Clinical Characteristics and Prognostic Factors of Treatment in Pediatric Posterior Cranial Fossa Ependymoma.

OBJECTIVE: The purpose of this study was to explore the clinical features and risk factors of outcomes in pediatric posterior cranial fossa ependymoma. We aim to provide evidence-based recommendations for the improvement of prognoses. PATIENTS AND METHODS: The clinical data, treatment modalities, approaches performed, recurrence rates and times, as well as the outcomes of 94 cases were analyzed retrospectively. The characters of neuroimaging were further studied. RESULTS: In data from the most recent follow-up, 27 cases had tumor recurrence. The time for tumor recurrence was 13.7 ± 7.7 months. The estimated overall survival and progression-free survival, based on Kaplan-Meier analysis, was 42.2 ± 2.9 months and 38.7 ± 3.4 months, respectively. Univariate analysis showed that being free of recurrence is closely related to the high tumor sphericity (p = 0.018), homogeneity of tumor texture (p = 0.001), and gross total resection (GTR; p < 0.001). Mortality is linked to low sphericity (p = 0.017) and brain stem edema (p = 0.005). Cerebellar mutism is correlated with posterosuperior compression of the 4th ventricle roof by the tumor. The incidence rate of cerebellar ataxia, cerebellar mutism, and cerebellar dysarthria is related to the rostral extension of the tumor within the 4th ventricle. The recurrence rate is higher in subtotal resection (STR) than in GTR, and the difference is significant (p < 0.001). Although there is no significant difference between the recurrence rates in the three types, an earlier recurrence is prone with tumors located in the paramidline-lateral compared to the midline (p = 0.021) and paramidline-medial areas (p = 0.042). CONCLUSIONS: Based on our data, GTR is indicated as the most optimal choice. Recurrence is linked to lower tumor sphericity, inhomogeneous tumor texture, and STR/partial resection. Tumor located on the lateral side might be prone for an early recurrence.

Application of Dextroscope in a Rare Type of Angiomatous Meningioma Characterized With Coral-Like Vessels.

A 43-year-old female diagnosed with meningioma was admitted to our department. Preoperative imaging revealed a spherical lesion located in the sphenoid ridge with obvious enhancement and inhomogeneous density into 3 layers on magnetic resonance (MR) images, coral-like vessel images inside the tumor was obtained after the raw computed tomography angiography data were imported into the Dextroscope virtual-reality system. Due to her progressive headache and visual deterioration, surgery was performed after comprehensive study in the Dextroscope system, details about the correlation among skull base, lesion, branches of internal carotid artery, and vessels inside the tumor were well demonstrated in this system. It is diagnosed as a rare type of angiomatous meningioma, based on the abnormal manifestation on images, which even make it important to make further evaluation before making any surgical plan. Surgical resection has been the optimal treatment for most meningiomas and is meticulously performed accordingly. The patient is doing fine with no evidence of tumor recurrence on recent MR scans.

[Microanatomic and three-dimensional reconstruction study of lateral wall and related structures of optic canal].

OBJECTIVE: To investigate the key microanatomic and radiological structures of optic canal comprehensively so as to provide anatomic parameters and procedural flows for the decompression of optic canal. METHODS: Gross observations and microscopic measurements were applied on 10 (20 sides) formalin-treated cadaveric specimens and 15 (30 sides) adult skulls. Using multislice helical CT (computed tomography)-aided three-dimensional reconstruction in combination with direct anatomic measurement, the investigators dissected, photographed, measured and analyzed the shape of optic canal and analyze its anatomic relationship with the adjoining structures. RESULTS: Optic canal was formed by the superior, inferior, medial and external walls and distal proximal opening. The lateral wall of optic canal was formed by anterior clinoid process with a length of (9.87 ± 1.34) mm, a width of (11.66 ± 2.35) mm, a base thickness of (5.35 ± 1.07) mm and a middle thickness of (4.50 ± 1.06) mm. Optic strut separating the optic canal from the superior orbital fissure was located inferiorly. And the distance between the apex of anterior clinoid process and the middle of ICA (internal carotid artery) groove was (4.25 ± 2.30) mm. The CSF (cerebrospinal fluid) leakage and secondary injury of optic nerve and injury of ICA, ophthalmic artery might occur during the surgical procedures due to the variation of anterior clinoid process. The microanatomic figures and radiological measurements had a mean difference very close to each other at (0.08 - 0.48) mm. No statistical difference was found (P > 0.05). CONCLUSION: Optic nerve, ophthalmic artery and ICA may be exposed by a high-speed drilling of the lateral wall of optic canal. The drilling dissection of lateral wall plays a vital role during a successful optic canal decompression. Radiological measurement and three-dimensional reconstruction of skull base may be of great clinical significance in lesion visualization. And it helps to make a better choice of surgical approaches. The measurements provide valuable references for surgeons and researchers.

