamov V.N., 1933; Bakulev A.N., 1936; Peltz B.A., 1974; Brugger G., 1976; Mayer U., 1982; Meche FV, 1983; Rostotskaya V.I., 1986; Borisova I.A., 1989; Sato N., Sato N., Katayama X., 1991; Mukhametzhanov X., Ivakina N.I., 1995; Ryabukha N.P., 1996; Melikyan A.G., 1999; Sufianov A.A., 2000).

According to N.I. Ivakina, X. Mukhametzhanova (1996) there are currently three main methods of treatment of intracranial cysts of the brain: 1) operations performed directly on the cyst; 2) various types of shunt operations (cystoperitoneal, cystoatrial, ventriculoperitoneal); 3) combined operations (on a cyst + shunting).

Complications and relapses after operations performed on the cyst are noted in 37-47%, with various types of shunt operations in 66-82.1% (Bersnev V.P., 1987; Borisova I.A., 1989; Lam C.D ., Dubisson D., 1990; Ivakina N.I., Mukhametzhanov X., 1995; Safin Sh.M., 1995; Pribytko A.G., 1997; Melikyan A.G., 1997, 2000; Lebedev V.V. ., 2000).

At the present stage, internal shunting of cysts by fenestration and connection of their cavity with the ventricles and subarachnoid spaces of the brain is recognized as the most physiological and pathogenetically substantiated method. But taking into account possible relapses, it is proposed to perform neuroscopic perforation of the walls of such cysts not so much for the purpose of fenestration as for simultaneous implantation of a particular type of internal shunt in the form of catheters, stents, etc. (Melikyan A.G. et al. 2000).

Known methods for the treatment of isolated intracerebral cysts, in which they perform operations on the ventricular system:

- ventriculoatriostomy,

- ventriculoperitoneostomy.

Operations performed on the ventricular system are absolutely ineffective with respect to the cyst, do not reduce the severity of focal and stem symptoms. Only a slight improvement can occur due to a decrease in the severity of hypertension-hydrocephalic syndrome. X. Mukhametzhanov, N.I. Ivakina. Congenital intracranial arachnoid cysts in children. Almaty, 1995, pp. 91-97.

Known methods of surgical treatment of cysts, in which a combination of operations performed on the cyst and ventricular system is performed:

- perforation of the cyst wall with a ventriculoscope + ventriculoatriostomy;

- cystoatriostomy + ventriculoatriostomy.

The combination of operations on the cyst and ventricular system are more effective, but do not stand comparison with operations on the cyst. This is apparently explained by the fact that manipulations on the cyst during combined operations were reduced mainly to ventriculoscopic perforation of their walls, which is clearly insufficient to ensure a constant outflow of cerebrospinal fluid from the cyst, the latter, possibly, is associated with the formation of a repeated adhesive process in the cyst region or the occurrence of an obstacle to the outflow of cerebrospinal fluid by valve type. The disadvantages of the above should also include the invasiveness of the operation and possible relapses, since surgical access is done directly on the cyst, and additionally for the installation of drainage systems, which increases the time of surgery and possible complications during surgery X. Mukhametzhanov, N.I. Ivakina " Congenital intracranial arachnoid cysts in children. " Almaty. 1995 p. 91-97.

A known method of surgical treatment of intracerebral arachnoid cysts is that in the area of localization of the cyst, an incision is made in the soft tissues of the head, a milling hole is placed over the projection of the cyst, the dura mater is opened, the cyst wall is perforated to create a message of the intracerebral isolated cyst cavity with healthy subarachnoid spaces. X. Mukhametzhanov, N.I. Ivakina. Congenital intracranial arachnoid cysts in children. Almaty, 1995, p. 97.

The disadvantages of the method:

- increased risk of damage to the tissue of the substance of the brain surrounding the cyst with ventriculoscopic perforation of the cyst wall, since the diameter of the working part of the ventriculoscope is 8 mm;

- violation of the outflow of cerebrospinal fluid from the cyst due to cicatricial obstruction of the formed porencephalic anastomosis after ventriculoscopic perforation of the cyst wall.

A known method of introducing a catheter into the cavity according to the copyright certificate No. 1398877, A 6 M 27/00, B.I. 20, 1988, p. 22. The catheter is fixed in the latch, the latch is above the cavity. The sequence of catheter fixation is as follows: first, the catheter is fixed in the fixator in the required position, then the catheter is inserted into the cavity of the ventricle of the brain, after which the fixator is rigidly fixed. The latch includes a bent catheter, latch and needle.

The disadvantage of this device is that with puncture of the ventricle of the brain, the possibility of trauma to the substance of the brain with a mandrel needle remains.

