The significance of short-term preoperative calcium and activated vitamin D3 supplementation in thyroidectomy: a randomized trial and prospective study.

Objective: The aim was to explore the effects of preoperative calcium and activated vitamin D3 supplementation on post-thyroidectomy hypocalcemia and hypo-parathyroid hormone-emia (hypo-PTHemia). Methods: A total of 209 patients were randomly divided into control group (CG) and experimental group (EG). Oral calcium and activated vitamin D3 supplementation were preoperatively administered to EG, whereas a placebo was administered to CG. Data on serum calcium, phosphorus, and PTH concentrations before operation, on postoperative day 1 (POPD1), at postoperative week 3 (POPW3), and on the length of postoperative hospitalization were collected. Results: The serum calcium, phosphorus, and PTH concentrations, as well as the incidence of postoperative hypocalcemia and hypo-PTHemia, did not significantly differ between EG and CG. Subgroup analysis revealed that the serum calcium concentrations of the experimental bilateral thyroidectomy subgroup (eBTS) on POPD1 and POPW3 were higher than that of the control bilateral thyroidectomy subgroup (cBTS) (P < 0.05); the reduction of serum calcium in eBTS on POPD1 and POPW3 was less than those in cBTS (P < 0.05). However, significant differences were not observed between the unilateral thyroidectomy subgroups (UTS) (P > 0.05). Moreover, the incidence of postoperative hypocalcemia in cBTS on POPD1 was significantly higher than that in eBTS (65.9% vs 41.7%) (P < 0.05). The length of hospitalization in cBTS (3.55 ± 1.89 days) was significantly longer than that (2.79 ± 1.15 days) in eBTS (P < 0.05). Conclusion: Short-term preoperative prophylactic oral calcium and activated vitamin D3 supplementation could effectively reduce the incidence of postoperative hypocalcemia and decrease the length of postoperative hospitalization in patients who have undergone bilateral thyroidectomy.

Kidney cancer with thyroid metastasis combined with thyroid carcinoma, a case report.

BACKGROUND: Thyroid cancer is the most common malignant tumor of the endocrine system. There have been some reports on kidney cancer with thyroid metastasis. However, kidney cancer has rarely been detected during thyroid cancer surgery. CASE PRESENTATION: We present a rare case of kidney cancer with thyroid metastasis, combined with thyroid carcinoma. A 66-year-old woman was admitted to our hospital in September 2021 due to enlarged left thyroid nodules for two years. The patient was diagnosed with a left thyroid nodule on physical examination in 2012. Extended radical resection of the thyroid cancer was performed. Intraoperatively, two thyroid lesions were identified. Thus, the patient was definitively diagnosed with kidney cancer with thyroid metastasis and papillary thyroid carcinoma. Furthermore, two metastatic nodules due to kidney cancer and one metastatic lymph node lesion due to thyroid cancer were found in the loose connective tissue adjacent to the thyroid. CONCLUSIONS: Kidney cancer with thyroid metastasis and thyroid carcinoma rarely co-occur, and it is difficult to identify the primary tumor. Although clinical examination methods are increasingly updated, the past medical history and physical examination are still very important.

Evaluation of a Precision Approach to Intraoperative Ropivacaine Nerve Block to Improve Postoperative Analgesia in 120 Patients Undergoing Thyroid Surgery.

BACKGROUND This study aimed to compare a precision approach to intraoperative nerve block with traditional analgesia to reduce postoperative pain in 120 patients during thyroid surgery. The precision intraoperative technique used 0.3% ropivacaine to block the lower branch of the transverse cervical nerve and the inner branches of the supraclavicular nerve. MATERIAL AND METHODS A total of 120 patients were prospectively enrolled in this study. All patients were randomly and evenly divided into 3 groups. In the precision group, 0.3% ropivacaine was used through the wound during surgery. In the traditional group, a superficial cervical plexus nerve block was performed before surgery. Saline was injected in the control group. The valuation of postoperative pain was assessed using the visual analogue scale (VAS). RESULTS Two hours after surgery, the VAS scores in the precision group, traditional group, and control group were 1.4±0.5, 1.6±0.7, and 2.8±1.0 (P<0.001), respectively. Then, the pain improvement was more significant after 6 h, as the VAS scores in the precision, traditional, and control groups were 1.0±0.5, 1.2±0.6, and 2.6±1.1 (P<0.001), respectively. Twenty-four hours after surgery, the VAS scores in the precision, traditional, and control groups were 0.7±0.3, 0.6±0.4, and 1.9±1.1 (P<0.001), respectively. CONCLUSIONS At a single center, the use of a precision intraoperative ropivacaine nerve block significantly reduced postoperative pain when compared with traditional analgesia for patients undergoing thyroid surgery.