[Microsurgery treatment with aneurysm on the top of basilar artery].

OBJECTIVE: To explore the efficacy and method of microsurgery for aneurysm on the top of basilar artery. METHODS: The investigators analyzed retrospectively the clinical data of 8 microsurgical patients with aneurysm on the top of basilar artery from May 2007 to September 2010. There were 5 males and 3 females with an average age of 52.6 years old. Six of 8 cases underwent clipping of aneurysm while other 2 patients received superficial temporal artery-radial artery-posterior cerebral artery bypass grafting surgery and clipping of aneurysm. RESULTS: On the basis of GOS (Glasgow outcome score), the postoperative recovery was excellent in 7 patients. And 1 patient suffered insufficiency of oculomotor nerve similarly as preoperatively. CONCLUSION: The surgical procedures for aneurysm of basilar artery are so complicated as to lead to many complications. A wise choice of operative approaches may yield a better outcome.

The Jugular Process: A Key Anatomical Landmark for Approaches to the Jugular Foramen.

OBJECTIVE: To describe the morphology and anatomical relationship of the jugular process (JP) and to elucidate its utility as a surgical landmark in the lateraland posterior lateral approaches to the jugular foramen. MATERIALS AND METHODS: Eight dry adult skulls and 10 silicon-injected cadaver heads were used for this study. The distances to selected structures and the thickness of the JP at 3 selected sites were measured. We also included the data of 20 thin-sliced 3-dimensional computed tomography scans. The radiology data of these patients were transferred to a workstation for 3-dimensional reconstruction. RESULTS: The JP, an irregular trapezoid structure, is an important surgical landmark when approaching the jugular foramen. Laterally the JP is rough with 1 or 2 prominences to which the rectus capitis lateralis is attached. The JP is relatively flat medially. The condylar part of the occipital bone could be conceived as a "3-story building." The JP, hypoglossal canal, and lateral and posterior condylar emissary veins are located on the middle floor. The stylomastoid foramen is found constantly in the triangle formed by the styloid process, JP, and the base of the mastoid process. CONCLUSIONS: The JP is an important surgical landmark in the identification of jugular foramen, especially in the lateral and posterior approaches. A better understanding of its morphology and its relationship with the surrounding structures is a prerequisite for accurate surgical planning and intraoperative orientation.

[Outcomes of early surgery combined with anti-vasospasm agents treat ruptured cranial aneurysms: an analysis of 127 cases].

OBJECTIVE: Retrospective study on 127 cases of early microsurgery combined with antivasospasm agents for treatment of subarachnoid hemorrhage after the rupture of intracranial aneurysm. To evaluate the microsurgery for early-stage (3 days) of ruptured aneurysm. METHODS: 127 cases of subarachnoid hemorrhage after the rupture of intracranial aneurysm were diagnosed by MRI and CTA. Patients underwent early microsurgical clipping of intracranial aneurysm followed by antivasospasm agents treatment were retrospectively analyzed for their clinical manifestation, characteristics of imaging presentation, the curative effects and experiences of different operative approaches, surgical methods and techniques, pharmaceutical treatment and other integrated management. RESULTS: In all 127 cases, organized blood clot accompanied with subarachnoid hemorrhage and cerebral vasospasm surrounding the ruptured aneurysm was found in the course of surgical probing, among which 21 aneurysms ruptured during the operation; according to the GOS, 109 cases were cured or free of symptom, 23 cases got a transient hemiparalysis or aggravation of hemiparalysis, among which 18 cases were free of symptom, 9 were slight disability, 6 were severe disability, 3 cases die when discharged. CONCLUSIONS: Early operation could prevent second-time rupture effectively, lower the death rate, and at the same time lower the occurrence of cerebral vasospasm and the succeeding damage caused. Cerebral vasospasm is still the serious complication of subarachnoid hemorrhage of ruptured aneurysm and inappropriate management would cause critical consequences. Antivasospasm agents used postoperative could help preventing cerebral vasospasm and maintaining function.

