Endovascular coiling vs. surgical clipping for unruptured intracranial aneurysm: A meta-analysis.

BACKGROUND: With increasing use of high-resolution imaging of brain, unruptured aneurysms are more and more frequently detected. With the advances in treatment techniques, an increasing number of aneurysms are now occluded using endovascular coiling instead of conventional surgical clipping. However, the better modality for unruptured intracranial aneurysm has been poorly understood. OBJECTIVE: The objective of this meta-analysis was to compare the outcomes between endovascular coiling and surgical clipping among patients with unruptured intracranial aneurysms. METHODS: PubMed, Embase, Web of Science, CENTRAL, and SIGLE were electronically searched from January 1, 1990 to March 13, 2012 with no language restriction for randomized or nonrandomized clinical controlled trials. Article screening and data extraction were conducted in duplicate. Results were statistically pooled through Review Manager 5 and StatsDirect 2.7.9. RESULTS: Seven studies met our inclusion criteria. The pooled risk ratios (coiling vs. clipping) were 0.59 (95% CI = 0.23-1.54) for death; 0.37 (95% CI = 0.10-1.41) for bleeding; 0.78 (95% CI = 0.38-1.58) for cerebral ischemia; 0.87 (95% CI = 0.70-1.08) for occlusion of aneurysm; 0.53 (95% CI = 0.18-1.52) for independence in daily activities. The pooled rates of death, bleeding, ischemia, occlusion of aneurysm, and mRS no less than 3 were 1% (95% CI = 0-2%), 2% (95% CI = 0-5%), 8% (95% CI = 4-13%), 82% (95% CI = 64-95%), and 5% (95% CI = 1-10%) for endovascular coiling, respectively, and 1% (95% CI = 0-2%), 6% (95% CI = 3-10%), 9% (95% CI = 5-15%), 95% (95% CI = 90-98%), and 8% (95% CI = 3-14%) for surgical clipping, respectively. We failed to evaluate quality of life and cognitive outcome due to insufficient data. Both meta-regression and sensitivity analysis showed consistent results. Furthermore, Begg's test and Egger's test failed to detect publication bias. CONCLUSION: We suggest that endovascular coiling and surgical clipping bear similar risk ratios of death, bleeding, cerebral ischemia, occlusion of aneurysm, and independence in daily activities and encourage further studies on quality of life and cognitive outcome. However, albeit the results in this meta-analysis are robust, due to great clinical heterogeneity and low quality of studies, the results in this meta-analysis should be interpreted with caution.

Association of polymorphisms in the elastin gene with sporadic ruptured intracranial aneurysms and unruptured intracranial aneurysms in Chinese patients.

It has been suggested that the elastin gene is a candidate gene for the development of intracranial aneurysms (IAs). We investigated the association of single-nucleotide polymorphisms (SNPs) in the elastin gene in sporadic subarachnoid hemorrhage and in patients with unruptured aneurysms in China. We genotyped 446 (47.9%) IA patients (308 ruptured and 138 unruptured) and 485 (52.1%) control subjects for seven exonic and intronic SNPs in the elastin gene and then evaluated their allelic associations with sporadic ruptured and unruptured IAs. We found that IA is associated with two SNPs in the elastin gene: rs2071307 (odds ratio 2.87; 95% confidence interval, 2.26-3.64; p < 0.001) and rs2856728 (odds ratio 2.12; 95% confidence interval, 1.71-2.62; p < 0.001). Furthermore, the minor allele of rs2071307 (allele A) was also associated with IA rupture; 31.3% of patients with ruptured IAs were carriers of the minor allele, whereas only 23.2% of patients with unruptured IAs carried the minor allele (odds ratio 1.51; 95% confidence interval, 1.09-2.10; p = 0.013). In conclusion, our study indicates that the elastin gene may be associated with the formation of IAs, and importantly, that it may also be associated with the rupture of IAs.

Pilot study on a fast postoperative programming approach to subthalamic nucleus stimulation in Parkinson's disease.

OBJECTIVES: T0 o evaluate the advantages and disadvantages of a fast post-operative screening method using deep brain stimulation (DBS) of the subthalamic nucleus (STN) in patients with Parkinson's disease. MATERIALS AND METHODS: Twenty-four patients implanted with electrodes for STN-DBS were divided into two groups : Group I received traditional programming and Group II was treated with the fast method. The time required for programming in each group and the treatment effects were analyzed. RESULTS: Significant postoperative improvement of the Unified Parkinson's Disease Rating Scale III was achieved in the "off medication" and "on stimulation" condition in both the groups (Group I: 51.2% vs. Group II: 54.0%, P<0.05). The average time needed for programming, however, was significantly shorter in Group II as compared to Group I (P<0.05). CONCLUSIONS: T0 he new fast method can significantly reduce the time required to find a preliminary effective STN-DBS protocol in the early postoperative phase without sacrificing clinical efficacy.