A known method of drainage of intracerebral isolated cysts using silicone drainage systems B.P. Simernitsky with a valve pump of various pressures, selected as a prototype. The method consists in the use of ventricular and abdominal drainage using stainless steel adapters connected to a valve pump of various pressures. The ventricular end of the drainage is inserted directly into the cystic cavity, with the help of adapters attached to the valve pump, which is fixed by interrupted sutures at the edge of the pump to the aponeurosis. The abdominal end of the drainage is carried out in the subcutaneous tissue of the neck, front surface of the chest and abdomen in the abdominal cavity. The valve pump is connected between them through metal adapters and is fixed to the bone by thread ligatures in the area of the treforation hole. Ivakina N.I., Simernitsky B.P., Rostotskaya V.I. Bypass surgery for intracranial arachnoid cysts in children. // In: Hydrocephalus: diagnosis and treatment. Riga, 1987. S.24-25.

The disadvantages of the prototype:

- for the removal of cerebrospinal fluid from the cavity of the intracerebral isolated cyst of the brain, additional surgical accesses are required on the neck, anterior surface of the chest and anterior abdominal wall, which increases the time of the operation and its invasiveness;

- Possible malfunction of the valve pump;

- possible obstruction of the abdominal end of the drainage located in the abdominal cavity, shrouded in an omentum.

The objective of the present invention is to reduce the trauma of surgical access, simplify the technique of surgery, increase the efficiency of drainage by eliminating the reverse flow of cerebrospinal fluid from the cyst, and reliably fix the drainage in the desired position.

The problem is achieved in that the method of drainage of intracerebral isolated cerebrospinal fluid cysts involves installing one end of the ventricular drainage into the cavity of the cyst, securing it and withdrawing the other end outside the cyst. The drainage is L-shaped, curved, the distal end brought into a healthy subarachnoid space, plugged and a longitudinal section of the drainage wall is made on it with the formation of a slit-like valve. On the drainage, at the level of the edge of the milling hole, an elastic sleeve is installed, for example from a section of drainage. The drainage is fixed by installing a metal bracket with shape memory along the edge of the milling hole, with one bracket leg being inserted between the coupling wall and the drainage, and the second between the bone and the outer surface of the dura mater. A longitudinal section is placed on the drainage wall not adjacent to the arachnoid membrane.

The novelty of the method:

- Installation of a L-shaped curved drainage creates an outflow of cerebrospinal fluid along the shortest distance from the cyst to the side of the subarachnoid spaces;

- The formation at the distal end of the drainage of the slit-like valve creates an obstacle to the reverse flow of cerebrospinal fluid from the subarachnoid space into the cavity of the cyst;

- In order to form a slit-like valve at the distal end of the drainage, a drainage wall is cut from the side not adjacent to the arachnoid membrane, which prevents the outflow of cerebrospinal fluid from the drainage;

- Installation on the drainage of an elastic sleeve 5 mm long, for example from a piece of drainage, helps simplify the technique of operation and fix the drainage at the edge of the milling hole;

- The installation of a fixing bracket made of metal with shape memory along the edge of the milling hole contributes to the reliable fixation of drainage for the coupling and the edge of the TMT.

The drainage is L-shaped for curving the cerebrospinal fluid from the cyst directly into the subarachnoid space at the shortest distance. The end of the drainage is muffled, for example, sealed or ligated, to prevent the backflow of cerebrospinal fluid from the subarachnoid space into the cyst cavity, while a slit valve is formed at the end of the drainage, departing from the edge of the drainage 0.5 cm, in the form of a linear longitudinal section 2 cm long of the wall of the distal end drainage.

The free end of loose drainage can migrate, and if it is not plugged, it can rest against the end of the arachnoid membrane or brain, which will lead to the termination of the outflow of cerebrospinal fluid.

To create the outflow of cerebrospinal fluid in one direction and to prevent the reverse flow of cerebrospinal fluid, a slit-shaped valve is used, which works in such a way that when the liquor accumulates in the cyst cavity, it flows out through the drainage and exits through the slit-shaped section of the distal end of the drainage into the subarachnoid space of the brain. The backflow of cerebrospinal fluid from the subarachnoid space into the cyst cavity is prevented by the closure of the walls of the slit-like valve.

The incision was made on the drainage wall, not adjacent to the arachnoid membrane, to create the possibility of free flow of cerebrospinal fluid from the cavity of the cyst into the subarachnoid space. The drainage is fastened through an elastic sleeve, which makes it easy to fix the drainage using a metal bracket with shape memory. One clamp leg is installed in the gap between the drain and the sleeve, which is “put on” to the drain and can be made from a part of the drain pipe of the same or larger diameter, which ensures reliable fixation of the bracket to the drain. The second leg of the bracket is fixed over the edge of the dura mater, it is inserted between the bone and the outer surface of the TMT, since the density of the tissue of the dura mater significantly exceeds the density of the tissue of the arachnoid membrane. Technically, it is more convenient to install the brace-retainer along the edge of the TMT, and in the area of the brace, the drainage bends with the creation of a given direction in the direction of the subarachnoid spaces of the brain.