Rectus Capitis Lateralis Muscle: A Cadaveric Study of a Key Surgical Landmark in the Posterior and Lateral Approaches to the Jugular Foramen.

OBJECTIVE: The rectus capitis lateralis (RCL) is a small cervical muscle that arises from the transverse process of C1 and is intimately related to the jugular process and jugular foramen. We describe its morphology, neurovascular relationships, and its utility as one of the key surgical landmarks in approaches to the jugular foramen. METHODS: Eight cadaveric heads were used to perform far-lateral and transmastoid approaches to the jugular foramen. The neurovascular relationships of the RCL were studied. RESULTS: The RCL originates from the transverse process of C1 and inserts onto the jugular process. It can be found in the muscular interval between the posterior belly of the digastric muscle and the superior oblique muscle with the occipital artery coursing between it and the posterior belly of the digastric muscle. It lies directly posterior to the internal jugular vein and cranial nerves (CNs) IX-XI as they exit the jugular foramen. The vertebral artery courses medially to the RCL as it exits foramen transversarium of C1. As the facial nerve exits the stylomastoid foramen, it is anterolateral to the RCL before turning to enter the parotid gland. The CN XII is seen between the RCL and the occipital condyle from a posterior view. CONCLUSIONS: The RCL usually is preserved unless jugular process needs to be removed to expose the jugular foramen. The RCL is an important surgical landmark for the early identification of the vertebral artery, internal jugular vein, facial nerve, and CNs IX-XII in approaches to the jugular foramen.

Risk factors and the prognosis of sexual dysfunction in male patients with pituitary adenomas: a multivariate analysis.

The impact of sexual dysfunction (SD) is distressing to many male patients with pituitary adenomas which affect both physical and psychological health. The research explored to identify risk factors affecting sexual function and the prognosis of male patients with pituitary adenomas. Two hundred and fifty-four male patients, who aged between 18 and 60 (mean ± s.d.: 44.16 ± 10.14) years and diagnosed with pituitary adenomas, were retrospectively analyzed. One hundred and fifty-nine patients (62.6%) complained of SD prior to surgery. The mean International Index of Erectile Function (IIEF-5) in patients with giant adenomas was 16.13 ± 2.51, much smaller than those with microadenomas or macroadenomas (P < 0.05). All the patients showed significant improvement in terms of erectile dysfunction (ED) following surgery (P < 0.05). In addition, complete resection achieved a higher degree of SD relief than partial resection. The incidence of SD in functioning pituitary adenomas (FPAs) was much higher than that in nonfunctioning pituitary adenomas (NFPAs) (P < 0.05). In addition, compared with NFPAs, males with prolactinomas (82.8%) had the higher prevalence of SD and significantly improvement following surgical intervention (P < 0.05). An inverse relationship was identified between decreasing testosterone levels and increasing incidence of SD before surgery (P < 0.05). There was no significant difference between 6 months and 12 months after surgery in serum testosterone level (P > 0.05). Our results indicated that surgical therapy could be optimized for improvements in SD and that testosterone levels can be used as a sensitive indicator to predict the recovery rate of sexual function in patients with pituitary adenomas following surgery and the serum testosterone level will stay stable in 6 months after surgery.

CLDN5 affects lncRNAs acting as ceRNA dynamics contributing to regulating blood­brain barrier permeability in tumor brain metastasis.

