临床小儿外科杂志  2024, Vol. 23 Issue (2): 140-146  DOI: 10.3760/cma.j.cn101785-202212039-008

引用本文  

王君璐, 张立, 刘剑钢, 等. 经颅脑血管多普勒超声在小儿Ⅰ型Chiari畸形诊断及疗效评估中的应用研究[J]. 临床小儿外科杂志, 2024, 23(2): 140-146.   DOI: 10.3760/cma.j.cn101785-202212039-008
Wang JL, Zhang L, Liu JG, et al. Application value of transcraniocerebral vascular Doppler ultrasonography in the diagnoses and postoperative evaluations of Chiari type Ⅰ malformation in children[J]. J Clin Ped Sur, 2024, 23(2): 140-146.   DOI: 10.3760/cma.j.cn101785-202212039-008

基金项目

上海市科学技术委员会上海市2020年度科技创新行动计划医学创新研究专项项目(20Y11905800)

通信作者

张立, Email: zhangl1@shchildren.com.cn

文章历史

收稿日期：2023-09-15
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经颅脑血管多普勒超声在小儿Ⅰ型Chiari畸形诊断及疗效评估中的应用研究
王君璐 , 张立 , 刘剑钢 , 刘瑜 , 肖波     
上海交通大学医学院附属儿童医院神经外科, 上海 200062
收稿日期：2023-09-15
基金项目：上海市科学技术委员会上海市2020年度科技创新行动计划医学创新研究专项项目(20Y11905800)
通信作者：张立, Email: zhangl1@shchildren.com.cn.
摘要：目的 研究经颅脑血管多普勒(transcraniocerebral vessel Doppler, TVD)超声技术在Ⅰ型Chiari畸形患儿诊断以及术后疗效评估中的应用价值。方法 回顾性分析2018年3月至2021年12月上海交通大学医学院附属儿童医院神经外科收治的27例Ⅰ型Chiari畸形患儿临床资料。按年龄分为两组, 学龄前组(1~6岁)15例, 学龄后组(7~16岁)12例。两组患儿均于术前、术后24 h及术后1个月行TVD超声探测, 以后颅窝内双侧大脑后动脉(posterior cerebral artery, PCA)、椎动脉(vertebral artery, VA)及基底动脉(basilar artery, BA)为靶血管, 收集相应靶血管的收缩期峰流速(peak systolic velocity, PSV)、舒张末期流速(end-diastolic velocity, EVD)及搏动指数(pulsative index, PI)等监测指标。分别比较两组患儿手术前后后颅窝动脉血流动力学差异; 比较27例患儿术前TVD与MRI诊断结果的一致性, 以及术后TVD检查结果与Tator疗效评估结果的一致性。结果 学龄前组患儿手术后双侧PCA的PSV较术前增加[左侧: (44.25±13.06)cm/s比(66.76±14.45)cm/s, t=5.148, P=0.023;右侧: (45.12±13.41)cm/s比(65.33±10.12)cm/s, t=5.389, P=0.021]、PI较术前降低[左侧: (1.18±0.42)比(0.91±0.18), t=4.545, P=0.033;右侧: (1.24±0.48)比(0.92±0.13), t=4.776, P=0.028];双侧VA的PSV[左侧: (43.50±11.99)cm/s比(70.94±7.56)cm/s, t=7.042, P=0.008;右侧: (44.56±8.45)cm/s比(68.82±9.02) cm/s, t=6.833, P=0.009]、EVD[左侧: (19.01±9.22)cm/s比(27.18±8.53)cm/s, t=4.587, P=0.032;右侧: (18.28±5.77)cm/s比(28.32±7.26) cm/s, t=4.683, P=0.030]较术前增加, 双侧PI较术前降低[左侧: (1.12±0.45)比(0.86±0.19), t=4.712, P=0.029;右侧: (1.31±0.46)比(0.84±0.31)cm/s, t=5.277, P=0.022];BA的PSV[(48.75±16.57)cm/s比(69.17±11.86)cm/s, t=5.413, P=0.019]、EVD[(27.73±7.34)cm/s比(27.18±8.53)cm/s, t=4.738, P=0.027]较术前增加、PI较术前降低[(1.13±0.55)比(0.90±0.28), t=4.721, P=0.030]。学龄后组患儿手术后双侧VA的PSV较术前增加[左侧: (48.16±18.47)cm/s比(53.77±24.73)cm/s, t=4.187, P=0.045;右侧: (45.72±18.53)cm/s比(56.31±19.82)cm/s, t=3.872, P=0.036], BA的PSV[(48.50±11.44)cm/s比(58.17±18.86)cm/s, t=5.108, P=0.024]、EVD[(18.63±9.91)cm/s比(23.19±10.63)cm/s, t=4.763, P=0.029]较术前增加、PI较术前降低[(1.06±0.42)比(0.92±0.25), t=4.572, P=0.032]。27例术前TVD超声检出率低于MRI(χ2=5.511, P=0.019);术后1个月Tator疗效评估症状改善19例(19/27, 70.4%)、无改善8例(8/27, 29.6%); TVD超声监测指标改善22例(22/27, 81.5%)、无改善5例(5/27, 18.5%), TVD超声检查与Tator疗效评估结果具有较高的一致性(χ2=0.911, P=0.340)。结论 小儿Ⅰ型Chiari畸形的诊断应以MRI检查结果为金标准, 但本研究中TVD超声具有一定的准确性和辅助性, 可有效显示Ⅰ型Chiari畸形患儿后颅窝动脉的血流动力学变化, 间接、无创地评估颅内压, 不仅可以帮助医师及时诊断、给予治疗, 同时TVD超声对于Ⅰ型Chiari畸形术后疗效评估也有良好的应用价值。
关键词：Chiari畸形    超声检查, 多普勒, 经颅    颅窝, 后    脑血管循环    外科手术    治疗结果    儿童    
Application value of transcraniocerebral vascular Doppler ultrasonography in the diagnoses and postoperative evaluations of Chiari type Ⅰ malformation in children
Wang Junlu , Zhang Li , Liu Jiangang , Liu Yu , Xiao Bo     
Department of Neurosurgery, Affiliated Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200062, China
Foundation item: Medical Innovation Research Project of 2020 Action Plan of Shanghai Municipal Science & Technology Commission (20Y11905800)
Corresponding author: Zhang Li, Email: zhangl1@shchildren.com.cn.