CSF fistula through the left lumbar region in adult following a ventriculoperitoneal shunt surgery: a rare case report.

A cranial spinal fluid fistula through left lumbar region following a ventriculoperitoneal (VP) shunt is an extremely rare complication. We report a 25-year-old man who presented with the leakage of clear fluid from the left lumbar region, 3 years after a VP shunt surgery. Computerized tomography scan of abdomen revealed that the distal end of the catheter penetrated into the inner layer of the wall of left lumbar region. He was managed successfully with abdominal part of shunt catheter removal from primary cervical and abdominal incision, a new abdominal part of VP shunt catheter replacement and prophylactic antibiotic.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms.

OBJECT: Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. METHODS: Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. RESULTS: Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. CONCLUSIONS: Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

An Echinococcosis multilocularis presenting as a giant anterior cranial basilar tumor.

Cerebral alveolar hydatid disease is a rare subtype of Echinococcus, and prevalent in northern China and Tibetan area. In this report, we presented a giant lesion of Echinococcus multilocularis which located in anterior cranial fossa, and discussed its clinicopathological and radiological features, and strategy of treatment.

Two anatomic variations of the vertebral artery in four patients.

In this article, we present four cases of rare anomalous aortic arch and vertebral arteries and discuss the possible embryologic etiologies. These include two cases in which the right vertebral artery originated from the right common carotid artery associated with an aberrant right subclavian artery originating from the middle of the aortic arch and two cases in which the left vertebral artery had a double origin from the left subclavian artery and aortic arch.

A delayed frontorbital abscess caused by a penetrating nonmissile foreign body (a bamboo stick).

We report an interesting case of delayed frontal abscess caused by a penetrating nonmissile foreign body, a bamboo stick in a 1.5-year-old male child. A parietal craniotomy was performed, and the brain abscess was resected along with the foreign body without any damage to the surrounding brain tissue. He also received the appropriate antibiotics. The child made a good recovery.

Intraventricular vascular malformations mimicking tumors: case reports and review of the literature.

Vascular malformations of the ventricular system are rare, and their clinical and radiologic characteristics vary depending on the location of the lesions. Many types are described, but a comprehensive summary is lacking. Herein, we add two cases to the literature and review known types of ventricular vascular malformations. One case involved a 37-year-old woman who presented with headache due to hydrocephalus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion of the foramen of Monro. The other case involved a 7-year-old boy who had dizziness and headache due to hydrocephalus. CT and MRI demonstrated a lesion of the third ventricle. In both cases, the images mimicked those of tumors with or without bleeding. As a result, the malformations were misdiagnosed, though surgical treatment was successful. In both cases, the lesions were proven to be arteriovenous malformations on pathologic evaluation. Correct diagnosis of ventricular vascular malformations is sometimes difficult but essential for good treatment planning. Their incidence is low. However, their bleeding and rebleeding rate is high, and they commonly cause hydrocephalus. Treatment should be timely and based on the type of lesion and its presentation.

The postoperative brain tumour stem cell (BTSC) niche and cancer recurrence.

Currently, surgical resection is one of only a few options for treating brain cancer. Unfortunately, postoperative tumour recurrence remains almost inevitable despite additional radiation or chemotherapy treatment following resection. Clinical observations and a growing body of experimental evidence have led to speculation that there is a population of persistent brain tumour stem cells (BTSCs)--or brain tumour initiating cells--that are difficult to completely remove surgically. Furthermore, residual BTSCs following surgery may actually be more resistant to subsequent radiation and/or chemotherapies. It remains to be determined if brain surgeries render the postoperative tissue microenvironment more favourable for the survival and growth of BTSCs, and therefore the recurrence of brain tumours.We hypothesise that BTSC-based tumour recurrence may develop within a specific niche of the aberrant tumour microenvironment. Even when the gross appearance of the primary tumour seems confined, BTSCs (albeit accounting only for a small population of tumour cells) may microscopically enter the stroma, hampering curative surgeries. This article discusses the theory that surgical resection of brain tumours generates niches recruiting BTSCs to the surgical wounds, stimulating the proliferation and invasiveness of BTSCs, and leading to tumour recurrence. Postoperative brains are marked with active wound repair in peritumoural margins, which is likely to be accompanied by increased inflammatory paracrine production, angiogenesis and reactive astrogliosis. The postoperative BTSC niche concept is consistent with the observation that brain tumour recurrence usually occurs in tissues that are proximal to the resection margin. In this article, we intend to reflect recent advances that may lead to novel strategies to eliminate postoperative brain tumour recurrence.

