To be thorough or tailored: influence of the arachnoid dissection range on the surgical outcomes of microvascular decompression for hemifacial spasm.

BACKGROUND: As one of the most fundamental elements in exposure and decompression, the dissection of arachnoid has been rarely correlated with the surgical results in studies on Microvascular decompression (MVD) procedures for Hemifacial spasm (HFS). MATERIALS AND METHODS: Patients' records of the HFS cases treated with MVD from January 2016 to December 2021 in our center was retrospectively reviewed. The video of the procedures was inspected thoroughly to evaluate the range of dissection of arachnoid. Four areas were defined in order to facilitate the evaluation of the dissection range. The correlation between the arachnoid dissection and the surgical outcomes were analyzed. RESULTS: The arachnoid structures between the nineth cranial nerve and the seventh, eighth cranial nerves were dissected in all cases, other areas were entered based on different consideration. The rate of neurological complications of the extended dissection pattern group was higher than that of the standard pattern group (P < 0.05). The procedures in which the arachnoid structure above the vestibulocochlear nerve was dissected, led to more neurological complications (P < 0.05). CONCLUSION: Thorough dissection as an initial aim for all cases was not recommended in MVD for HFS, arachnoid dissection should be tailored to achieving safety and effectiveness during the procedure.

The impact of time to evacuation on outcomes in endoscopic surgery for supratentorial spontaneous intracerebral hemorrhage: a single-center retrospective study.

Supratentorial spontaneous intracerebral hemorrhage (SICH) can be treated with endoscopic surgery, but the optimal timing remains uncertain. We retrospectively analyzed data from 46 patients who underwent endoscopic surgery for supratentorial SICH. We examined the relationship between time to evacuation and functional outcome at 3 months, adjusting for prognostic factors. Surgical outcomes and complications were compared between patients with early (≤ 12 h) or late (> 12 h) evacuation. Median time to evacuation was 12 h, and the rate of unfavorable outcome (modified Rankin Scale > 3 at 3 months) was 32.6%. Longer time to evacuation was independently associated with unfavorable outcome (odds ratio per hour delay: 1.26). Late evacuation carried a 7.25-fold higher risk of unfavorable outcome compared to early evacuation. This association held across subgroups based on hematoma volume, location, and intraventricular extension (P for interaction > 0.05). Patients with late evacuation had fewer spot signs (24% vs. 4.8%, P = 0.035) and markers of hemorrhagic expansion (36% vs. 9.5%, P = 0.018), longer neurosurgical intensive care unit (NSICU) stay (3.2 vs. 1.9 days, P = 0.011) and hospital stay (15.7 vs. 11.9 days, P = 0.014), and higher 30-day mortality (28.6 vs. 4%, P = 0.036) and complication rates (57.1% vs. 28.0%, P = 0.023). This study suggests a potential association between early endoscopic evacuation of supratentorial SICH and improved functional outcomes, lower 30-day mortality and reduced complications. The need for timely intervention in managing supratentorial SICH is highlighted, yet further validation through multi-center prospective studies is essential to substantiate these findings and provide a higher level of evidence.

Endoscopic far-lateral supracerebellar infratentorial approach for resection of dumbbell-shaped trigeminal schwannoma: surgical techniques and preliminary results.

