腦囊蟲病手術(shù)治療對(duì)策探討(附6例病例)

溫玉星，鄭詩(shī)豪，黃紹崧，林 偉

腦囊蟲病手術(shù)治療對(duì)策探討(附6例病例)

溫玉星，鄭詩(shī)豪，黃紹崧，林 偉

目的根據(jù)腦囊蟲病的特征，探討手術(shù)治療對(duì)策。方法對(duì)神經(jīng)外科收治的6例腦囊蟲病患者，根據(jù)不同病情特征，應(yīng)用不同手術(shù)對(duì)策治療，觀察術(shù)后療效。結(jié)果6例患者經(jīng)不同手術(shù)治療1年后隨訪觀察，除1例因腦積水需再次行腦室-腹腔分流術(shù)外。其余患者均獲手術(shù)成功，且恢復(fù)情況良好，一直未出現(xiàn)新的神經(jīng)損害癥狀。結(jié)論6例患者，根據(jù)不同病情特征，應(yīng)用不同手術(shù)治療對(duì)策，有效消除了腦囊蟲病的并發(fā)癥和致殘，值得今后同行手術(shù)借鑒和參考。

腦囊蟲??；診斷；治療

囊蟲病是由豬肉絳蟲的幼蟲(囊尾蚴)寄生于人體引起的疾病，它比成蟲引起的豬肉絳蟲病危害性更大[1]。囊尾蚴可以寄生于人體的不同組織器官，其中以腦組織最為常見(jiàn)。主要寄生于腦實(shí)質(zhì)、腦室、蛛網(wǎng)膜下腔和各腦底池中，引發(fā)癲癇[2]、頭痛、顱高壓、精神障礙、腦膜炎、記憶力下降等癥狀。由于患者的臨床表現(xiàn)復(fù)雜多樣，輕者可無(wú)任何癥狀，重者可引起重度神經(jīng)功能障礙[3-4]。過(guò)去，福建省的仙游、龍海等沿海地區(qū)囊蟲病極為多見(jiàn)。改革開放后，隨著居民個(gè)體散養(yǎng)豬的減少和人們衛(wèi)生意識(shí)水平提高，該病發(fā)病率已在逐年下降，致使當(dāng)前大多數(shù)醫(yī)務(wù)人員特別是年青醫(yī)務(wù)人員，缺乏對(duì)此病手術(shù)治療的對(duì)策。為此，我們特將本院2010年至2017年收治的6例腦囊蟲病進(jìn)行了手術(shù)治療對(duì)策的探討。

1 材料與方法

1.1材料 6例囊蟲病患者，均通過(guò)手術(shù)及病理確診。其中男性4例，女性2例。年齡12～63歲。農(nóng)村患者5例，城鎮(zhèn)患者1例。均有囊蟲病感染史。

1.2臨床癥狀 有頭痛、頭暈、惡心、嘔吐者4例，有癲癇發(fā)作病史3例，有皮下結(jié)節(jié)者2例，有肢體活動(dòng)障礙、肌力下降者2例，有視物模糊者1例。詳見(jiàn)表1。

1.3影像學(xué)診斷 6例患者術(shù)前磁共振(MRI)檢查均清晰顯示囊蟲病灶周圍，具有水腫帶的典型特征，有2例在囊壁內(nèi)側(cè)可見(jiàn)囊蟲頭節(jié)。6例中病灶位于腦實(shí)質(zhì)型4例，側(cè)裂池1例，側(cè)腦室1例。

1.4實(shí)驗(yàn)室檢查 6例患者中，5例血清或腦脊液囊蟲酶聯(lián)免疫吸附試驗(yàn)陽(yáng)性，其中血清檢查4例陽(yáng)性，腦脊液檢查5例陽(yáng)性；血常規(guī)檢驗(yàn)，嗜酸性粒細(xì)胞增高者5例；糞便檢出絳蟲卵者1例。詳見(jiàn)表2。

1.5手術(shù)治療對(duì)策 一是腦實(shí)質(zhì)囊蟲摘除術(shù)，二是腦室、腦池囊蟲摘除術(shù)。

表1 6例腦囊蟲患者基本情況
Tab.1 The basic features of 6 patients with cerebral cysticercosis