Abstract: Objective To explore the application value of transcranialcerebral vessel Doppler (TVD) ultrasonography in the diagnoses and postoperative evaluations of type Ⅰ Chiari malformation in children. Methods From March 2018 to December 2021, the relevant clinical data were retrospectively reviewed for 27 children with type Ⅰ Chiari malformation. Based upon age, they were assigned into two groups of preschool (aged 1-6 year, n=15) and school-age (aged 7-16 year, n=12). TVD was detected at pre-operation, 24 h post-operation and 1 month post-operation. Posterior cerebral artery (PCA), bilateral vertebral artery (VA) and basilar artery (BA) in posterior cranial fossa were selected as target vessels. Peak systolic velocity (PSV), end-diastolic velocity (EVD) and pulsative index (PI) of the corresponding target vessels were monitored. Hemodynamic profiles of posterior cranial fossa were compared in different age groups at pre-operation versus post-operation. The accuracy of diagnosis was compared with magnetic resonance imaging (MRI) at pre-operation and the consistency of efficacy compared with Tator evaluation post-operation. Results PSV of bilateral PCA post-operation spiked in preschool group as compared with that pre-operation [left (44.25±13.06) vs. (66.76±14.45) cm/s, t=5.148, P=0.023; right (45.12±13.41) cm/s vs. (65.33±10.12) cm/s, t=5.389, P=0.021) and PI declined [left (1.18±0.42) vs. (0.91±0.18), t=4.545, P=0.033; right (1.24±0.48) vs. (0.92±0.13), t=4.776, P=0.028), bilateral VA PSV [left (43.50±11.99) vs. (70.94±7.56) cm/s, t=7.042, P=0.008; right (44.56±8.45) vs. (68.82±9.02) cm/s, t=6.833, P=0.009], preoperative EVD rose [left (19.01±9.22) vs. (27.18±8.53) cm/s, t=4.587, P=0.032; right (18.28±5.77) vs. (28.32±7.26) cm/s, t=4.683, P=0.030]and preoperative bilateral PI dropped [left (1.12±0.45) vs. (0.86±0.19), t=4.712, P=0.029; right (1.31±0.46) vs. (0.84±0.31) cm/s, t=5.277, P=0.022], BA PSV [(48.75±16.57) vs. (69.17±11.86) cm/s, t=5.413, P=0.019], preoperative EVD increased [(27.73±7.34) vs. (27.18±8.53) cm/s, t=4.738, P=0.027) and preoperative PI decreased [(1.13±0.55) vs. (0.90±0.28), t=4.721, P=0.030]; PSV of bilateral VA after surgery in school-age group was higher than that pre-operation [left (48.16±18.47) vs. (53.77±24.73)cm/s, t=4.187, P=0.045; right [(45.72±18.53) vs. (56.31±19.82) cm/s, t=3.872, P=0.036)], BA PSV [(48.50±11.44) vs. (58.17±18.86) cm/s, t=5.108, P=0.024], preoperative EVD increased [(18.63±9.91) vs. (23.19±10.63) cm/s, t=4.763, P=0.029]and preoperative PI declined [(1.06±0.42) vs. (0.92±0.25), t=4.572, P=0.032]. Preoperative TVD detection rate of 27 cases was lower than that of MRI (χ2=5.511, P=0.019). At 1 month after Tator efficacy evaluation, there were improvements (n=19, 70.4%) and non-improvements (n=8, 29.6%). TVD ultrasonic monitoring parameters improved (n=22, 81.5%) and stagnated (n=5, 18.5%). There was consistency between TVD ultrasound and Tator efficacy evaluation [χ2=0.911, P=0.340]. Conclusions MRI is a gold diagnostic standard for Chiari type Ⅰ malformation in children. However, TVD ultrasound has some accuracy and auxiliary effects. It can effectively depict the hemodynamic changes of posterior fossa artery and indirectly and non-invasively assess intracranial pressures. Thus it enables clinicians to make a timely diagnosis, offer a proper treatment and make an accurate assessment of outcomes.
Key words: Chiari Malformation    Ultrasonography, Doppler, Transcranial    Cranial Fossa, Posterior    Cerebrovascular Circulation    Treatment Outcome    Treatment Outcome    Child    