Thus, the outflow of cerebrospinal fluid from the intracerebral isolated cyst occurs in one direction - from the cyst cavity to the side of the subarachnoid spaces of the brain, thereby creating a constant communication of the cyst cavity with the subarachnoid spaces of the brain.

The method of cystosubarachnoid drainage of isolated intracerebral cysts using one ventricular drainage creates the shortest distance for a constant outflow of cerebrospinal fluid from the cyst cavity into the subarachnoid space, which is less traumatic than cystoperitoneal bypass surgery and more effective compared to simple ventriculoscopic perforation of the cyst wall cerebrospinal fluid current.

The invention is illustrated by drawings:

Figure 1. Drainage installation diagram;

Figure 2. Drainage;

Figure 3. Locking bracket, A is the bracket in the open state, B is the bracket in the closed, working state.

The essence of the method is as follows: after examining the patient and establishing the presence and location of the cyst (1) in the operating room under sterile conditions, a linear incision of the soft tissues was made above the location of the cyst (2). The wound edges were diluted with a retractor, hemostasis was performed in the bones (3), a milling hole (4) was placed above the cyst location with a standard milling cutter, the dura mater (5), the arachnoid membrane (6) were opened, using ventricular drainage and a hard conductor inserted inside Ventricular drainage performed puncture of the cyst, positioning the proximal end of the drainage in the cavity of the cyst (1). With the correct entry into the cavity of the cyst, after removing the conductor through the drainage, the cerebrospinal fluid begins to flow out on its own. The drainage is bent, directing the distal end toward the subarachnoid spaces. On the drainage, at the edge of the milling hole in the place of contact with the dura mater, an elastic sleeve was installed. The fixing bracket was cooled with chloroethyl, the legs of the staples were parted, one of the legs was inserted between the drainage (8) and the sleeve (11), and the second leg was placed between the bone and the outer surface of the dura mater. The bracket (13) under the influence of ambient temperature takes its original shape and rigidly fixes the elastic sleeve (11) with drainage (8) along the edge of the milling hole to the edge of the dura mater. At the free end of the ventricular drainage (9), 0.5 cm from the distal edge, a longitudinal linear incision (10) of one 2 cm long drainage wall is made. The distal end (9) of the drainage (8) is sealed by sealing or bandaged and placed in a subarachnoid space so that the slot 10 does not adjoin the arachnoid membrane (6). This creates the possibility of a constant outflow of cerebrospinal fluid from the cavity of the cyst in the direction of the subarachnoid spaces of the brain. The postoperative wound is sutured in layers tightly. The reverse flow of cerebrospinal fluid from the subarachnoid space to the cyst cavity is not possible due to the presence of a slit-like valve at the distal end of the drainage.

Example. A 47-year-old patient N., 47, was admitted to the Scientific and Educational Center of the State Scientific Center for Surgery and Health at OSSh on August 23, 1999 with complaints of headaches of the frontotemporal localization mainly on the left, aggravated after physical and psychoemotional stresses, an increase in spasticity in the right arm and leg, and speech impairment. From the anamnesis, it is known that four years ago he suffered a closed head injury, hemorrhagic contusion of the brain with a serious degree of severity with a primary lesion of the left parietal lobe, subarachnoid hemorrhage, was treated conservatively in the neurosurgical department of M. Discharged with gradual improvement for outpatient observation and aftercare a neurologist at the place of residence, rehabilitation courses were conducted 2 times a year, including nootropics, vascular drugs, vitamin therapy, absorbable lay down drinking, exercise therapy, massage of limbs, physiotherapy. The deterioration in well-being in the form of an increase in the above symptoms has been noted for the last 6 months. A comprehensive examination of the patient in the neurosurgical department was performed:

- R-graphy of the skull - no bone-traumatic injuries were detected, signs of intracranial hypertension.

- Neuroophthalmologist - hypertensive retina angiopathy.

- Doppler ultrasound of extracranial vessels - angioedema in the carotid pool on the right and a decrease in cerebral blood flow in the carotid pool on the left, indirect signs of intracranial hypertension.

- ECHO - ES - no displacement of the median structures of the brain was detected, additional ECHO signals in the parietal region on the left, signs of intracranial hypertension.

- EEG - a focus of epipodic activity at the junction of the crown-head on the left, prolapse processes predominate in the focus, cerebral manifestations are pronounced, compensated by neurodynamics with an interest in the mid-stem structures of the brain.

