肥胖与颅底表现：临床意义与管理

文献信息

中文摘要

肥胖已成为颅底疾病的重要修饰因素。尽管肥胖常在阻塞性睡眠呼吸暂停、麻醉风险和伤口愈合的背景下被讨论，但其最重要的颅底表现通常是通过慢性颅内压升高介导的。自发性脑脊液（CSF）漏和颅底脑膨出现在被广泛认为是获得性缺损，常见于患有特发性颅内高压（IIH）的超重或肥胖患者。这种关系对诊断、手术规划、重建、术后管理和长期复发预防具有直接意义。重要的是，活动性自发性CSF漏患者可能不表现出IIH的典型体征，因为漏本身可能提供部分CSF分流。因此，缺乏视乳头水肿或视觉症状不应错误地让临床医生放心颅内压正常。阻塞性睡眠呼吸暂停可能通过缺氧、高碳酸血症和静脉引流受损进一步导致间歇性颅内压升高，并且在内镜颅底重建后产生独特的围手术期挑战，因为必须平衡气道正压与保护修复的需要。本综述总结了肥胖相关颅底表现的病理生理学、临床表现、诊断评估和管理，重点强调自发性CSF漏、脑膨出、IIH、阻塞性睡眠呼吸暂停、内镜修复、颅内压管理和术后气道考虑。

英文摘要

Obesity has become an important modifier of skull base disease. Although obesity is discussed in the context of obstructive sleep apnea, anesthesia risk, and wound healing, its most important skull base manifestation is often mediated through chronically elevated intracranial pressure. Spontaneous cerebrospinal fluid (CSF) leaks and skull base encephaloceles are now widely recognized as acquired defects that commonly arise in overweight or obese patients with idiopathic intracranial hypertension (IIH). This relationship has direct implications for diagnosis, surgical planning, reconstruction, postoperative management, and long-term recurrence prevention. Importantly, patients with active spontaneous CSF leaks may not display the classic signs of IIH because the leak itself may provide partial CSF diversion. Thus, the absence of papilledema or visual symptoms should not falsely reassure the clinician that intracranial pressure is normal. Obstructive sleep apnea may further contribute to intermittent intracranial pressure elevation through hypoxia, hypercapnia, and impaired venous drainage, and it creates unique perioperative challenges after endoscopic skull base reconstruction because positive airway pressure must be balanced against the need to protect the repair. This review summarizes the pathophysiology, clinical presentation, diagnostic evaluation, and management of obesity-associated skull base manifestations, with emphasis on spontaneous CSF leaks, encephaloceles, IIH, obstructive sleep apnea, endoscopic repair, intracranial pressure management, and postoperative airway considerations.