BACKGROUND: Trigeminal schwannomas (TSs) are mostly benign tumors. However, dumbbell-shaped TSs are most challenging for surgeons and pose a high surgical risk. OBJECTIVE: We describe the technique of the purely endoscopic far-lateral supracerebellar infratentorial approach (EFL-SCITA) for removing dumbbell-shaped TSs and further discuss the feasibility of this approach and our experience. METHODS: EFL-SCITA was performed for resection of 5 TSs between January 2020 and March 2023. The entire procedure was performed endoscopically with the goal of total tumor resection. During the operation, the tumor was exposed in close proximity and multiple angles under the endoscope, and the peri-tumor nerves were carefully identified and protected, especially the normal trigeminal fiber bundles around the tumor. RESULTS: All the tumors of 5 patients involved the middle and posterior cranial fossa, of which total removal was achieved in 2 patients and near-total removal in 3 patients. The most common preoperative symptoms were relieved after surgery. Two patients had postoperative mild facial paralysis (House-Brackmann grade II), and 1 patient had abducens palsy; both recovered during the follow-up period. Two patients experienced new postoperative facial hypesthesia, and 1 experienced mastication weakness, which did not recover. There was no tumor recurrence or residual tumor growth during the follow-up period in any of the patients. CONCLUSION: EFL-SCITA is a new and effective alternative for the surgical treatment of TSs. For dumbbell-shaped TSs, this approach provides sufficient surgical field exposure and freedom of operation.

Endoscopic resection of thalamic lesions via supracerebellar infratentorial approach: a case series and technical note.

The deep location of the thalamus and the complex neural circuits in the surrounding area make surgery extremely challenging. Feasibility and advisability of using a supracerebellar infratentorial approach (SCITA) for endoscopic resection of thalamic lesions remains to be further evaluated. Fifteen patients who underwent endoscopic resection of thalamic via SCITA from 2014 to 2021 were retrospectively collected. We analyzed preoperative tumor-related variables and surgical procedures in detail, as well as postoperative outcomes. Lesions mainly located in the posterior and/or medial part of the thalamus, and some of them expanded downward, or backward. The mean size of them was 30 × 24 mm. Five of the nine patients with preoperative hydrocephalus underwent cerebrospinal fluid shunts to relieve increased intracranial pressure. Among the 15 patients, 4 were glioblastoma, 3 were pilocytic astrocytoma, and the rest included 1 case of anaplastic astrocytoma, melanoma, polymorphous low-grade neuroepithelial tumor of the young, rosette-forming glioneuronal tumor, inflammatory lesion, diffuse midline glioma, and cavernous hemangioma. The majority of patients (10/15) achieved gross total resection, which has become more pronounced since paramedian SCITA was used in place of the midline approach in 2020 (6/8). Three patients had unresolved or new onset of clinical symptoms after surgery, resulting in a decreased KPS score at discharge. Neuro-endoscopic techniques can ameliorate many of the shortcomings of the SCITA. With the accumulation of experience and technological progress, more deficiencies of this approach may be improved, enabling safe and effective resection of posterior and/or medial part thalamic lesions.

Endoscopic Resection of a T-Shaped Benign Fibrous Histiocytoma at the Skull Base in a Pediatric Patient.

BACKGROUND: Benign fibrous histiocytoma (BFH) is a benign tumor composed of cells with characteristics of histiocytes and with fibroblastic components. BFHs are rare lesions, especially in the skull base. CLINICAL PRESENTATION: Here, the authors report the case of a 9-year-old girl presented with reduced binocular vision for 2 months. The computerized tomography (CT) of the tumor appearance was high-density annular sclerosis. The tumor was removed via nasal endoscopic approach. Final pathologic diagnosis was benign fibrous histiocytoma. The post-operative period was uneventful after 8 months, and the visual acuity was improved to some extent. DISCUSSION AND CONCLUSION: This is the first case of BFH in a pediatric patient that was removed by endoscope. For similar case, endoscopic resection might be the first choice, including pediatric patient. Moreover, the CT feature and literature review may provide further insight into the diagnosis and management.

Improving Carbon Stock Estimates for In-Use Harvested Wood Products by Linking Production and Consumption-A Global Case Study.