序號(hào)number年齡age性別gender流行病史epidemichistory病程/月course主要癥狀mainsymptoms體征signs112男生食豬肉史3四肢抽搐、頭痛(-)223男生飲豬血史4頭痛頸強(qiáng)直334女居住地為有絳蟲病流行史2視物模糊視乳頭水腫446男生食豬肉史1頭痛、肌力下降(-)548女生食豬肉史3行走不穩(wěn)、抽搐肌張力增高663男生食豬肉史5頭痛、四肢抽搐(-)

表2 6例腦囊蟲患者實(shí)驗(yàn)室檢查
Tab.2 Laboratory examinations of 6 patients with cerebral cysticercosis

序號(hào)血液blood腦脊液cerebrospinalfluid糞便feces嗜酸性粒細(xì)胞eosnophils(×109/L)抗囊尾蚴抗體Anti?cysticercoidantibody抗囊尾蚴抗體Anti?cysticercoidantibody壓力pressure(mmH2O)蛋白質(zhì)protein(mg/L)白細(xì)胞數(shù)Whitebloodcells(×106/L)蟲卵Ova10．1(+)(+)21010010-21．6(-)(+)15022040-30．56(+)(+)1308070-40．7(+)(-)24048028-50．33(-)(+)300260170+60．89(+)(+)190390300-

2 結(jié) 果

6例患者中4例行腦實(shí)質(zhì)囊蟲摘除術(shù)，2例行腦室、腦池囊蟲摘除術(shù)。術(shù)后4例患者癥狀消失，2例患者癥狀改善。均無(wú)嚴(yán)重并發(fā)癥?；颊咝g(shù)后再經(jīng)規(guī)范囊蟲藥物治療6-36個(gè)月后隨訪結(jié)果，除1例患者偶爾出現(xiàn)癲癇癥狀，后經(jīng)抗癲癇藥物治療很快得到控制，另2例出現(xiàn)腦積水，再行腦室腹腔分流術(shù)，腦室系統(tǒng)也已接近正常。

3 討 論

豬肉絳蟲成蟲寄生在腸道引起的疾病，稱為豬肉絳蟲病，其幼蟲引起的疾病為豬囊尾蚴病，主要侵犯運(yùn)動(dòng)較多的肌肉內(nèi)，亦可侵犯腦、眼、心臟等重要器官，其中腦囊尾蚴病是最常見(jiàn)的一種。人體感染囊尾蚴的途徑，分內(nèi)源性(亦稱自身感染)與外源性感染(亦稱異體感染)兩種。內(nèi)源性感染，是因患者惡心、嘔吐，引起腸道逆蠕動(dòng)，致使寄生在腸道的成蟲孕節(jié)，返流入胃或十二指腸，這時(shí)孕節(jié)中的大量成熟蟲卵，經(jīng)消化后孵出六鉤蚴，侵入腸壁血管或淋巴管隨血液或淋巴液而擴(kuò)散，這種自身感染的囊蟲病，其危害性遠(yuǎn)遠(yuǎn)大于外源性感染。外源性感染，是因食入被蟲卵污染的食物所致，由于食入的蟲卵有限，故引起的囊蟲病灶數(shù)量不多，危害也相對(duì)較小。

侵入腦部的囊蟲所引起的腦囊蟲病，臨床最常見(jiàn)的癥狀是癲癇，發(fā)生率約60%～80%，其發(fā)作形式、程度及頻率與囊蟲數(shù)目、寄生部位密切相關(guān)，少數(shù)患者可出現(xiàn)癲癇持續(xù)狀態(tài)。尤其當(dāng)囊尾蚴死亡后，分解出的異體蛋白，可加重癲癇發(fā)作；其次是頭痛，但腦囊蟲病引起的頭痛癥狀缺乏特異性；再次為顱內(nèi)壓增高，是因腦水腫引起，它多見(jiàn)于側(cè)腦室、第三或第四腦室腦囊蟲患者[6]。當(dāng)囊蟲侵犯第四腦室時(shí)還可引起B(yǎng)run綜合征[7]，這時(shí)患者一旦改變頭位，即可引發(fā)小腦扁桃體下疝，致頭暈、嘔吐、神志不清甚至心跳呼吸驟停，值得高度警惕。對(duì)于言語(yǔ)障礙、肢體乏力等癥狀多與相應(yīng)神經(jīng)功能支配區(qū)域受累有關(guān)。