Clinical significance of chemokine receptor CXCR4 and mammalian target of rapamycin (mTOR) expression in patients with diffuse large B-cell lymphoma.

To assess the relevance of C-X-C chemokine receptor type 4 (CXCR4) and mammalian target of rapamycin (mTOR) to large-B-cell lymphoma (DLBCL), levels of protein expression were measured in 56 DLBCL patients who had received rituximab-based therapy. Of these, 34 were positive for CXCR4 expression (60.7%) and 31 for mTOR (55.4%). CXCR4 expression was positively correlated with mTOR expression (r = 0.602; p = .000). CXCR4 expression was significantly associated with high lactate dehydrogenase (LDH) level (p = .009), high IPI score (p = .030) and non-GCB subtype (p = .006). Furthermore, the expression levels of CXCR4 and mTOR were negatively correlated with the chance of remission (p < .05). Kaplan-Meier analysis indicated significantly shorter progression-free survival (PFS) and overall survival (OS) in patients positive for CXCR4 and mTOR expression. The combination therapy with CXCR4 inhibitor WZ811 and mTOR inhibitor everolimus showed syncergistic effect in DLBCL cell lines. These results suggest that the expression of CXCR4 and mTOR may be suitable as biomarkers of the prognosis of DLBCL and for development of new therapeutic strategies.

Volumetric magnetic resonance imaging analysis in patients with short-term remission of Cushing's disease.

OBJECTIVE: The data on patients with short-term remission of Cushing's disease (CD) might provide information that is not available from previous long-term remission studies. We aimed to investigate structural changes in the brain in these patients and to examine whether these changes were associated with clinical characteristics. DESIGN: A cross-sectional study was performed. METHODS: Thirty-four patients with CD (14 with CD in short-term remission and 20 with active CD) and 34 controls matched for age, sex and education underwent clinical evaluation and magnetic resonance imaging brain scans. Biometric measurements, disease duration and remission duration data were collected. Grey matter volumes in the whole brain were examined using voxel-based morphometry (VBM). RESULTS: No differences were observed in the grey matter volumes of the medial frontal gyrus (MFG) and cerebellum between the patients with remitted CD and healthy controls, whereas patients with active CD had smaller grey matter volumes in these two regions compared with controls and patients with remitted CD. Furthermore, significant correlations were found between remission time and grey matter values in these regions in short-term remission patients with CD. Additionally, greater grey matter volumes in the bilateral caudate of short-term remission patients with CD were observed. CONCLUSIONS: Trends for structural restoration were found in CD patients with short-term remission. This finding was associated with the number of days elapsed since curative surgery and the current age of the patients. This study enhances our understanding of potential reversibility after the resolution of hypercortisolism in CD patients.

Altered gray and white matter microstructure in Cushing's disease: A diffusional kurtosis imaging study.

Exposure to chronic hypercortisolism has multiple adverse effects on brain biology in humans. Cushing's disease (CD) represents a unique and natural human model for examining the effects of hypercortisolism on the brain. This cross-sectional study used Diffusional Kurtosis Imaging (DKI) to investigate the microstructure alterations in both white matter (WM) and gray matter (GM) of CD patients and to determine the relationship of these changes with clinical characteristics. DKI images were obtained from 15 active CD patients. DKI parametric maps were estimated through voxel-based analyses (VBA) and compared with 15 healthy controls matched for age, sex and education. In addition, correlations were analyzed between the altered DKI parameters and clinical characteristics. Compared with healthy controls, CD patients mainly exhibited significantly altered diffuse parameters in the GM and WM of the left medial temporal lobe (MTL). The mean values of increased radial diffusivity (RD) of CD patients in GM of the left hippocampus/parahippocampal gyrus correlated positively with the clinical severity of CD. Additionally, we also found altered kurtosis parameters in the cerebellum and frontal lobe. DKI imaging of CD patients could represent complementary information in both white matter and gray matter. The impairment of the left MTL might explain some part of the memory and cognition impairments in CD patients.