The blood­brain barrier (BBB) constitutes an efficient organization of tight junctions that limits the delivery of tumor to the brain. The principal tight junction protein in BBB is claudin­5 (CLDN5), but its mechanism of action remains largely unknown. Long non­coding RNAs (lncRNAs) are aberrantly expressed in many cancers, some lncRNAs play key roles in regulating BBB permeability and are involved in tumor brain metastasis. In particular, lncRNAs can function as competing endogenous RNAs (ceRNAs). Herein, we investigated whether ceRNA dysregulation is associated with alterations of the level of CLDN5 in human brain vascular endothelial hCMEC/D3 cells. The Affymetrix Human Transcriptome Array 2.0 and Affymetrix GeneChip miRNA 4.0 Array were used to detect the expression levels of 2,578 miRNAs, 22,829 lncRNAs, and 44,699 mRNAs in pLL3.7­CLDN5­transfected and pLL3.7 control hCMEC/D3 cells. The distinctly expressed miRNAs, lncRNAs, and mRNAs were subjected to construction of miRNA­lncRNA­mRNA interaction network. A total of 41 miRNAs, 954 lncRNAs, and 222 mRNAs were found to be differentially expressed between the CLDN5­overexpressing and control group. 148 lncRNA acting as ceRNAs were identified based on the miRNA­lncRNA­mRNA interaction network. The function of differential mRNA in the network was determined by GO and pathway analysis. The potential roles of the 27 ceRNAs were revealed, the possible biology functions of these regulatory ceRNAs mainly included tight junction, focal adhesion, cell­cell adhesion, cell growth and apoptosis. The identified sets of miRNAs, lncRNAs and mRNAs specific to CLDN5­overexpressing hCMEC/D3 cells were verified by quantitative real­time RT­PCR experiment. Our study predicts the biological functions of a multitude of ceRNAs associated with the alteration of CLDN5 in brain vascular endothelial cells. Our data suggest that these dysregulated ceRNAs, in conjunction with the high CLDN5 levels, could serve as useful targets of prevention of brain metastasis formation. Further studies are warranted to determine the role of these ceRNAs in facilitating the function of CLDN5 in brain­tumor barrier.

Clinical Features and Prognostic Risk Factors of Choroid Plexus Tumors in Children.

BACKGROUND: Decision-making concerning the treatment of choroid plexus tumor (CPT) in pediatric patients remains a topic of considerable debate. The aim of this work was to describe clinical features and prognostic risk factors of CPT in the pediatric population and to provide theoretical opinions regarding clinical decisions for CPT. METHODS: The data of 96 patients with CPT and younger than 14 years were retrospectively analyzed. Clinical characteristics such as pathological type of CPTs, rate and severity of hydrocephalus, treatment and outcome, and recurrence were investigated. For categorical variables, the Pearson's Chi-square test was performed. The Mann-Whitney U-test was used for comparisons between nonnormally distributed parameters. Log-rank test was used for progression-free survival (PFS). RESULTS: The study included 70 choroid plexus papilloma (CPP) cases, 17 atypical choroid plexus papilloma (aCPP) cases, and 9 choroid plexus carcinoma (CPC) cases. Compared with patients with CPP or aCPP, patients with CPC had a shorter disease course (median: CPP, 4 months; aCPP, 2 months; CPC, 1 month; H: 23.5, P < 0.001), higher rate of acute hydrocephalus (CPP, 27.1%; aCPP, 52.9%; CPC, 77.8%; χ2 = 10.9, P < 0.05), and lower incidence of cure rate (CPP, 85.7%; aCPP, 70.5%; CPC, 33.3%; χ2 = 13.5, P < 0.05). The severity of hydrocephalus with tumor in the lateral or third ventricle was significantly higher than that with tumors in the fourth ventricle (severe hydrocephalus: lateral ventricle, 51.7%; third ventricle, 47.0%; fourth ventricle, 11.1%; χ2 = 26.0, P < 0.001). Patients with gross total surgical resection had no better PFS than those with partial resection because of the use of adjuvant therapy in the latter (χ2 = 4.0, P > 0.05). Patients with CPC experienced shorter time for recurrence than those with CPP or aCPP (χ2 = 40.1, P < 0.0001). CONCLUSIONS: Our results indicated that CPP in the fourth ventricle could trigger serious clinical symptoms at an early stage, requiring early intervention. Adjuvant treatment might be necessary for patients with partially resected CPP, aCPP, and CPC to achieve a favorable outcome.