- Computed tomography of the brain according to the standard method - an intracerebral isolated post-traumatic cyst of the parietal lobe on the left, measuring 5 by 4 cm, smoothness of the furrows and signs of atrophy of the brain substance in the areas adjacent to the cyst, no displacement of the median structures of the brain was detected, but there are initial signs hydrocephalic transformation of the ventricular system of the brain on the affected side (left).

- Lumbar puncture - lumbar pressure increased to 180 mm long.st., contrast cisternography with omnipack by introducing contrast after lumbar puncture revealed a lack of patency of the contrast medium in the cyst cavity with signs of impaired cerebrospinal circulation in the left side of the brain adjacent to the cyst, which indicates the presence of local post-traumatic convexital arachnoiditis with impaired cerebrospinal circulation and the lack of communication of subarachnoid spaces with a cyst cavity. The ventricular system is not contrasted, ventricular reflux is not. Delayed tomography revealed a decrease in contrast resorption in the left hemisphere.

In neurological status, along with the above complaints, pyramidal insufficiency was revealed in the form of right-sided spastic, moderate hemiparesis with elements of motor aphasia, hemiparetic gait, smoothness of the right nasolabial fold, spontaneous horizontal and vertical nystagmus of 1 degree.

On August 30, 1999, an operation was performed under ETN: Application of a milling hole in the parietal region on the left, cyst-subarachnoid bypass.

Operation Protocol:

Under endotracheal anesthesia, a linear incision was made over the cyst site (1) of the skin (2), subcutaneous tissue, aponeurosis, and the parietal bone was exposed (3). A milling hole (4) was applied in the center of the cyst location, the dura mater (5), the arachnoid membrane (6) were opened, the cyst cavity was punctured (1), with ventricular drainage, and a clear cerebrospinal fluid was obtained. In the place of the edge of the dura mater, an elastic coupling (11) is installed on the drainage, in the form of a drainage segment, a leg of an unbent bracket in the cooling state (13) is inserted into the gap between the drainage and the coupling, another leg is inserted beyond the outer surface of the edge of the dura mater. Drainage is fixed to the dura mater. In the distal section of the drainage, 1 cm from the edge, a linear section of the outer wall of the drainage was made, a slit valve (10) was formed, the distal end of the drainage behind the slit valve was ligated, and laid in a subarachnoid space. A hemostatic sponge is laid on a defect of the dura mater, the wound is sutured in layers.

The postoperative period was favorable, the sutures were removed on the 10th day, healing by primary intention. Neurological status showed a regression of cerebral symptoms in the form of relief of headaches, as well as decreased manifestations of spasticity in the right arm and leg, walks independently without assistance with support on a cane, and speech has improved. Examined on an outpatient basis by a neurosurgeon, after 6 months, it was noted:

- Neuroophthalmologist - angioedema of the retinal vessels.

- EEG - cerebral manifestations are diffuse mainly on the left, compensated by neurodynamics, no focus of pathological activity was detected.

- Doppler ultrasound of extracranial vessels - improved blood flow in the common carotid artery on the left.

- Computed tomography of the brain - the size of the cyst has decreased (2 by 2 cm).

The patient was re-hospitalized in the NHL 8 months after the operation, where, along with the course of complex rehabilitation treatment (exercise therapy, massage vascular preparations, nootropics, restorative treatment, vitamin therapy), an additional examination was performed:

Lumbar pressure decreased to 130 mm East

Computer-assisted contrast cisternography revealed an improvement in patency of the subarachnoid cerebrospinal fluid spaces on the convexital surface of the parietal region on the left, the cyst cavity decreased to 2 cm in diameter, and the cystosubarachnoid shunt.

Thus, the proposed method for drainage of intracerebral isolated cerebrospinal fluid cysts is a less traumatic and highly effective method of surgical treatment of intracerebral isolated cerebral cysts. It combines simplicity, reliability and high efficiency, and also allows to achieve a good clinical effect in the postoperative period in this category of patients.

At present, 9 patients with isolated intracerebral cysts of the brain using this method have been operated on at the Scientific and Research Center for Surgery and Health at the Leninsk-Kuznetsk Center for General Medicine. According to the proposed technique, all patients received good treatment results.

Claims (2)

1. A method for draining intracerebral isolated cerebrospinal fluid cysts, including performing a milling hole, installing drainage into the cyst cavity, fixing and withdrawing its distal end beyond the cyst, characterized in that after installing the proximal end of the drainage in the cyst cavity, the distal end is bent, drowned, produced a longitudinal section of the wall and sent to the subarachnoid space, the drainage is fixed with a sleeve, which is installed on the drainage at the level of the milling hole, and staples made of metal with memory fo We, the bracket is set so that its one leg is between the sleeve wall and the drain, and the second - between the bone and the outer surface of the dura mater. 2. The method according to claim 1, characterized in that the longitudinal section is performed on the wall of the drainage, not adjacent to the arachnoid membrane.

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