We developed a method to better estimate the carbon stocks of in-use harvested wood products (HWP) by using the Eora multiregional input-output tables to link global HWP production and end uses, compared to existing global-scale studies that focused on semifinished HWP. Using the new method, we allocated global HWP to country-specific end uses, including solid HWP used in (1) construction, (2) furniture production, and (3) other end uses, and as (4) household and sanitary paper and (5) other paper and paper products, while the HWP carbon stocks in these end uses were estimated using the Stock Change Approach. We reported that HWP produced globally contained an annual average of 277.7 teragram carbon in 1992-2015, of which 63.0, 12.6, 76.7, 9.1, and 116.3 teragram carbon were consumed by the above five end uses, respectively. By 2015, the carbon stocks of global in-use HWP produced since 1992 accumulated to 2938 teragrams of carbon, of which the above five HWP end uses accounted for 1489, 268, 890, 0, and 291 teragrams of carbon, respectively. Country-specific HWP production and consumption varied significantly, with the eight leading consuming countries (United States, China, Japan, Canada, Germany, Russia, United Kingdom, and France) accounting for 69% of the global in-use HWP carbon stocks.

A low cost and stepwise training model for skull base repair using a suturing and knotting technique during endoscopic endonasal surgery.

PURPOSE: Cerebrospinal fluid leakage is always the primary complication during the endoscopic endonasal skull base surgery. Dural suturing technique may supply a rescue method. However, suturing and knotting in such a deep and narrow space are difficult. Training in the model can improve skills and setting a stepwise curriculum can increase trainers' interest and confidence. METHODS: We constructed an easy model using silicone and acrylic as sphenoid sinus and using the egg-shell membrane as skull base dura. The training is divided into three steps: Step 1: extracorporeal knot-tying suture on the silicone of sphenoid sinus, Step 2: intra-nasal knot-tying suture on the same silicone, and Step 3: intra-nasal egg-shell membrane knot-tying suture. Fifteen experienced microneurosurgical neurosurgeons (Group A) and ten inexperienced PGY residents (Group B) were recruited to perform the tasks. Performance measures were time, suturing and knotting errors, and needle and thread manipulations. The third step was assessed through the injection of full water into the other side of the egg to verify the watertight suture. The results were compared between two groups. RESULTS: Group A finishes the first and second tasks in significantly less time (total time, 125.1 ± 10.8 vs 195.8 ± 15.9 min) and fewer error points (2.4 ± 1.3 vs 5.3 ± 1.0) than group B. There are five trainers in group A who passed the third step, this number in group B was only one. CONCLUSIONS: This low cost and stepwise training model improved the suture and knot skills for skull base repair during endoscopic endonasal surgery. Experienced microneurosurgical neurosurgeons perform this technique more competent.

Novel Biomarkers for Non-functioning Invasive Pituitary Adenomas were Identified by Using Analysis of microRNAs Expression Profile.

The microRNAs (miRNAs) are involved in multiple pathological processes among various types of tumors. However, the functions of miRNAs in benign brain tumors are largely unexplored. In order to explore the pathogenesis of the invasiveness in non-functional pituitary adenoma (NFPA), the miRNAs expression profile was analyzed between invasive and non-invasive non-functional pituitary adenoma by miRNAs microarray. Six most significant differentially expressed miRNAs were identified including four upregulated miRNAs hsa-miR-181b-5p, hsa-miR-181d, hsa-miR-191-3p, and hsa-miR-598 and two downregulated miRNAs hsa-miR-3676-5p and hsa-miR-383. The functions and corresponding signaling pathways of differentially expressed miRNAs were investigated by bioinformatics techniques, including Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. The result of GO analysis indicates regulation of voltage-gated potassium channel activity, positive regulation of sodium ion transport, positive regulation of GTPase activity, negative regulation of Notch signaling pathway, etc. KEGG pathway reveals a series of biological processes, including prolactin signaling pathway, endocrine and other factor-regulated calcium reabsorption, fatty acid metabolism, neuroactive ligand-receptor interaction, etc. The miRNAs hsa-miR-181a-5p was verified by quantitative real-time PCR, and the expression level was in accordance with the microarray result. Our result can provide the evidence on featured miRNAs which play a prominent role in pituitary adenoma as effective biomarkers and therapeutic targets in the future.