Altered spontaneous brain activity in Cushing's disease: a resting-state functional MRI study.

CONTEXT AND OBJECTIVE: Cushing's disease (CD) provides a unique and naturalist model for studying the influence of hypercortisolism on the human brain and the reversibility of these effects after resolution of the condition. This cross-sectional study used resting-state fMRI (rs-fMRI) to investigate the altered spontaneous brain activity in CD patients and the trends for potential reversibility after the resolution of the hypercortisolism. We also aim to determine the relationship of these changes with clinical characteristics and cortisol levels. SUBJECTS AND METHODS: Active CD patients (n = 18), remitted CD patients (n = 14) and healthy control subjects (n = 22) were included in this study. Amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) values were calculated to represent spontaneous brain activity. RESULTS: Our study resulted in three major findings: (i) active CD patients showed significantly altered spontaneous brain activity in the posterior cingulate cortex (PCC)/precuneus (PCu), occipital lobe (OC)/cerebellum, thalamus, right postcentral gyrus (PoCG) and left prefrontal cortex (PFC); (ii) trends for partial restoration of altered spontaneous brain activity after the resolution hypercortisolism were found in several brain regions; and (iii) active CD patients showed a significant correlation between cortisol levels and ALFF/ReHo values in the PCC/PCu, a small cluster in the OC and the right IPL. CONCLUSIONS: This study provides a new approach to investigating brain function abnormalities in patients with CD and enhances our understanding of the effect of hypercortisolism on the human brain. Furthermore, our explorative potential reversibility study of patients with CD may facilitate the development of future longitudinal studies.

Gambogic acid induces EGFR degradation and Akt/mTORC1 inhibition through AMPK dependent-LRIG1 upregulation in cultured U87 glioma cells.

Glioblastoma multiforme (GBM) is the most common malignant tumor in adults' central nervous system (CNS). The development of novel anti-cancer agents for GBM is urgent. In the current study, we found that gambogic acid induced growth inhibition and apoptosis in cultured U87 glioma cells, which was associated with Akt/mTORC1 (mTOR complex 1) signaling in-activation. To restore Akt activation by introducing a constitutively active (CA) Akt attenuated gambogic acid-induced cytotoxicity against U87 cells. For mechanism study, we found that gambogic acid induced LRIG1 (leucine-rich repeat and Ig-like domain-containing-1) upregulation, which was responsible for EGFR (epidermal growth factor receptor) degradation and its downstream Akt/mTORC1 inhibition. Further, we provided evidence to support that AMPK (AMP-activated protein kinase) activation mediated gambogic acid-induced LRIG1 upregulation, U87 cell apoptosis and growth inhibition, while AMPK inhibition by shRNA or compound C reduced gambogic acid-induced EGFR/Akt inhibition and cytotoxicity in U87 cells. We here proposed novel signaling mechanism mediating gambogic acid-induced cytotoxic effects in glioma cells.

Diagnosis and therapy for Cushing's disease with negative dynamic MRI finding: a single-centre experience.