Claudin-5 regulates blood-brain barrier permeability by modifying brain microvascular endothelial cell proliferation, migration, and adhesion to prevent lung cancer metastasis.

AIMS: To investigate the roles of Claudin-5 (CLDN5) in regulating the permeability of the blood-brain barrier (BBB) during lung cancer brain metastasis. RESULTS: By silencing and overexpressing the CLDN5 gene in human brain vascular endothelial (hCMEC/D3) cells, we demonstrated the attenuation of cell migration ability and CLDN5's significant positive role in cell proliferation in CLDN5-overexpressing hCMEC/D3 cells and observed the opposite result in the CLDN5 knockdown group. The reinforced CLDN5 expression reduced the paracellular permeability of hCMEC/D3 cells and decreased the invasion of lung adenocarcinoma A549 cells. Overall, 1685 genes were found to be differentially expressed between the CLDN5-overexpressing cells and the control cells using the Affymetrix Human Transcriptome Array 2.0 (HTA 2.0), and the function of these genes was determined by Gene Ontology and pathway analyses. The possible biological functions of the 1685 genes include cell proliferation, adhesion molecules, and the Jak-STAT, PI3K-Akt, Wnt, and Notch signaling pathways. The identified sets of mRNAs that were specific to CLDN5-overexpressing hCMEC/D3 cells were verified by a qRT-PCR experiment. CONCLUSION: CLDN5 regulates the permeability of BBB by regulating the proliferation, migration, and permeability of hCMEC/D3 cells, especially through the cell adhesion molecule signaling pathway, to enhance the function of the tight junctions, which was involved in reducing the formation of lung cancer brain metastasis.

Large and giant medial sphenoid wing meningiomas involving vascular structures: clinical features and management experience in 53 patients.

BACKGROUND: Large and giant medial sphenoid wing meningiomas that are located deeply in the skull base where they are closely bounded by cavernous sinus, optic nerve, and internal carotid artery make the gross resection hard to achieve. Also, this kind of meningiomas is often accompanied by a series of severe complications. Therefore, it was regarded as a formidable challenge to even the most experienced neurosurgeons. This study aimed to investigate the clinical features and management experience of patients with large and giant medial sphenoid wing meningiomas. METHODS: In this study, 53 patients (33 female and 20 male, mean age of 47.5 years) with large and giant medial sphenoid wing meningiomas were treated surgically between April 2004 to March 2012, with their clinical features analyzed, management experience collected, and treatment results investigated retrospectively. RESULTS: In this study, gross total resection (Simpson I and II) was applied in 44 patients (83%). Fifty-three patients had accepted the routine computed tomography scan and magnetic resonance imaging scan as postoperative neuroradiological evaluation. Their performance showed surgical complications of vascular lesions and helped us evaluate patients' conditions, respectively. Meanwhile, the drugs resisting cerebral angiospasm, such as Nimodipine, were infused in every postoperative patient through vein as routine. As a result, 11 patients (21%) were found to have secondary injury of cranial nerves II, III, and IV, and nine patients got recovered during the long-term observing follow-up period. Temporary surgical complications of vascular lesions occurred after surgery, such as cerebral angiospasm, ischemia, and edema; 24 patients (45%) appeared to have infarction and dyskinesia of limbs. Overall, visual ability was improved in 41 patients (77%). No patient died during the process. CONCLUSIONS: Microsurgical treatment may be the most effective method for the large and giant medial sphenoid wing meningiomas. The surgical strategy should focus on survival and postoperative living quality.

Subtemporal transtentorial petrosalapex approach for giant petroclival meningiomas: analyzation and evaluation of the clinical application.