Differential DNA methylome profiling of nonfunctioning pituitary adenomas suggesting tumour invasion is correlated with cell adhesion.

Global and gene-specific changes to the epigenome are hallmarks of most tumours including those of pituitary origin, and this fact might offer important clues about diagnostic and therapeutic applications. We performed global DNA methylation screening with 6 invasive and 6 noninvasive nonfunctioning pituitary adenomas (PA) to investigate whether DNA methylation was associated with the invasion of nonfunctioning pituitary adenomas. An additional seven PAs were included as an independent cohort to validate the initial results. Five thousand nine hundred thirty-one CpGs were selected (△ߠ≥0.15 and p value ≤0.01) as differentially methylated sites (DMSs). The hypomethylated DMSs in the invasive PAs were significantly more than the hypermethylated sites. Cluster analysis of 339 CpGs (△ߠ≥0.25 and p value ≤0.001) demonstrated a complete distinction between the invasive and noninvasive nonfunctioning groups. GO analysis of the three hundred seven corresponding genes shown they were involved in homophilic cell adhesion, cell-cell adhesion, cell adhesion and biological adhesion. The mRNA expression of GALNT9 which contain a validated DMS was significantly downregulated in invasive group. Our findings indicate that the differential DNA methylome profiling of invasive and noninvasive nonfunctioning PAs suggesting tumour invasion is correlated with cell adhesion.

Activation of PI3K/Akt pathway by CD133-p85 interaction promotes tumorigenic capacity of glioma stem cells.

The biological significance of a known normal and cancer stem cell marker CD133 remains elusive. We now demonstrate that the phosphorylation of tyrosine-828 residue in CD133 C-terminal cytoplasmic domain mediates direct interaction between CD133 and phosphoinositide 3-kinase (PI3K) 85 kDa regulatory subunit (p85), resulting in preferential activation of PI3K/protein kinase B (Akt) pathway in glioma stem cell (GSC) relative to matched nonstem cell. CD133 knockdown potently inhibits the activity of PI3K/Akt pathway with an accompanying reduction in the self-renewal and tumorigenicity of GSC. The inhibitory effects of CD133 knockdown could be completely rescued by expression of WT CD133, but not its p85-binding deficient Y828F mutant. Analysis of glioma samples reveals that CD133 Y828 phosphorylation level is correlated with histopathological grade and overlaps with Akt activation. Our results identify the CD133/PI3K/Akt signaling axis, exploring the fundamental role of CD133 in glioma stem cell behavior.

Purely endoscopic resection of pineal region tumors using infratentorial supracerebellar approach: How I do it.

BACKGROUND: Infratentorial supracerebellar approach via microscope still has some limitations in resection of pineal region tumors. METHODS: The authors describe a purely endoscopic infratentorial supracerebellar approach for resection of pineal region tumors with matched air-driven arm and navigation. The lateral oblique position is adopted. The same bimanual microsurgical techniques are utilized in this endoscopic approach with panoramic view and satisfying comfort. CONCLUSIONS: Purely endoscopic resection of pineal region tumors using infratentorial supracerebellar approach is feasible. It may be considered as an alternative approach for certain pineal region tumors.

The value of 3D-FIESTA MRI in detecting non-iatrogenic cerebrospinal fluid rhinorrhoea: correlations with endoscopic endonasal surgery.