OBJECTIVE: Most patients with Cushing's disease (CD) will have evidence of an adenoma on high-resolution magnetic resonance imaging (MRI). However, a significant minority of patients with CD and biochemical hypercortisolaemia have no visible adenoma on MRI. The purpose of this study was to evaluate the diagnostic value of preoperative biochemical assessment and accuracy of MRI findings on surgical outcome. DESIGN: Retrospective data set analyses. PATIENTS AND MEASUREMENT: The clinical, endocrinological, histopathological and surgical outcomes of 24 consecutive CD patients with negative MRI findings were compared with those of 95 consecutive age- and sex-matched CD patients with pituitary adenomas on MRI. RESULTS: The total remission rate was 86.6%. Among all patients, 87 had concordant positive endocrine tests and underwent neurosurgery, while bilateral inferior petrosal sinus sampling (BIPSS) was performed in 12 and 50 other patients with negative and positive MRI, respectively. A pituitary adenoma, confirmed by pathological examination, was found in 83.3% and 93.6% of patients with negative and positive MRI, respectively. The remission rate was not different between patients with negative and positive MRI (87.5 % and 86.3%, respectively; P > 0.05) or between patients who did not undergo BIPSS with negative MRI and patients with positive MRI (P > 0.05). The remission rate of patients who underwent BIPSS with negative MRI was not different from those not undergoing BIPSS (P > 0.05). The recurrence rate was higher, although not statistically different, in patients with negative MRI compared to positive ones. CONCLUSIONS: Based on the findings outlined, MRI-negative CD may be a surgically remediable syndrome, with a pathophysiological basis that primarily involves a pituitary cause of the hypercortisolaemia.

Cauda equina hemangioblastoma at L5 vertebral level related to von Hippel-Lindau disease.

Hemangioblastoma (HB) is uncommon, with only a few cases of hemangioblastoma with von Hippel-Lindau disease (VHL) located in cauda equina previously reported. We describe a case of hemangioblastoma misdiagnosed as nerve sheath tumour in the cauda equina.

Primary choroid plexus papilloma in the pituitary fossa: case report and literature review.

Choroid plexus papillomas are rare tumors of the central nervous system and are usually confined to the ventricular system. We illustrated a primary choroid plexus papilloma in the pituitary fossa. A 31-year-old female presented with amenorrhea and intermittent galactorrhoea, with no visual complaints in the last 2 years. Endocrine testing showed no hormone excess or deficiency of the pituitary and target glands, except for a higher prolactin level (56 ng/ml). A sharply circumscribed regular mass in the sellar region occupying the entire sella turcica and extending into the suprasellar cistern was demonstrated on MR imaging with gadolinium diethylenetriamine pentaacetic acid. The patient underwent an endonasal trans-sphenoidal approach. Complete microsurgical excision and complete preservation of the normal pituitary gland was achieved, with normal prolactin level. The histopathology showed that the lesion was a choroid plexus papilloma. Theories of the origin, the differential diagnosis, and treatment of the rare tumor are discussed.

Assessment of bilateral inferior petrosal sinus sampling in the diagnosis and surgical treatment of the ACTH-dependent Cushing's syndrome: a comparison with other tests.

BACKGROUND: Bilateral inferior petrosal sinus sampling (BIPSS), currently, is the gold standard test for the differential diagnosis of Cushing's syndrome (CS), but few data are available on the efficacy and accuracy of BIPSS in the qualitative diagnosis of ACTH-dependent CS and lateralization of Cushing's disease (CD); especially, the evaluation of BIPSS in all CD patients with transsphenoidal surgery (TSS). As a result, we investigated whether such invasive test compared other noninvasive tests may affect the efficacy and accuracy of diagnosis and TSS treatment in ACTH-dependent CS. OBJECTIVE: We investigated the efficacy and lateralized accuracy of diagnostic and therapeutic of BIPSS in ACTH-dependent CS. SETTINGS: A retrospective analysis was conducted at a single care center in Ruijin Hospital, Shanghai City. PARTICIPANTS: CD was confirmed by histopathology in one hundred and nineteen patients, include sixty-four patients with BIPSS procedure; and ectopic ACTH syndrome (EAS) also was histological confirmed in five patients. MAIN INTERVENTIONS AND OUTCOMES: Sixty-nine patients were all administrated with BIPSS test. Additionally, other noninvasive tests included endocrine examinations, low and high dose dexamethasone suppression test (LDDST and HDDST); imagine examinations include magnetic resonance imaging (MRI) and positron emission tomography and computerized tomography (PET-CT).Gradients of inferior petrosal sinus (IPS) to peripheral (IPS/P) ACTH were calculated before and after BIPSS procedure completed five minutes. RESULTS: In patients with proven pituitary cases, stringent response criteria in MRI and HDDST testing were fully by 51.6% and 60.3% respectively. While BIPSS, gave direct evidence of CD in 90.6% of these cases. The sensitivity for a basal IPS/P gradient greater than 2 was 89.1%, with 100% specificity and a diagnostic accuracy of 87.5%. A subgroup of 14 patients (all were CD) had contradictory responses to routine test with HDDST; while the sensitivity, specificity and accuracy of BIPSS were 100% respectively. Compared with the MRI and DST, we accepted Receiver Operating Characteristic (ROC) curve analysis showed that BIPSS performance is the best efficacy diagnosis tool in CS. In total, 57 of 64 patients with CD had an IPS/P gradient greater than 2, resulting in the sensitivity, specificity and diagnostic accuracy are 90.5%, 100%, 95.2% respectively. Additionally, the accuracy value of BIPSS in indicating dominant side should also be stressed in adenoma lateralization of CD. Finally, BIPSS test contributed most in the remission efficacy of TSS; then remission rate of underwent BIPSS group is 92.2% compared to the rate of 80% in without BIPSS group (p<0.01), Compared with other noninvasive tests, turn out the highest accuracy rate in remission. CONCLUSIONS: The application of BIPSS is associated with efficacy and accuracy of ACTH-dependent CS and lateralization of CD, what's more, all above, we can conclude that BIPSS is associated with the surgical therapy in CD patients. Therefore, BIPSS dedicate to the diagnosis, treatment and intraoperation administration of ACTH-dependent CS.