Chiari畸形即小脑扁桃体下疝畸形(Chiari malformation, CM), 于1891年由Chiari提出，是指小脑扁桃体等后颅窝解剖结构经枕骨大孔疝出至椎管的一种先天性发育异常，是一种颅颈交界区畸形疾病，临床分为四型，以Ⅰ型最常见。Ⅰ型CM是指经影像学检查证实小脑扁桃体疝入枕骨大孔平面以下超过5 mm[1-2]。Chiari畸形的发病率为0.56% ~1%，儿童发病率为0.6% ~1%[3]。手术是目前治疗CM的优选方案，而后颅窝是相对危险的手术区域。后颅窝解剖结构特殊，不仅包含部分后组颅神经、脑和脊髓，更有大脑后动脉和椎基底动脉等重要结构，畸形下疝的结构可对其造成压迫，进而出现相应的病理生理学及血流动力学改变。本文旨在探讨经颅脑血管多普勒(transcraniocerebral vessel Doppler, TVD)超声技术在Ⅰ型Chiari畸形患儿诊断及术后疗效评估中的应用价值，供临床参考。

资料与方法 一、临床资料

本研究为回顾性研究。收集2018年3月至2021年12月上海交通大学医学院附属儿童医院神经外科收治的27例Ⅰ型Chiari畸形患儿作为研究对象。病例纳入标准：①年龄≤16岁；②经CT或MRI确诊为Ⅰ型Chiari畸形(下疝程度低于枕骨大孔平面5 mm但未达到第1颈椎后弓水平，延髓和四脑室位置正常)，病历资料齐全；③接受手术治疗并签署知情同意书；④伴或不伴脊髓空洞症。排除标准：①接受保守治疗的Ⅰ型Chiari畸形确诊患儿；②合并其他器官功能不全；③为再下疝患儿；④伴有颅内占位性疾病、颅骨破坏性疾病、脑积水等。(伦理编号：2024R028 — E01)

将年龄1~6岁的患儿纳入学龄前组，共15例，男10例、女5例，年龄(3.80±1.61)岁；将年龄7~16岁的患儿纳入学龄后组，共12例，男5例、女7例，年龄(9.50±2.78)岁。两组患儿临床表现：颈神经根症状(颈肩后枕部疼痛、眩晕、躯体感觉障碍、肢端麻木等)20例；小脑功能障碍(行走不稳、共济失调等)18例；颅高压症状(头痛、呕吐、视乳头水肿)10例；锥体束损伤症状(肢体无力、肌张力/肌力降低等)9例；后组颅神经压迫症状(饮水呛咳、吞咽困难、睡眠呼吸障碍等)6例。

二、研究方法 (一) 手术与麻醉

均行后颅窝减压加或不加环枕筋膜松解术。患儿取俯卧位，头架固定，取枕下正中切口，切开枕外粗隆至第2颈椎棘突皮肤，逐层切开、分离枕部肌肉组织，充分显露枕鳞及环椎后弓，咬除枕骨鳞部及枕骨大孔后缘，并形成大小约3 cm×2 cm的骨窗，于环椎后弓咬除约1.5 cm，分离、松解、切除增厚环枕筋膜至硬膜，分层缝合枕部肌肉、皮肤。

采取静脉吸入复合全身麻醉。术中全程联合神经电生理监测，麻醉过程中七氟醚最低肺泡有效浓度(minimal alveolar concentration, MAC)保持在0.5，且不使用肌松药物[4-9]。诱导麻醉：咪达唑仑0.05 mg/kg，丙泊酚2 mg/kg，舒芬太尼0.2 μg/kg，罗库溴铵0.6 mg/kg或苯磺顺阿曲库铵1 mg/kg。麻醉维持：丙泊酚1~2mg·kg-1·h-1泵注，瑞芬太尼10 ug·kg-1·h-1泵注。