With the advent of microsurgery and surgical techniques, along with the improvement in neuroimaging techniques and the microanatomy in cadaver study, improvement in terms of surgical morbidity and mortality has been remarkable; however, controversy still exists regarding the optimal surgical strategies for giant petroclival meningiomas (GPMs). We report a study of clinical and radiological features as well as the surgical findings and outcomes for patients with GPM treated at our institution over the past 6 years. During a 6-year period (April 2004 to March 2010), 16 patients with GPM underwent surgery by subtemporal transtentorial petrosal apex approach during which electrophysiological monitoring of cranial nerves and brainstem function were reviewed. There were nine females and seven males with a mean age of 56.9 years (range from 32 to 78 years). The most frequent clinical manifestations were headache (93.7%) and dizziness (93.7%). Regions and directions of tumor extension include clivus, parasellar, and cavernous sinus, as well as compression of brainstem, and so on. The trochlear nerve was totally wrapped in nine cases (56.2%). The postoperative Karnofsky Performance Scale (KPS) score was 76.3 ± 13.1. Mean maximum diameter of the tumors on magnetic resonance imaging was 5.23 cm (range, 4.5 to 6.2 cm). Subtemporal transtentorial petrosalapex approach was performed in all 16 cases. Gross total resection was achieved in 14 cases (87.5%) and subtotal resection in 2 cases (12.5%) with no resultant mortality. Follow-up data were available for all 16 patients, with a mean follow-up period of 28.8 months (range from 4 to 69 months), of which 11 (68.75%) lived a normal life (KPS, 80-100). Our suggestion is that GPM could be completely resected by subtemporal transtentorial petrosalapex approach. The surgical strategy of GPM should be focused on survival and postoperative quality of life. Microneurosurgical technique plays a key role in tumor resection and preservation of nerve function. Intraoperative electrophysiological monitoring also contributes dramatically to the preservation of the nerve function. Complete resection of the tumor should be attempted at the first operation. Any remnant is treated by radiosurgery.

Subtemporal transpetrosal apex approach: study on its use in large and giant petroclival meningiomas.

BACKGROUND: The subtemporal transtentoral approach has been reported for nearly two decades; however it was not well used due to some limitations in dealing with large and giant petroclival meningiomas. The clinical outcome and merit of the modified subtemporal transpetrosal apex approach in large and giant petroclival meningiomas, as well as the choices, the improvements and the therapy strategies of the microsurgical approach in such patients were evaluated in this study. METHODS: Totally 25 cases of large and giant petroclival meningiomas undergone the modified subtemporal transpetrosal apex approach between April 2004 and January 2010 were enrolled in this study. The choice and improvement of the approach, the basis of anatomy and related research, the effect of accessory equipment, the exposure of tumor and the changes of neurofunction pre- and post-operation were all reviewed retrospectively. The operation outcomes and complications in this approach were also compared with those in the transpetrous presigmoid approach done in 14 cases in the same period. RESULTS: All 25 cases underwent the modified subtemporal transpetrosal apex approach under electrophysiologic monitoring of cranial nerves and brain stem function. Trochlear nerve was partly wrapped in 14 cases, totally wrapped but can be explored in the initial segment of the cerebellum tentorium in 8 cases, totally wrapped and could not be seen until tumor was partly removed in 3 cases. The cerebellum tentorium was cut along the temporal bone from the anterior part of the apex to the mastoid part of superior petrous sinus in 6 cases, from the posterior part of the apex to the mastoid part of superior petrous sinus in 19 cases. Gross tumor resection was accomplished in 17 (68%) patients, subtotal resection in 7 (28%) patients, and partial resection in 1 (4%) patient. The most common postoperative complication was new neurological deficits or aggravations of preexisting deficit (64%). Follow-up ranged from 3 to 69 months. Compared with the transpetrous presigmoid approach done in 14 cases in the same period, the modified subtemporal transpetrosal apex approach showed obvious advantages such as simplicity in manipulating, microinvasiveness, less time-consuming, less complication, higher rate of tumor resection though the rates of gross tumor resection might be of no significant difference. CONCLUSIONS: Modified subtemporal transpetrosal apex approach has obvious advantages compared with the transpetrous presigmoid approach. Some complications need to be solved by practice and modification of the approach as well as the accumulation of the experiences.