BACKGROUND: In this study, we investigated the value of three-dimensional (3D) fast-imaging employing steady-state acquisition (FIESTA) magnetic resonance imaging (MRI) in detecting non-iatrogenic cerebrospinal fluid (CSF) rhinorrhoea and compared it with regular MRI and 3D magnetisation prepared rapid acquisition gradient echo (MPRAGE) MRI sequences, as well as high-resolution computed tomography (HRCT) imaging. We also present the endoscopic experiences of such cases. METHOD: From June 2011 to Feb 2016, 17 patients with non-iatrogenic cerebrospinal fluid rhinorrhoea were included. Seven patients had spontaneous rhinorrhoea, three patients had invasive tumours, and the remaining patients had traumatic aetiologies. All the patients underwent HRCT, regular MRI sequence imaging, 3D-MPRAGE MRI sequence imaging and 3D-FIESTA MRI sequence imaging for the preoperative evaluations of the leakages. For each patient, the CSF fistula site was confirmed by intraoperative neuronavigation and endoscopic findings. Statistical analyses were performed. All patients underwent endoscopic multilayer repair. RESULTS: The sensitivities of the HRCT, regular MRI (T1 and T2), 3D-MPRAGE and 3D-FIESTA modalities for identifying CSF leakage were 58.8 %, (11.8 % and 29.4 %), 74.7 %, and 88.2 %, respectively. The origins of the leakages included the cribriform plate (18 %), ethmoidal fovea (23 %), lateral recess of the sphenoid (17 %), sellar floor (12 %), ethmoidal roof (12 %), junction of the fovea and cribriform plate (6 %) and the junction of sellar and sphenoidal planum (6 %). Two patients required repair. The first was under local anaesthesia when the nasal packing was removed, and the second underwent repair at the same site a half-year later due to hydrocephalus. Lumbar drainage was performed in all cases. No major complications were encountered. CONCLUSIONS: The endoscopic endonasal approach is safe and effective for the treatment of CSF rhinorrhoea. The 3D-FIESTA MR modality is superior to 3D-MPRAGE MR and HRCT in the depiction of the CSF fistula site. Due to its non-invasive and reliable properties, 3D-FIESTA MR should be the preferred preoperative examination for the patients with non-iatrogenic CSF rhinorrhoea.

Application of the hemi-semi-laminectomy approach in the microsurgical treatment of C2 schwannomas.

STUDY DESIGN: Retrospective analysis of 9 cases of C2 schwannomas who were treated microsurgically with hemi-semi-laminectomy approach. OBJECTIVE: To review the clinical data and describe several operative nuances and pearls from our experience about the hemi-semi-laminectomy approach that provided successful resection of C2 schwannomas. SUMMARY OF BACKGROUND DATA: Compared with hemi-laminectomy, the hemi-semi-laminectomy is a more minimally invasive approach for excising spinal neurinomas, which can preserve as much of the mechanically relevant bone structures and facet joints as possible. There are no previous reports about the resection of C2 schwannomas with the hemi-semi-laminectomy approach. METHODS: Between June 2006 and February 2011, a consecutive series of 9 patients underwent surgery for C2 schwannomas. All patients were treated microsurgically with a midline posterior hemi-semi-laminectomy approach. Data regarding age, sex, duration and type of symptoms, topographical locations, and surgical results were investigated retrospectively. RESULTS: Of the 9 C2 schwannomas, 8 were located both intradurally and extradurally (dumbbell shaped), and 1 was located extradurally. The initial symptom was numbness of the extremity in 7 patients, neck pain in 1 patient, and clumsiness of the upper extremity in 1 patient. The average duration from initial symptom to surgery was 7.9 months. The average follow-up time was 39.6 months. There were no major surgical complications and tumor recurrence during the follow-up period. Remarkable neurological recovery was observed in 9 patients. CONCLUSIONS: The hemi-semi-laminectomy is a more minimally invasive approach that can preserve as much of the mechanically relevant bone structures as possible, so that the integrity of the arch of the atlas and the lamina of C2 can be maintained. This approach can provide sufficient field for the resection of the C2 schwannomas that do not extend to the ventral side of the vertebral artery in the anterolateral direction. The minimally invasive access and the remarkable results associated with this approach make it a valid alternative in selected cases.

GPR65 sensing tumor-derived lactate induces HMGB1 release from TAM via the cAMP/PKA/CREB pathway to promote glioma progression.