(二) TVD超声检查方法及监测指标

1. TVD超声检查方法：使用深圳理邦公司生产的经颅多普勒血流分析仪，选择频率为2 MHz的低频超声探头，根据中国神经超声操作规范及文献报道，以后颅窝枕骨大孔区受压血管的双侧大脑后动脉(posterior cerebral artery, PCA)、椎动脉(vertebral artery, VA)和基底动脉(basilar artery, BA)为靶血管，经颞后窗探测PCA，调整探测深度为60~67 mm，夹角在15°以内，探测面向探头的血流(标度中为正值)[10-12]；再通过枕窗探测VA和BA，调整探测深度为55~65 mm，夹角在15°以内，探测背向探头的血流(标度中为负值)；频谱均以最清晰、最大血流速度为取样标准。

2. 监测指标：分别于手术前、手术后24 h以及术后1个月行TVD超声探测，记录相应靶血管的收缩期峰流速(peak systolic velocity, PSV)(正常值：PCA为45~85 cm/s；VA和BA均为45~80 cm/s)、舒张末期流速(end-diastolic velocity, EVD)(正常值：PCA为22~45 cm/s；VA和BA均为20~40 cm/s)和搏动指数(pulsative index, PI)(正常值：PCA为0.8~1；VA和BA均为0.8~1.05)等。

(三) 手术后疗效评估标准

本研究以Tator评估作为疗效评估标准[13]。Tator评估于1982由美国学者Tator提出并以其姓氏命名，作为Chiari畸形患儿手术后疗效评估的标准。Tator评估主要根据患儿主观症状和主要体征变化进行评价，患儿手术后症状及体征缓解、消失，或主要症状及体征明显缓解或部分缓解，判定为有效；主要症状及体征较术前无明显缓解或加重，甚至出现新的神经功能损害症状，判定为无效。

三、统计学处理

采用SPSS 20.0进行统计学处理。对以频数、构成比表示的计数资料采取χ2检验进行组间比较。两组手术前后靶血管的PSV、EVD、PI等服从正态分布的计量资料采用x±s表示，组内比较采取配对t检验，P﹤0.05为差异有统计学意义。

结果

学龄前组患儿行减压手术后，双侧PCA的PSV、VA的PSV、EVD和BA的PSV、EVD增快；双侧PCA、VA和BA的PI均降低，后颅窝枕骨大孔区压力明显缓解，差异具有统计学意义(P＜0.05)。见表 1。

表 1 学龄前组Ⅰ型Chiari畸形患儿手术前后血流动力学比较(x±s) Table 1 Comparison of preoperative versus postoperative hemodynamics in children with type Ⅰ Chiari deformity in preschool group(x±s)

学龄后组患儿行减压手术后，双侧VA的PSV和BA的PSV、EVD增快；BA的PI降低，后颅窝枕骨大孔区压力有所缓解，差异具有统计学意义(P＜0.05)。见表 2。

表 2 学龄后组Ⅰ型Chiari畸形患儿手术前后血流动力学比较(x±s) Table 2 Comparison of preoperative versus postoperative hemodynamics in children with type Ⅰ Chiari deformity in school-age group(x±s)

27例Ⅰ型Chiari畸形患儿手术前TVD超声检出率低于MRI检查，差异有统计学意义(P＜0.05)。见表 3。手术后1个月TVD超声检查与Tator疗效评估具有一致性，差异无统计学意义(P>0.05)。见表 4。

表 3 27例Ⅰ型Chiari畸形患儿术前TVD超声与MRI检查结果比较[例(%)] Table 3 Comparison of preoperative TVD ultrasonography and MRI in 27 children with type Ⅰ Chiari malformation[n(%)]

表 4 27例Ⅰ型Chiari畸形患儿手术后1个月TVD超声检查结果与Tator疗效评估比较[例(%)] Table 4 Comparison of TVD ultrasonic results and Tator efficacy evaluation in 27 children with type Ⅰ Chiari malformation at 1 month post-operation[n(%)]
讨论

TVD超声检查是一种快捷、安全、无创、可流体定量的检查方式[14]。与传统诊断金标准MRI相比，其具有操作简便、可重复性强、可及时动态评估等优点。本研究对比TVD超声与MRI检查结果发现，TVD超声检查对于Ⅰ型Chiari畸形的检出率较MRI低(P < 0.05)，提示TVD超声检查特异性不如MRI，但TVD超声在显示受压部位血流灌注方面具有明显优势。经TVD超声检查可以显示后颅窝受压血管血流动力学变化，可根据受压血管提供的PSV、EVD、PI等参数计算脑灌注压，从而间接评估颅内压情况[15]。相较于传统影像学检查, 床旁TVD可以通过实时测量颅内大动脉血流情况获取脑血流动力学信息及形态学信息, 不仅可为临床早期诊断和及时治疗提供参考，同时可以全面客观反映病情的严重程度。Chiari畸形是一种复杂的神经系统疾病，需要MRI成像技术与TVD等流体力学技术相互结合快速诊断，从而进一步确定椎基底动脉走向以及脑脊液和血流动力学等病理生理学情况，为Ⅰ型Chiari畸形的诊断提供可靠证据。