[Microsurgery for intracranial aneurysm:analysis of 438 cases].

OBJECTIVE: To summarize the experience of surgical therapy in a series of 438 patients with intracranial aneurysms. METHODS: A retrospective analysis was made on the clinical data of 438 patients, in terms of the perioperative management, timing of surgery, surgical skills, and The HUNT-HESS grade. RESULTS: 438 patients with 476 aneurysms underwent microsurgery, in which 450 aneurysms were clipped, 14 were wrapped, 8 were isolated,4 were cut. 32 aneurysms were ruptured (6.72%) during the operation. The relation between Hunt-Hess scale and mortality is significant postpone operation (> or =7 d) has got a better curative effect than the early. CONCLUSIONS: Microsurgical treatment is a confirmed effective method with intracranial aneurysms. The higher of HUNT-HESS grade will result to the worse clinical outcome.

Risk Factors Analyses for Seizure Recurrence in Different Periods After Refractory Epilepsy Surgery: A Prospective Single-Center Study.

OBJECTIVE: To evaluate the potential risk factors associated with seizure recurrence in different periods after epilepsy surgery. METHODS: A total of 303 patients with refractory epilepsy after epilepsy surgery were included. The Kaplan-Meier method with log-rank test and univariate and multivariate Cox proportional hazards model were performed to calculate the comparison of survival curves between groups and identify the risk factors associated with seizure recurrence in different periods after surgery. RESULTS: The significant predictors of seizure recurrence were determined, including duration of epilepsy (P = 0.018), seizure types (P = 0.009), magnetic resonance imaging findings (P = 0.007), intracranial electroencephalographic recordings (P = 0.002), sides of epileptogenic zone (P = 0.025), and types of surgery (P = 0.002). Moreover, the significant predictors of seizure recurrence within 12 months after surgery were also included, such as gender (P = 0.007), duration of epilepsy (P = 0.013), intracranial electroencephalographic recordings (P = 0.003), and types of surgery (P < 0.001). Our results indicated that the variables of magnetic resonance imaging findings (P = 0.015), sides of epileptogenic zone (P = 0.004), and seizure relapse within 12 months after surgery (P < 0.001) were significantly associated with seizure recurrence in 12-36 months after surgery. Seizure relapse within 12 months after surgery (P < 0.001) was also associated with seizure recurrence >36 months after surgery. CONCLUSIONS: We reconfirmed the well-known risk factors associated with seizure recurrence and also identified the controversial variables. In addition, we found that the risk factors associated with seizure recurrence were different in different periods after epilepsy surgery.

A comparative study on therapeutic method of traumatic epidural hematoma.

OBJECTIVE: To explore the therapeutic methods, surgical indications and clinical practice of minimally invasive surgery on traumatic epidural hematoma (EDH). METHODS: Retrospective study was made on 135 patients with traumatic EDH admitted into our hospital from June 2002 to August 2005. Sixty-five patients were treated with mini-invasive negative pressure drainage (treatment group), 70 patients with comparable condition used traditional craniotomy (control group). The mean time of operation, average days in hospital, expenditure and prognosis of two groups were recorded and analyzed. RESULTS: There was no significant difference in therapeutic efficacy between two groups. Patients in treatment group had a shorter hospital stay and less expenditure than those in control group. CONCLUSION: Mini-invasive negative pressure drainage is simple, effective, economical and applicable to some traumatic EDH patients.

[Expressions of CD31 and vWF in arachnoid villus endothelium cell from experimental animal with Hydrocephalus].