BACKGROUND: Lactate has emerged as a critical regulator within the tumor microenvironment, including glioma. However, the precise mechanisms underlying how lactate influences the communication between tumor cells and tumor-associated macrophages (TAMs), the most abundant immune cells in glioma, remain poorly understood. This study aims to elucidate the impact of tumor-derived lactate on TAMs and investigate the regulatory pathways governing TAM-mediated tumor-promotion in glioma. METHODS: Bioinformatic analysis was conducted using datasets from TCGA and CGGA. Single-cell RNA-seq datasets were analyzed by using UCSC Cell Browser and Single Cell Portal. Cell proliferation and mobility were evaluated through CCK8, colony formation, wound healing, and transwell assays. Western blot and immunofluorescence staining were applied to assess protein expression and cell distribution. RT-PCR and ELISA were employed to identify the potential secretory factors. Mechanistic pathways were explored by western blotting, ELISA, shRNA knockdown, and specific inhibitors and activators. The effects of pathway blockades were further assessed using subcutaneous and intracranial xenograft tumor models in vivo. RESULTS: Elevated expressions of LDHA and MCT1 were observed in glioma and exhibited a positive correlation with M2-type TAM infiltration. Lactate derived from glioma cells induced TAMs towards M2-subtype polarization, subsequently promoting glioma cells proliferation, migration, invasion, and mesenchymal transition. GPR65, highly expressed on TAMs, sensed lactate-stimulation in the TME, fueling glioma cells malignant progression through the secretion of HMGB1. GPR65 on TAMs triggered HMGB1 release in response to lactate stimulation via the cAMP/PKA/CREB signaling pathway. Disrupting this feedback loop by GPR65-knockdown or HMGB1 inhibition mitigated glioma progression in vivo. CONCLUSION: These findings unveil the intricate interplay between TAMs and tumor cells mediated by lactate and HMGB1, driving tumor progression in glioma. GPR65, selectively highly expressed on TAMs in glioma, sensed lactate stimulation and fostered HMGB1 secretion via the cAMP/PKA/CREB signaling pathway. Blocking this feedback loop presents a promising therapeutic strategy for GBM.

Endoscopic Supracerebellar Infratentorial Transpineal Approach for Posterior-Medial Thalamic Lesions: Surgical Technique and Clinical Experience.

BACKGROUND AND OBJECTIVES: Accessing lesions in the posterior-medial thalamus can be challenging because of their deep location and intricate neurovascular anatomy. This study aims to describe the techniques and feasibility of the endoscopic supracerebellar infratentorial transpineal approach for treating posterior-medial thalamus lesions. METHODS: We reviewed and analyzed the clinical outcomes and endoscopic surgical experience of 11 patients with posterior-medial thalamic lesions. The first 4 cases used the endoscopic midline supracerebellar infratentorial transpineal approach, whereas the subsequent 7 cases used the endoscopic contralateral paramedian supracerebellar infratentorial transpineal approach. All cases involved the upward transposition of the pineal gland to access the posterior-medial thalamus. The extent of resection and the endoscopic techniques were the main focus of analysis. Neurological examinations and MRI/computed tomography follow-up were conducted for 3-12 months after surgery. RESULTS: The pathology of the group included 6 gliomas, 1 cavernous malformation, 1 inflammation, 1 melanoma, and 2 hematomas. All 11 patients achieved gross total resection (6 patients, 54.5%) or subtotal resection (5 patients, 45.5%) with no new neurological deficits. Most patients (9 patients, 81.8%) experienced improvement in Karnofsky Performance Status after surgery. Postoperative hydrocephalus occurred in 2 patients (18.2%) and was relieved by endoscopic third ventriculostomy. CONCLUSION: The endoscopic supracerebellar infratentorial transpineal approach is an effective approach for removing posterior-medial thalamic lesions that require access through the third ventricle surfaces of the thalamus. The endoscopic contralateral paramedian supracerebellar infratentorial transpineal approach provides a more superior and lateral view of the posterior-medial thalamic lesions.