Comparisons of 2/3Sh estimation technique to computer-assisted planimetric analysis in epidural, subdural and intracerebral hematomas.

OBJECTIVE: The formula 1/2abc was suitable for the estimation of the epidural, acute subdural, most intracerebral and even some chronic subdural hematoma volume, but its accuracy was prone to be affected by some particular shapes of hematomas. In this study, we aimed to validate a more accurate method for the estimation of the epidural, subdural and intracerebral hematoma volume. METHODS: In the present study, hematomas were categorized into the epidural, subdural and intracerebral groups, and every hematoma in three subgroups was respectively estimated with the following methods, including the computer-assisted planimetric analysis (gold standard), 2/3Sh, 1/2abc, 1/3abc and Tada's formula. Moreover, the percentage deviation of the estimated hematoma volume by every method in comparison with gold standard was assessed respectively. RESULTS: Compared with gold standard (39.59 ± 24.47 ml), the formula 2/3Sh (40.55 ± 26.58 ml, P > 0.05) overestimated the epidural hematoma volume by nearly 1% (0.01 ± 0.09, P > 0.05); similarly, the formula 2/3Sh (70.56 ± 49.06 ml, P > 0.05) in comparison with gold standard (69.98 ± 45.99 ml) overestimated the subdural hematoma volume by nearly <1% (-0.00 ± 0.13, P > 0.05). In addition, the intracerebral hematoma volume assessed by the formula 2/3Sh in contrast with gold standard (33.33 ± 33.19 ml) was 33.88 ± 34.39 ml (P > 0.05) with an only 2% (-0.02 ± 0.15, P > 0.05) underestimation. DISCUSSION: The formula 2/3Sh in contrast with other methods was a precise, simple, convenient estimation method, which was suitable for the epidural, subdural and intracerebral hematoma volume.

A precise, simple, convenient and new method for estimation of intracranial hematoma volume--the formula 2/3Sh.

OBJECTIVES: The formula 1/2abc was a relatively reliable technique for the estimation of mostly intracranial hematoma volume, but its accuracy was prone to be affected by some particular shapes of hematoma, such as multinodular, separated and so on. In this work, we aimed to validate a more accurate method for the estimation of intracranial hematoma volume, which were free limitations of axial slices shapes. METHODS: We investigated the computed tomography (CT) scans of 186 patients with intracranial hematoma. The volume values of 186 intracranial hematomas were respectively assessed using five different methods. RESULTS: For the formula 2/3Sh, the excellent correlation coefficient obtained using Pearson and Spearman's coefficients were 0.990 and 0.990, respectively. Meanwhile, the estimated intracranial hematoma volume using the formula 2/3Sh was fairly precise, with a <1% (-0.00+/-0.14, p>0.05) underestimation. However, the intracranial hematoma volume values were estimated by the formulas 1/2abc, Tada and 1/3abc, in comparison with the gold standard (43.16+/-37.55 ml), were 45.98+/-39.97 ml (p>0.05) with a 5% (0.05+/-0.25, p<0.05) overestimation, 48.12+/-41.84 ml (p>0.05) with 10% (0.10+/-0.26, p<0.05) overestimation and 30.65+/-26.65 ml (p<0.05) with a nearly 29% (-0.29+/-0.16, p<0.05) underestimation, respectively. DISCUSSIONS: Owing to the area, length and width of the largest axial hematoma slice clearly marked in CT imaging, the formula 2/3Sh in comparison with other methods was a precise, simple and convenient estimation technique.