Chiari畸形是一种先天性发育异常所致颅颈交界区畸形疾病，临床表现包括颈枕疼痛、头晕、耳鸣、恶心、共济失调、眼球震颤、痛温觉改变、呼吸睡眠障碍及吞咽困难，严重者可出现高位截瘫和神经心理功能障碍等[16-17]。有明显临床症状者需要手术治疗，而手术方式的选择存在较大争议[18-19]。目前国内外对于成人Ⅰ型Chiari畸形的手术治疗以非单纯后颅窝减压等手术方式为主[20-22]。针对低龄儿童Ⅰ型Chiari畸形的手术方式有陈昆等[23]、朱泽章等[24]、陈飞[25]、Massimi等[26]报道的单纯后颅窝减压手术。本研究选择单纯后颅窝减压加或不加环枕筋膜松解手术，结果显示学龄前组Ⅰ型Chiari畸形患儿手术后双侧PCA的PSV、PI，双侧VA的PSV、EVD、PI，BA的PSV、EVD、PI均较手术前有显著改变(P＜0.05)；学龄后组Ⅰ型Chiari畸形患儿手术后双侧VA的PSV，BA的PSV、EVD、PI均较手术前有显著改变(P＜0.05)，提示单纯后颅窝减压加或不加环枕筋膜松解手术治疗Ⅰ型Chiari畸形有一定临床疗效。随着减压手术后后颅窝容积扩大、小脑扁桃体向上回缩，枕骨大孔区压迫得以缓解，即可恢复后颅窝脑脊液的正常流速，同时受压血管的血流速度加快，血管阻力降低。根据王蒙等[27]、Janjua等[28]研究经验，基底动脉腹侧受压(齿状突脱位造成)时间过久可能导致与颅内压增高相关的癫痫及认知行为障碍等发生，TVD超声检查可以直观显示椎基底动脉的血流速度和搏动指数，确定椎基底动脉的血管弹性和压力情况，间接判断颅内压。Blanco等[29-30]、Capel等[31]研究表明，搏动指数是评价大脑小动脉阻力状况的重要指标, 可间接反映颅内压情况, 与颅内压呈正相关。近年来术前联合多普勒超声诊断的临床应用逐渐增多，对手术方式的选择具有良好的判断价值；术中实时监测枕颈交界区血管和脑脊液的峰值流速，根据数值辅助判定是否切开硬脑膜及蛛网膜下腔探查等，可以较术前评估更为精确地调整手术方式，这对于减少手术后并发症有着重要意义[32]。未来实现Ⅰ型Chiari畸形的个性化治疗，将成为手术治疗的趋势，因此，TVD超声不仅为Ⅰ型Chiari畸形诊断和治疗方案的选择提供了参考，更为术中实时调整手术方案提供了客观的判断标准。

临床上Chiari畸形手术后疗效的评估主要针对临床症状改善情况，多采用量表评估，如Tator评估、CCOS(chicago chiari outcome scale, CCOS)预后量表、Barthel生活指数量表、FMA (Fugl-Meyer Assessment, FMA)运动评分量表、QOL-BREF (Quality of Life-Brief Scale, QOL-BREF)生活质量评分量表等，其结果往往较为主观[33-34]。目前较为客观的评价方法是PC-MRI，该方法联合磁共振定量研究脑脊液流体分析技术，虽然无创，但操作复杂且价格偏高，容易受到人力和环境等内外因素影响[35]。TV D超声是近年来在手术室及重症监护室中新发展起来的一种监测脑血流灌注的方法，是一种无创、简便、廉价的超声流体定量技术。本研究于术后1个月对比TVD超声与Tator疗效评估结果显示，Tator评估症状改善19例(70.4%)、症状无改善8例(29.6%)；TVD超声显示监测指标改善22例(81.5%)、无改善5例(18.5%)，TVD超声检查对于Ⅰ型Chiari畸形患儿的术后疗效的评估与Tator评估比较无统计学意义(P>0.05)。证实TVD超声技术对于小儿Ⅰ型Chiari畸形减压手术后的疗效评估具有重要意义，相比主观评估能够客观提供监测指标数据，是直接评价术后疗效的有效、实用方法。