OBJECTIVE: The aim of this study was to investigate the CD-31 and vonWillebrand factor (vWF) expressions and the cell morphological alterations ofarachnoid villus endothelium in different stages of animal hydrocephalus. METHODS: Silicon oil was injected into the fourth ventricle of experimental canine for buildinghydrocephalus model. The post-injection ethology of the canine was observed, and thescoring of Tarlov n was performed. The magnetic resonance (MR) images of canineskulls were achieved for verification of hydrocephalus at 3 day, 2 weeks, and 12 Cweeks post-injection. The expressions of CD-31 and von Willebrand factor (vWF) inthe arachnoid villus endothelium cells at different stages of hydrocephalus werestudied by immunofluorescence histochemistry. RESULTS: Experimental hydrocephalusanimal model was built up satisfactorily by injection of silicon oil. Experimentalcanines appeared the hydrocephalus symptoms and Tarlov scoring decrease. MRimages revealed progressive ventricular enlargement in different stages ofhydrocephalus. The immunofluorescence histochemistry staining showed that CD31 expressed positively in all the endothelium cells, including the endothelium cell of thevillus. The immunofluorescence histochemistry staining showed that the vWFexpression in the endothelium of the villus was diminished when compared to that innormal sinus wall. And in sub-acute and chronic hydrocephalus, the expression of vonWillebrand factor increased. CONCLUSIONS: The fourth ventricular injection of siliconoil may induce the hydrocephalus animal model. The expression of von Willebrandfactor in the endothelium cell of arachnoid villus increases during progressedhydrocephalus.

Thoracic spine extradural arteriovenous fistula: case report and review of the literature.

BACKGROUND: Spinal extradural arteriovenous fistula is a rare, disabling, but potentially treatable disease. Only 27 cases have been reported so far in the past 40 years. CASE DESCRIPTION: An 18-year-old adolescent girl developed repeated back pain and mild paraplegia after a training course. Magnetic resonance imaging revealed a vessel-like lesion at the spinal extradural space, compressing the spinal medulla at the T5 level. Angiography disclosed a focal fistula fed by branches of the intercostal artery. The vascular mass was surgically removed and confirmed pathologically. CONCLUSION: Spinal extradural arteriovenous fistulas have an arterial supply that originates outside the spinal dura, with venous draining into the spinal extradural venous plexus. They may lead to myelopathy, radiculopathy, or spontaneous extradural hematoma, due to dilated vein compression, blood stealing, or spinal venous hypertension. Extradural hematoma needs emergency laminectomy and clot evacuation. And extradural arteriovenous fistulas should be treated actively by embolization, surgical resection, or both. Appropriate treatment will stabilize the patient or result in neurological improvement.

[Cathepsin B expression and malignances and angiogenesis in gliomas].

OBJECTIVE: To test the expression of Cathepsin B (CB) protease in gliomas and to investigate its correlation with the malignance and angiogenesis of gliomas. METHODS: Immunochemistry technique of strept actividin-biotin complex (SABC) was used to identify the CB expression and to measure the microvessel density (MVD) in 47 gliomas samples and 5 normal human brain tissues from patients with spontaneous cerebral hemorrhage. RESULTS: No CB expression was detected in the normal brain tissues. The expression levels of CB in astrocytoma, anaplastoma, and glioblastoma were 30% (6/20 weak positive), 86.7% (3/15 weak and, 10/15 moderate positive), and 100.0% (2/12 moderate and 10/12 strong positive), respectively. The malignances of gliomas increased with CB expression (r=0. 77, P<0.05). The MVD also increased with CB expression (r= 0.56, P<0. 05), with an average of 15.57 +/- 8.52, 22.50 +/- 14.42, 39.85 +/- 8.75 and 49.90 +/- 11.30 for the negative, weak, moderate, and strong CB expression gliomas respectively. CONCLUSION: CB expression is positively correlated with the malignances and angiogenesis of gliomas. CB expression could be one of the indicators for the degree of malignances and invasion of gliomas.

[An experimental research of hyperthermic preconditioning on the spinal cord injury].

OBJECTIVE: To assess the effects of hyperthermic preconditioning on spinal cord injury(SCI) in rats. METHODS: A total of 96 SD rats were divided into control(A), trauma(B) and hyperthermic preconditioning (C) group. SCI models were made by static compression. The animals were decapitated at 6 h, 12 h, 1 d, 2 d, 3 d, 1 w, 2 w and 3 w after injury. With in situ hybridization and immunohistochemistry, the expression of HSP70 after spinal cord injury was studied at the transcript level and translation level respectively. Neurological outcome was evaluated by the combined behavioral score (CBS). RESULTS: Neurological outcome in Group C was significantly higher than that in Group B (P < 0.05). In-situ hybridization and Immunohistochemistry analysis showed that expression of HSP70 in spinal cord elevated after hyperthermic preconditioning; furthermore, the level of HSP70 in Group C was significantly higher than that in Group B (P < 0.05). CONCLUSION: Hyperthermic preconditioning might improve neurological outcome after spinal cord injury in rats, and the protective mechanism in this connection might involve the induction of HSP70 synthesis in spinal cord.