Analysis of Diffusion-Weighted and T2-Weighted Imaging in the Prediction of Distinct Granulation Patterns of Somatotroph Adenomas.

OBJECTIVE: The heterogeneity of the somatotroph adenomas, especially for sparsely granulated (SG) and densely granulated (DG) subtypes, has attracted great attention in identifying their imaging biomarker. The purpose of the current study was to compare the diagnostic performance of diffusion-weighted and T2-weighted magnetic resonance imaging (MRI) sequences for preoperatively distinguishing the granulation patterns of somatotroph adenomas. METHODS: Thirty-two patients with a clinical diagnosis of somatotroph adenomas from October 2018 to March 2023 were included in this study. Coronal diffusion-weighted imaging (DWI) and T2-weighted MRI sequence data were collected from 3.0T MRI and compared between SG and DG groups. The immunohistochemistry was used to confirm the electron microscopy pathologic subtypes and Ki67 expression levels of somatotroph adenomas postoperatively. RESULTS: Patients in the SG group had significantly higher signal intensity (SI) ratio of DWI (rDWI) (P < 0.001), lower SI ratio of apparent diffusion coefficient (rADC) (P < 0.001), and higher SI ratio of T2-weighted imaging (P = 0.011). The combined diagnosis index of rDWI and rADC had the highest diagnostic efficiency in predicting SG adenomas (sensitivity, 93.3%; specificity, 88.2%; P < 0.001). The rDWI and rADC values had positive and negative correlations with the Ki67 index and tumor maximum diameter, respectively. Lower rADC×103 was an independent predictor for SG adenomas. CONCLUSIONS: Our results indicated that compared with previously used T2-weighted imaging, the DWI sequence, especially the combined diagnosis index of rDWI and rADC, could more efficiently distinguish the granulation patterns of somatotroph adenomas preoperatively.

Evaluating the learning curve of endoscopic surgery for spontaneous intracerebral hemorrhage: A single-center experience in a county hospital.

BACKGROUND: Endoscopic surgery has shown promise in treating Spontaneous Intracerebral Hemorrhage (sICH), but its adoption in county-level hospitals has been hindered by the high level of surgical expertise required. METHODS: In this retrospective study at a county hospital, we utilized a Cumulative Sum (CUSUM) control chart to visualize the learning curve for two neurosurgeons. We compared patient outcomes in the learning and proficient phases, and compared them with expected outcomes based on ICH score and ICH functional outcome score, respectively. RESULTS: The learning curve peaked at the 12th case for NS1 and the 8th case for NS2, signifying the transition to the proficient stage. This stage saw reductions in operation time, blood loss, rates of evacuation < 90 %, rebleeding rates, intensive care unit stay, hospital stay, and overall costs for both neurosurgeons. In the learning stage, 6 deaths occurred within 30 days, less than the 10.66 predicted by the ICH score. In the proficient stage, 3 deaths occurred, less than the 15.88 predicted. In intermediate and high-risk patients by the ICH functional outcome score, the proficient stage had fewer patients with an mRS ≥ 3 at three months than the learning stage (23.8 % vs. 69.2 %, P = 0.024; 40 % vs. 80 %, P = 0.360). Micromanipulating bipolar precision hemostasis and aspiration devices in the endoport's channels sped up the transition from learning to proficient. CONCLUSION: The data shows a learning curve, with better surgical outcomes as surgeons gain proficiency. This suggests cost benefits of surgical proficiency and the need for ongoing surgical education and training in county hospitals.

Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations.