姚晓辉等[36]报道彩色多普勒超声检查是Chiari畸形患儿手术前后测量枕骨大孔区脑脊液流动的有效方法。但临床上对于Chiari畸形后颅窝的血流动力学研究甚少，本研究结果表明，TVD超声能够动态观察后颅窝功能血管的血流动力学改变，间接评估后颅窝压力情况，不仅是小儿Ⅰ型Chiari畸形诊断和治疗的重要参考，也是术中实时调整手术方案的重要客观参数，更在手术后疗效评估中有显著优势。本研究存在以下局限性：①样本量较小，未能考虑到其他可能影响结果的因素；②本研究是一项单中心、回顾性研究，存在一定的选择偏倚和信息偏倚；③本研究未对TVD超声技术应用于小儿Ⅰ型Chiari畸形患儿手术后的长期疗效进行评估。

利益冲突  所有作者声明不存在利益冲突

作者贡献声明  张立、王君璐负责研究的设计、实施和起草文章；王君璐进行病例数据收集及分析；肖波、张立负责研究设计与酝酿，并对文章知识性内容进行审阅

参考文献
[1]
McVige JW, Leonardo J. Neuroimaging and the clinical manifestations of Chiari malformation type Ⅰ (CMI)[J]. Curr Pain Headache Rep, 2015, 19(6): 18. DOI:10.1007/s11916-015-0491-2
[2]
Gilmer HS, Xi MQ, Young SH. Surgical decompression for Chiari malformation type Ⅰ: an age-based outcomes study based on the Chicago Chiari Outcome Scale[J]. World Neurosurg, 2017, 107: 285-290. DOI:10.1016/j.wneu.2017.07.162
[3]
Keser N, Kuskucu A, Is M, et al. Familial Chiari type 1:a molecular karyotyping study in a Turkish family and review of the literature[J]. World Neurosurg, 2019, 121: e852-e857. DOI:10.1016/j.wneu.2018.09.235
[4]
Deiner S. Highlights of anesthetic considerations for intraoperative neuromonitoring[J]. Semin Cardiothorac Vasc Anesth, 2010, 14(1): 51-53. DOI:10.1177/1089253210362792
[5]
Rozet I, Metzner J, Brown M, et al. Dexmedetomidine does not affect evoked potentials during spine surgery[J]. Anesth Analg, 2015, 121(2): 492-501. DOI:10.1213/ANE.0000000000000840
[6]
Sloan TB, Vasquez J, Burger E. Methohexital in total intravenous anesthesia during intraoperative neurophysiological monitoring[J]. J Clin Monit Comput, 2013, 27(6): 697-702. DOI:10.1007/s10877-013-9490-1
[7]
熊巍, 王增春, 张军卫, 等. 全麻下脊柱脊髓手术中神经电生理监测异常的原因分析[J]. 中国康复理论与实践, 2017, 23(4): 424-429.
Xiong W, Wang ZC, Zhang JW, et al. Analysis of abnormalities of intraoperative neurophysiological monitoring in spinal and spinal cord surgery under general anesthesia[J]. Chin J Rehabil Theory Pract, 2017, 23(4): 424-429. DOI:10.3969/j.issn.1006-9771.2017.04.013
[8]
Koht A, Sloan TB, Toleikis JR. 围术期神经系统监测[M]. 韩如泉, 乔慧, 译. 第2版. 北京: 北京大学医学出版社, 2013: 74-78.
Koht A, Sloan TB, Toleikis JR. Monitoring nervous systems for anesthesiologists and other healthcare professionals[M]. Han RQ, Qiao H, Translated. Edition Ⅱ. Beijing: Peking University Medical Press, 2013: 74-78.
[9]
于琳琳, 王军, 马越, 等. 不同肌松水平对术中脊髓神经电生理监测的影响[J]. 首都医科大学学报, 2017, 38(3): 357-360.
Yu LL, Wang J, Ma Y, et al. Effects of different neuromuscular blockade levels on intraoperative spinal cord monitoring[J]. J Cap Med Univ, 2017, 38(3): 357-360. DOI:10.3969/j.issn.1006-7795.2017.03.006
[10]
中国医师协会神经内科医师分会神经超声专业委员会, 中华医学会神经病学分会神经影像协作组. 中国神经超声的操作规范1[J]. 中华医学杂志, 2017, 97(39): 3043-3050.
Specialty Committee of Neuroultrasonography, Branch of Neurologists, Chinese Medical Association, Neuroimaging Collaborative Group, Branch of Neurology, Chinese Medical Association. Operating Standards of Neuroultrasonography in China (Ⅰ)[J]. Natl Med J China, 2017, 97(39): 3043-3050. DOI:10.3760/cma.j.issn.0376-2491.2017.39.002
[11]
Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition[J]. Neurosurgery, 2017, 80(1): 6-15. DOI:10.1227/NEU.0000000000001432
[12]
Abu Rahma AF, Bandyk DF. 无创性血管诊断学: 治疗实用指南[M]. 邢英琦, 译. 第3版. 北京: 人民卫生出版社, 2016: 117-139.
