自發性顱內低壓最近發展

10.6666/ClinMed.201802_81(2).0016

王嚴鋒

自發性顱內低壓(spontaneous intracranial hypotension) ； 腦脊髓液(cerebrospinal fluid) ； 磁振造影(magnetic resonance imaging) ； 血液貼片(epidural blood patch)

臨床醫學月刊

81卷2期（2018 / 02 / 23）

81 - 86

繁體中文

自發性顱內低壓的主要臨床特徵是姿勢性頭痛，由位於脊椎處的腦脊髓液滲漏所引發，常見於壯年，以女性居多。主要的致病機制可能來自於腦脊髓液滲漏後引發的容積不足或壓力下降。典型的個案在顯影後的腦部磁振造影上，可見瀰漫性硬膜腦顯影，其他的發現包括了硬膜下出血/積液、靜脈構造鼓脹、腦下垂體充血和腦部下沉等等。腦脊髓液滲漏的定位不僅可提供診斷所需的重要訊息，更可提供後續治療的指引，尤其是硬膜上血液貼片的施打。以往定位有賴於侵入性的影像技術，如同位素腦池攝影或電腦斷層脊椎攝影，近年來重T2加權磁振脊髓攝影的問世，使得影像定位精確而有效率。針對腦脊髓液滲漏施打的血液貼片通常較施打於其他部位來得有效，由於血液貼片通常可在注射部位附近分布，因此影像定位足供參考，但對於手術修補硬膜破孔而言，則需更精確的定位。首次血液貼片療效預測因子包括了腹側硬膜上積液的長度、中腦-橋腦夾角和施打血液貼片的體積。硬膜下出血是主要的併發症，可能導致預後不佳甚至死亡，在厚度較厚或發生意識改變的病患，應在治療腦脊髓液滲漏後及早進行手術引流，以避免後續併發症的發生。

1. (2013).The International Classification of Headache Disorders, 3rd edition (beta version).Cephalalgia,33,629-808.
2. Beards, SC,Jackson, A,Griffiths, AG(1993).Magnetic resonance imaging of extradural blood patches: appearances from 30 min to 18 h.Br J Anaesth,71,182-188.
3. Burtis, MT,Ulmer, JL,Miller, GA(2005).Intradural spinal vein enlargement in craniospinal hypotension.Am J Neuroradiol,26,34-38.
4. Chen, YC,Wang, YF,Li, JY(2016).Treatment and prognosis of subdural hematoma in patients with spontaneous intracranial hypotension.Cephalalgia,36,225-231.
5. Chiapparini, L,Farina, L,D´Incerti, L(2002).Spinal radiologic findings in nine patients with spontaneous intracranial hypotension.Neuroradiology,44,143-150.
6. Cho, KI,Moon, HS,Jeon, HJ(2011).Spontaneous intracranial hypotension: efficacy of radiologic targeting vs blind blood patch.Neurology,76,1139-1144.
7. Chung, SJ,Im, JH,Lee, JH(2004).Determining factors related to pachymeningeal enhancement on brain MRI in CSF hypovolaemia.Cephalalgia,24,903-905.
8. Front, D,Penning, L(1973).Subcutaneous extravasation of cerebrospinal fluid demonstration by scinticisternography.J Nucl Med,15,200-201.
9. Fuh, JL,Wang, SJ,Lai, TH(2008).The timing of MRI determines the presence or absence of diffuse pachymeningeal enhancement inpatients with spontaneous intracranial hypotension.Cephalalgia,28,318-322.
10. Headache Classification Subcommittee of the International Headache Society(2004).The International Classification of Headache Disorders, 2nd Edition.Cephalalgia,24,1-160.
11. Hochman, MS,Naidich, TP,Kobetz, SA(1992).Spontaneous intracranial hypotension with pachymeningeal enhancement on MRI.Neurology,42,1628-1630.
12. Kranz, PG,Amrhein, TJ,Choudhury, KR,Tanpitukpongse, TP,Gray, L(2016).Time-Dependent Changes in Dural Enhancement Associated With Spontaneous Intracranial Hypotension.Am J Roentgenol,207,1283-1287.
13. Kranz, PG,Tanpitukpongse, TP,Choudhury, KR(2016).Imaging Signs in Spontaneous Intracranial Hypotension: Prevalence and Relationship to CSF Pressure.Am J Neuroradiol,37,1374-1378.
14. Kranz, PG,Tanpitukpongse, TP,Choudhury, KR,Amrhein, TJ,Gray, L(2016).How common is normal cerebrospinal fluid pressure in spontaneous intracranial hypotension?.Cephalalgia,36,1209-1217.
15. Labadie, EL,Antwerp, JV,Bamford, CR(1976).Abnormal lumbar isotope cisternography in an unusual case of spontaneous hypoliquorrheic headache.Neurology,26,135-139.
16. Lai, TH,Fuh, JL,Lirng, JF(2007).Subdural haematoma in patients with spontaneous intracranial hypotension.Cephalalgia,27,133-138.
17. Mokri, B(1999).Spontaneous cerebrospinal fluid leaks: from intracranial hypotension to cerebrospinal fluid hypovolemia: evolution of a concept.Mayo Clin Proc,74,1113-1123.
18. Rabin, BM,Roychowdhury, S,Meyer, JR(1998).Spontaneous intracranial hypotension: spinal MR findings.Am J Neuroradiol,19,1034-1039.
19. Sable, SG,Ramadan, NM(1991).Meningeal enhancement and low cerebrospinal fluid pressure headache. An MRI study.Cephalalgia,11,275-276.
20. Schaltenbrand G. Neure anschauungen zur pathophyiologie der liquorzirkulation. Zentrab Neurochir 1938;3:290-300.
21. Schievink, WI(2005).Cranial MRI predicts outcome of spontaneous intracranial hypotension.Neurology,64,1282-1284.
22. Schievink, WI.(2006).Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension.JAMA,295,2286-2296.
23. Schievink, WI.(2008).Spontaneous spinal cerebrospinal fluid leaks.Cephalalgia,28,1345-1356.
24. Schievink, WI,Maya, MM,Chu, RM(2015).False localizing sign of cervico-thoracic CSF leak in spontaneous intracranial hypotension.Neurology,84,2445-2448.
25. Schievink, WI,Maya, MM,Jean-Pierre, S(2016).A classification system of spontaneous spinal CSF leaks.Neurology,87,673-679.
26. Tsai, PH,Fuh, JL,Lirng, JF(2007).Heavily T2-weighted MR myelography in patients with spontaneous intracranial hypotension: a case-control study.Cephalalgia,27,929-934.
27. Tsai, PH,Fuh, JL,Lirng, JF(2008).Comparison between heavily T2-weighted MR and CT myelography studies in two patients with spontaneous intracranial hypotension.Cephalalgia,28,653-657.
28. Wang, YF,Fuh, JL,Lirng, JF(2015).Cerebrospinal fluid leakage and headache after lumbar puncture: a prospective non-invasive imaging study.Brain,138,1492-1498.
29. Wang, YF,Lirng, JF,Fuh, JL(2009).HeavilyT2-weighted MR myelography vs CT myelography in spontaneous intracranial hypotension.Neurology,73,1892-1898.
30. Wu, JW,Hseu, SS,Fuh, JL(2017).Factors predicting response to the first epidural blood patch in spontaneous intracranial hypotension.Brain,140,344-352.

1. 陳相如,梁雅淳(2021)。疑似腦脊髓液滲漏之顱內低壓中醫診治。中醫藥研究論叢，24(2)，93-103。