Aberrant CpG island hypermethylation profile is associated with atypical and anaplastic meningiomas.

Hypermethylation of promoter CpG islands is a common epigenetic event in a variety of human cancers. The aim of this study was to investigate whether promoter hypermethylation of cancer-related genes is involved in the development and progression of meningiomas. The methylation status at the promoter region of 10 cancer-related genes was examined by methylation-specific polymerase chain reaction in a cohort of 48 meningiomas including 16 benign, 19 atypical, and 13 anaplastic variants. The relationship of promoter hypermethylation and transcriptional silencing was determined by treatment of cells with demethylating agent 5-aza-2'-deoxycytidine followed by reverse transcription-polymerase chain reaction. Our results showed that 50% (24/48) of meningiomas exhibited promoter hypermethylation in at least one of the genes but not in normal leptomeninges, indicating that aberrant hypermethylation is tumor-specific. Promoter hypermethylation was detected in glutathione S -transferases P1 at 27%, thrombospondin-1 at 15%, retinoblastoma 1 at 10%, cyclin-dependent kinase inhibitor 2A at 10%, O 6 -methylguanine-DNA methyltransferase at 6%, and death-associated protein kinase 1, von Hippel-Lindau, p14 ARF , and cyclin-dependent kinase inhibitor 2B, each at 4%. No promoter hypermethylation was detected in the tissue inhibitor of metalloproteinase 3 gene. Treatment of IOMM-Lee meningioma cell line with 5-aza-2'-deoxycytidine restored expression of O 6 -methylguanine-DNA methyltransferase and death-associated protein kinase 1, providing evidence that promoter hypermethylation contributes to transcriptional silencing. The frequencies of methylation of any single gene in benign, atypical, and malignant meningiomas were 6% (1/16), 74% (14/19), and 69% (9/13), respectively. Of 48 tumors, 13 (27%) showed that concurrent hypermethylation of two or more genes studied were of atypical or anaplastic type. Statistical analysis revealed that the incidence of promoter hypermethylation of any single gene, of multiple genes, or of glutathione S -transferase P1 was significantly associated with atypical and anaplastic meningiomas ( P < .0001, P = .004, and P = .004, respectively). In conclusion, this study demonstrates that aberrant hypermethylation profile is associated with atypical and anaplastic meningiomas, suggesting that epigenetic change may be involved in malignant progression of meningiomas.

Neuroprotective effect of exogenous vascular endothelial growth factor on rat spinal cord neurons in vitro hypoxia.

BACKGROUND: Vascular endothelial growth factor (VEGF) is well known as a hypoxia-induced protein. That it markedly increased expression of VEGF and improvement of rat motor function after spinal cord injury suggested that VEGF could play a neuroprotective role in ischaemic tolerance. This study investigated whether vascular endothelial growth factor has direct neuroprotective effects on rat spinal cord neurons. METHODS: We employed primary cultures of embryonic rat spinal cord neurons, then administrated different concentrations of VEGF164 in the culture medium before hypoxia when the number of neurons was counted and the cell viability was detected by MTT. The neuronal apoptosis and expression of VEGF and its receptor genes were evaluated by terminal deoxynucleotidyl transferase mediated dUTP nick-end labelling (TUNEL) and immunohistochemistry. The VEGFR2/FLK-1 inhibitor, SU1498, was used to confirm whether the neuroprotective effect of VEGF was mediated through VEGFR2/Flk-1 receptors. RESULT: In hypoxic conditions, the number and viability of neurons decreased progressively, while the number of TUNEL-positive cells increased along with the prolongation of hypoxic exposure. When the concentration of VEGF in cell culture medium reached 25 ng/ml, the cell viability increased 11% and neuronal apoptosis reduced to half, this effect was dose dependent and led to an approximately 25% increase in cell viability and about threefold decrease in TUNEL-positive cells at a maximally effective concentration of 100 ng/ml. In normal conditions, VEGF/Flk-1 but not VEGF/Flt-1 gene expressed at a low level: after hypoxia, the expression of VEGF/Flk-1, but not VEGF/Flt-1 was significantly increased. The protective effect of VEGF was blocked by the VEGFR2/Flk-1 receptor tyrosine kinase inhibitor, SU1498. CONCLUSIONS: VEGF has direct neuroprotective effects on rat spinal cord neurons, which may be mediated in vitro through VEGFR2/Flk-1 receptors.