Abu Rahma AF, Bandyk DF. Noninvasive vascular diagnosis: a practical guide to therapy[M]. Xing YQ. Translated. Edition Ⅲ. Beijing: People's Medical Publishing House, 2016: 117-139.
[13]
Tator CH, Meguro K, Rowed DW. Favorable results with syringosubarachnoid shunts for treatment of syringomyelia[J]. J Neurosurg, 1982, 56(4): 517-523. DOI:10.3171/jns.1982.56.4.0517
[14]
闫晓静. 超声检查对早产儿脑损伤的临床价值[J]. 影像研究与医学应用, 2019, 3(4): 154-155.
Yan XJ. Clinical value of ultrasonography in premature infants with brain injury[J]. J Imaging Res Med Appl, 2019, 3(4): 154-155. DOI:10.3969/j.issn.2096-3807.2019.04.104
[15]
Ikuta T, Mizobuchi M, Katayama Y, et al. Evaluation index for asymmetric ventricular size on brain magnetic resonance images in very low birth weight infants[J]. Brain Dev, 2018, 40(9): 753-759. DOI:10.1016/j.braindev.2018.05.007
[16]
Varon A, Whitt Z, Kalika PM, et al. Arnold-Chiari type 1 malformation in Potocki-Lupski syndrome[J]. Am J Med Genet A, 2019, 179(7): 1366-1370. DOI:10.1002/ajmg.a.61187
[17]
Lacy M, Ellefson SE, DeDios-Stern S, et al. Parent-reported executive dysfunction in children and adolescents with Chiari malformation type 1[J]. Pediatr Neurosurg, 2016, 51(5): 236-243. DOI:10.1159/000445899
[18]
Chatrath A, Marino A, Taylor D, et al. Chiari I malformation in children-the natural history[J]. Childs Nerv Syst, 2019, 35(10): 1793-1799. DOI:10.1007/s00381-019-04310-0
[19]
Luciano MG, Batzdorf U, Kula RW, et al. Development of common data elements for use in Chiari malformation type Ⅰ clinical research: an NIH/NINDS project[J]. Neurosurgery, 2019, 85(6): 854-860. DOI:10.1093/neuros/nyy475
[20]
Grossauer S, Koeck K, Vince GH. Intraoperative somatosensory evoked potential recovery following opening of the fourth ventricle during posterior fossa decompression in Chiari malformation: case report[J]. J Neurosurg, 2015, 122(3): 692-696. DOI:10.3171/2014.10.JNS14401
[21]
张科, 陈赞, 程宏伟, 等. Chiari畸形Ⅰ型的个体化手术治疗[J]. 中华神经外科杂志, 2016, 32(12): 1244-1247.
Zhang K, Chen Z, Cheng HW, et al. Individualized surgical treatments for Chiari malformation type Ⅰ[J]. Chin J Neurosurg, 2016, 32(12): 1244-1247. DOI:10.3760/cma.j.issn.1001-2346.2016.12.012
[22]
段海锋, 茹小红, 李海峰, 等. Chiari畸形Ⅰ型37例显微外科治疗体会[J]. 中华脑科疾病与康复杂志(电子版), 2019, 9(4): 210-214.
Duan HF, Ru XH, Li HF, et al. Therapeutic experiences of microsurgery for Chiari type Ⅰ malformation: a report of 37 cases[J]. Chin J Brain Dis Rehabil (Electron Ed), 2019, 9(4): 210-214. DOI:10.3877/cma.j.issn.2095-123X.2019.04.005
[23]
陈昆, 林佳平, 张明亮. 单纯后颅窝减压术治疗低龄儿童Chiari畸形Ⅰ型[J]. 深圳中西医结合杂志, 2018, 28(15): 161-162.
Chen K, Lin JP, Zhang ML. Simple posterior fossa decompression for type Ⅰ Chiari malformation in children with low collar[J]. Shenzhen J Integr Tradit Chin West Med, 2018, 28(15): 161-162. DOI:10.16458/j.cnki.1007-0893.2018.15.077
[24]
朱泽章, 谢丁丁, 沙士甫, 等. 低龄儿童Chiari畸形Ⅰ型后颅窝减压术后小脑位置及形态的变化对脊髓空洞转归的影响[J]. 中国骨与关节杂志, 2015, 4(10): 737-741.
Zhu ZZ, Xie DD, Sha SF, et al. Correlation between changes of cerebellum morphology and syrinx resolution after posterior fossa decompression in children with type Ⅰ Chiari malformation[J]. ChinJ Bone Jt, 2015, 4(10): 737-741. DOI:10.3969/j.issn.2095-252X.2015.10.003
[25]
陈飞. 单纯后颅窝骨性减压+环枕筋膜松解术治疗Arnold-Chiari I畸形的临床疗效分析[J]. 牡丹江医学院学报, 2014, 35(5): 51-53.
