- 期刊
Clinical Experience of Ventriculoperitoneal Shunt Dysfunction in a Patient with Hydrocephalus after Brain Injury: A Case Report
引流管功能異常在水腦症病患之治療經驗：病例報告
摘要
本文報告一位43歲男性因車禍導致顱內出血併發水腦症，接受顱骨與血塊移除及植入引流管手術。術後兩個月發現有腦室細隙現象(slit-ventricle syndrome)，於是將中壓式腦室腹膜引流管(ventriculoperitoneal shunt with median pressure valve)更改爲高壓式腦室腹膜引流管(ventriculoperitoneal shunt with high-pressure valve)。然而術後神經學症狀仍未改善，於是將抗虹吸裝製(anti-siphon device)置入並執行顱骨回填手術。病人一連串術後雖影像學上腦室細隙現象雖有改善，但是癲癇發作次數頻繁，且以抗癲癇藥物治療無效。病人因癲癇發作再次入院後，改以置入可調式腦室腹腔引流管(programmable ventriculoperitoneal shunt)。一開始設定爲140 mm H2O，之後根據其臨床神經學症狀，在兩個月內的時間內往下調整爲70 mmH2O。癲癇在半年追蹤期內不再發生，病人臨床上從昏迷指數(Glasgow coma scale)由11分進步到15分，認知功能量表(Rancho Los Amigos stage)由3級進步到5級，modified Rankin scale 由5級進步爲3級。腦室細隙現象不僅由影像學上診斷，有時仍會以頭痛、嗜睡、噁心、認知功能不良、失禁、癲癇頻繁的發作來表現，被認爲是因爲短暫的引流管阻塞導致腦壓升高。因此必須先將引流管設爲高壓，改善其腦室細隙現象，之後往下調整爲低壓以便產生足夠的負壓來引流腦脊髓液，以達到腦脊髓液吸收與製造的平衡，避免腦組織產生扭力(torsion)，病人於臨床神經學的症狀便會有重大的進步。由於放置引流管後腦室細隙現象發生率約5%，而且會影響到病人復健的成果，所以在復健的過程中需了解引流管的術後併發症，而可調式腦室腹膜引流管也提供了一種非手術性的調整引流壓力的方法，以供醫師遇到類似案例時的參考。
並列摘要
We report a case of an adult patient with post-traumatic hydrocephalus who was treated using a ventriculoperitoneal (VP) shunt with a fixed pressure setting valve. Slit ventricle syndrome was found two months later and an antisiphon device (ASD) was added. A fixed pressure valve with ASD was found not to be optimal in terms of improving his neurological symptoms and a programmable valve system was therefore implanted with a pressure setting of 140 mmH2O in the beginning. The valve then was gradually programmed to reduce down to 70 mmH2O over two months. This case demonstrates that selection of a shunting device is difficult, and even after deliberate selection and use of an antisiphon device, slit ventricle syndrome could not be avoided. In addition, the patient in this case had increased episodes of seizure that were associated with acute intracranial hypertension; these were caused by obstruction. Good clinical monitoring of such patients is needed because of the intermittent nature of the high intracranial pressure symptoms. Notwithstanding this, minor complications involving shunt dysfunction may be neglected once the initial treatment has been completed in the neurosurgical ward and the patient has been transferred to a rehabilitation ward. It should be noted that this patient was very sensitive to over-drainage and siphoning was required in order to generate an effective transmantle pressure gradient. Thus, the highest valve setting available was used at the beginning of treatment and this was followed by a methodically lowering of the opening pressure based on the clinical response and computed tomography findings. Overall, the programmable valve shunt system would seem to be more effective when there is a need to deal with shunt dysfunction non-invasively.