血清和腦脊液免疫學(xué)檢驗(yàn)有助于腦囊蟲病的診斷。頭部CT和MRI檢查對(duì)腦囊蟲的診斷有重要意義，CT對(duì)于囊蟲鈣化病灶的診斷優(yōu)于MRI，但MRI對(duì)于早期腦囊蟲病的定性、定位及分布情況的診斷明顯優(yōu)于CT[9]。頭顱MRI對(duì)軟組織內(nèi)的囊蟲顯影清晰，可根據(jù)其分布部位、大小、囊壁厚薄、頭節(jié)是否存在,將其分為活蟲期、退變死亡期和鈣化期等[10]。

目前對(duì)于囊蟲病的治療藥物是吡喹酮和阿苯噠唑。其中吡喹酮?dú)⑾x效果明顯，能使囊蟲在短時(shí)間內(nèi)大量死亡，但缺點(diǎn)是其分解產(chǎn)物給患者帶來(lái)嚴(yán)重副反應(yīng)，引起癲癇持續(xù)發(fā)作、顱內(nèi)壓增高、甚至腦疝危及生命，因此，對(duì)于囊蟲病灶多者必須與激素聯(lián)用。阿苯達(dá)唑藥物作用溫和，在腦脊液中滲透性好，且不與其他藥物相互作用[11]。總之，在使用抗蟲藥物殺蟲時(shí)，除應(yīng)嚴(yán)格把控適應(yīng)癥外，還要積極應(yīng)用皮質(zhì)激素、脫水藥物、抗癲癇藥物等，以減輕不良副反應(yīng)。

腦囊蟲的手術(shù)治療，主要用于藥物治療無(wú)效、有嚴(yán)重神經(jīng)癥狀的腦實(shí)質(zhì)囊蟲病和腦室系統(tǒng)內(nèi)囊蟲病，其目的是為了摘除囊蟲，解除腦積水、緩解顱高壓危象[12]。手術(shù)治療對(duì)策包括雙側(cè)顳肌減壓術(shù)、腦脊液分流術(shù)及腦室內(nèi)囊蟲摘除術(shù)[15]。

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Diagnosisandtherapyofcerebralcysticercosiswith6casereportsattached

WEN Yu-xing, ZHENG Shi-hao, HUANG Shao-song, LIN Wei

(DepartmentofNeurosurgery,FujianProvincialHospital,Fuzhou350001,China)

We explored the feature and therapeutic methods of cerebral cysticercosis. The effect of different surgical treatment was analyzed on 6 patients with cerebral cysticercosis who had undergone surgery at Fujian Provincial Hospital.Results showed that 2 of 6 cases underwent an excision of ventricle or cisternalcysticercus. Three cases were performed an excision of brain parenchyma cysticercus. The decompressivecraniectomy under bilateral temporalis was performed on 1 patient with cerebral cysticercosis. One case underwent ventriculo-peritoneal shunt because of hydrocephalus after a year of follow-up. The operations of 6 cases were all successfully performed. All patients recovered well after the operation. No newly neurobiological injuries were observed. Timely and accurate neurosurgery contributes to reduce the incidence of complications and cut down disability rate of cerebral cysticercosis, and buy time and fight for an opportunity for drug therapy of cerebral cysticercosis as well. It significantly improves the safety and therapeutic effect of anti-cysticercosis drugs.

cerebral cysticercosis; diagnosis; therapy

10.3969/j.issn.1002-2694.2017.10.019

福建省立醫(yī)院神經(jīng)外科，福州 350001

383

A

1002-2694(2017)10-0943-03

2017-06-14編輯李友松