Chen F. Clinical analysis of the treatment of Arnold-Chiari I malformation with simple posterior cranial fossa bone decompression and circumferential occipital fascia release surgery[J]. J Mudanjiang Med Univ, 2014, 35(5): 51-53. DOI:10.13799/j.cnki.mdjyxyxb.2014.05.023
[26]
Massimi L, Frassanito P, Chieffo D, et al. Bony decompression for Chiari malformation type Ⅰ: long-term follow-up[J]. Acta Neurochir Suppl, 2019, 125: 119-124. DOI:10.1007/978-3-319-62515-7_17
[27]
王蒙, 胡岩, 左玉超, 等. 儿童Chiari畸形1型的诊断与治疗: 国际专家共识(2021)解读[J]. 中华神经医学杂志, 2022, 21(8): 757-761.
Wang M, Hu Y, Zuo YC, et al. Diagnosis and treatment of Chiari malformation type 1 in children: Interpretations of International Expert Consensus (2021)[J]. Chin J Neuromed, 2022, 21(8): 757-761. DOI:10.3760/cma.j.cn115354-20220511-00318
[28]
Janjua MB, Ivasyk I, Greenfield JP. Vertebrobasilar insufficiency due to distal posterior inferior cerebellar artery compression in Chiari 1.5[J]. World Neurosurg, 2017, 104: 1050. e1-1050. e6. DOI:10.1016/j.wneu.2017.05.089
[29]
Blanco P, Matteoda M. Images in emergency medicine. Extra-axial intracranial hematoma, midline shift, and severe intracranial hypertension detected by transcranial color-coded duplex sonography[J]. Ann Emerg Med, 2015, 65(2): e1-e2. DOI:10.1016/j.annemergmed.2014.08.042
[30]
Blanco P, Blaivas M. Applications of transcranial color-coded sonography in the emergency department[J]. J Ultrasound Med, 2017, 36(6): 1251-1266. DOI:10.7863/ultra.16.04050
[31]
Capel C, Padovani P, Launois PH, et al. Insights on the hydrodynamics of Chiari malformation[J]. J Clin Med, 2022, 11(18): 5343. DOI:10.3390/jcm11185343
[32]
Balestrino A, Consales A, Pavanello M, et al. Management: opinions from different centers-the Istituto Giannina Gaslini experience[J]. Childs Nerv Syst, 2019, 35(10): 1905-1909. DOI:10.1007/s00381-019-04162-8
[33]
王鑫, 李永宁, 高俊, 等. 芝加哥Chiari畸形预后量表在Ⅰ型Chiari畸形合并脊髓空洞手术疗效评估中的价值[J]. 中国临床神经外科杂志, 2019, 24(9): 554-556.
Wang X, Li YN, Gao J, et al. Value of Chicago Chiari Malformation Prognostic Scale in evaluating the surgical efficacy of type Ⅰ Chiari malformation plus syringomyelia[J]. Chin J Clin Neurosurg, 2019, 24(9): 554-556. DOI:10.13798/j.issn.1009-153X.2019.09.014
[34]
吴飞, 汪洋, 刘将, 等. 一种术前评分标准在Chiari Ⅰ畸形手术方式选择中的应用价值[J]. 医学信息, 2021, 34(3): 124-126, 130.
Wu F, Wang Y, Liu J, et al. Application of preoperative scoring standard in the selection of surgical approaches for Chiari I malformations[J]. Med Inf, 2021, 34(3): 124-126, 130. DOI:10.3969/j.issn.1006-1959.2021.03.034
[35]
刘晓虎, 罗霜, 付兵, 等. PC-MRI在Ⅰ型Chiari畸形枕大池成形术后疗效评估中的应用[J]. 中国临床神经外科杂志, 2022, 27(1): 22-24.
Liu XH, Luo S, Fu B, et al. Clinical application of phase-contrast magnetic resonance image in postoperative evaluation of Chiari malformation type Ⅰ[J]. Chin J Clin Neurosurg, 2022, 27(1): 22-24. DOI:10.13798/j.issn.1009-153X.2022.01.008
[36]
姚晓辉, 成睿, 张世渊, 等. 神经内镜联合导航及术中超声多普勒治疗Chiari畸形Ⅰ型的疗效[J]. 中华神经外科杂志, 2018, 34(9): 937-940.
Yao XH, Cheng R, Zhang SY, et al. Efficacy study of treating Chiari type Ⅰ malformation under neuroendoscope assisted with neuronavigation and intraoperative ultrasonography[J]. Chin J Neurosurg, 2018, 34(9): 937-940. DOI:10.3760/cma.j.issn.1001-2346.2018.09.015