PURPOSE: Transoral resection of the odontoid has been accepted as a standard procedure to decompress the cervicomedullary junction during the past several decades. The endoscopic transnasal odontoidectomy is emerging as a feasible surgical alternative to conventional microscopic transoral approach. In this article, we describe several operative nuances and pearls from our experience about this approach, which provided successful decompression. METHODS: From September 2009 to April 2010, three consecutive patients with basilar invagination, of which the etiology was congenital osseous malformations, underwent endoscopic transnasal odontoidectomy. All patients presented with myelopathy. The last two cases also received occipitocervical fixation and bone fusion during the same surgical episode to ensure stability. RESULTS: All the patients were extubated after recovery from anesthesia and allowed oral food intake the next day. Cerebrospinal fluid rhinorrhea was found in the second case and cured by continuous lumber drainage of cerebrospinal fluid. No infection was noted. The average follow-up time was more than 24 months. Remarkable neurological recovery was observed postoperative in all patients. CONCLUSION: The endoscopic transnasal odontoidectomy is a feasible approach for anterior decompression of pathology at the cervicomedullary junction. The advantages over the standard transoral odontoidectomy include elimination of risk of tongue swelling and teeth damaging, improvement of visualization, alleviation of prolonged intubation, reduction of need for enteral tube feeding and less risk of affecting phonation. The minimally invasive access and faster recovery associated with this technique make it a valid alternative for decompression of the ventral side of the cervicomedullary junction.

Multi-omics analysis of N6-methyladenosine reader IGF2BP3 as a promising biomarker in pan-cancer.

Background: Insulin-like growth factor 2 mRNA-binding protein 3 (IGF2BP3) has been reported to exhibit an oncogenic effect as an RNA-binding protein (RBP) by promoting tumor cell proliferation, migration and invasion in several tumor types. However, a pan-cancer analysis of IGF2BP3 is not currently available, and the exact roles of IGF2BP3 in prognosis and immunology in cancer patients remain enigmatic. The main aim of this study was to provide visualization of the systemic prognostic landscape of IGF2BP3 in pan-cancer and to uncover the potential relationship between IGF2BP3 expression in the tumor microenvironment and immune infiltration profile. Methods: Raw data on IGF2BP3 expression were obtained from GTEx, CCLE, TCGA, and HPA data portals. We have investigated the expression patterns, diagnostic and prognostic significance, mutation landscapes, functional analysis, and functional states of IGF2BP3 utilizing multiple databases, including HPA, TISIDB, cBioPortal, GeneMANIA, GESA, and CancerSEA. Moreover, the relationship of IGF2BP3 expression with immune infiltrates, TMB, MSI and immune-related genes was evaluated in pan-cancer. IGF2BP3 with drug sensitivity analysis was performed from the CellMiner database. Furthermore, the expression of IGF2BP3 in different grades of glioma was detected by immunohistochemical staining and western blot. Results: We found that IGF2BP3 was ubiquitously highly expressed in pan-cancer and significantly correlated with diagnosis, prognosis, TMB, MSI, and drug sensitivity in various types of cancer. Besides, IGF2BP3 was involved in many cancer pathways and varied in different immune and molecular subtypes of cancers. Additionally, IGF2BP3 is critically associated with genetic markers of immunomodulators in various cancers. Finally, we validated that IGF2BP3 protein expression was significantly higher in glioma than in normal tissue, especially in GBM. Conclusions: IGF2BP3 may be a potential molecular biomarker for diagnosis and prognosis in pan-cancer, especially for glioma. It could become a novel therapeutic target for various cancers.

Natural capital investments in China undermined by reclamation for cropland.

Globally, rising food demand has caused widespread biodiversity and ecosystem services loss, prompting growing efforts in ecological protection and restoration. However, these efforts have been significantly undercut by further reclamation for cropland. Focusing on China, the world's largest grain producer, we found that at the national level from 2000 to 2015, reclamation for cropland undermined gains in wildlife habitat and the ecosystem services of water retention, sandstorm prevention, carbon sequestration and soil retention by 113.8%, 63.4%, 52.5%, 29.0% and 10.2%, respectively. To achieve global sustainability goals, conflicts between inefficient reclamation for cropland and natural capital investment need to be alleviated.