Intramedullary cavernous malformations: clinical features and surgical technique via hemilaminectomy.

OBJECTIVE: The purpose of this study was to define the clinical features and the surgical technique of unilateral hemilaminectomy for treating intramedullary cavernous malformations. MATERIALS AND METHODS: Retrospective chart was performed in 16 patients with histologically diagnosed intramedullary cavernous malformations. All patients were treated with unilateral hemilaminectomy and microsurgical resection of the malformations. The pre- and postoperative neurological state was evaluated using Frankel scale. RESULTS: There were nine females and seven males (mean age 38 years) harbouring symptomatic intramedullary cavernous malformations. The annual retrospective haemorrhage rate was 3.1% per patient/year. All cavernous malformations were completely resected. Twelve of 16 patients experienced the improvement of the neurological state and in four patients, clinical features remained unchanged during the follow-up period. Static and dynamic plain radiograph film showed none of them had spinal deformity or spinal instability. CONCLUSION: According to the defined bleeding risk, symptomatic and MRI-morphologically growing intramedullary cavernous malformations should be totally surgically removed, to avoid the recurrence and rebleeding of the residue. A least traumatic myelotomy, as well as a meticulous microsurgical technique and the intraoperative somatosensory evoked potentials monitoring, together with selection of a minimally invasive microsurgical approach (hemilaminectomy), leads to a favourable outcome and prevents additional morbidity.

Surgical Management of PICA Aneurysm and Incidental Facial Nerve Schwannoma: Case Report.

We report a patient with a posterior inferior cerebellar artery (PICA) aneurysm and an incidental facial nerve schwannoma at the cerebellopontine angle (CPA). A 46-year-old woman presented with the sudden onset of a severe headache, nausea, and vomiting. She had no other abnormal neurological symptoms and signs. Computed tomography (CT) showed hemorrhage in the fourth ventricle. Cerebral angiography demonstrated an aneurysm arising from the tonsillomedullary segment of the left PICA. A facial nerve schwannoma was incidentally found as the aneurysm was being clipped. The aneurysm was clipped via a left transcondylar approach. Subsequently, the schwannoma (2 x 3 x 2 mm) was resected from the facial nerve fascicles, and the facial nerve was preserved. Postoperatively, the patient developed mild to moderate dysfunction of the facial nerve (House-Brackmann grade III [H-B III]) but her hearing was intact. Both a facial nerve schwannoma involving the CPA and an aneurysm involving the PICA can be managed through the transcondylar approach. An asymptomatic facial nerve schwannoma can be resected safely with minimal facial nerve dysfunction.

Delayed hemorrhage following microvascular decompression. Three case reports.

Postoperative hemorrhage is one of the most dangerous complications following microvascular decompression (MVD), and usually occurs within the first 24 hours after MVD operation, whereas delayed hemorrhage is extremely rare. The possible mechanisms of acute and delayed postoperative hemorrhage following MVD seem to be different. Three of 685 patients treated by MVD developed delayed hematoma more than 24 hours after surgery, including two cases at the operative site and one at a remote site. The possible causes of such delayed hemorrhage are discussed. Postoperative monitoring is extremely important after the MVD procedure. If any hemorrhage can be identified at the early stage, valuable time can be won for treatment and better outcome.

[Diagnosis and treatment of jugular foramen neurinomas].

OBJECTIVE: To study the clinical features and treatments of jugular foramen neurinomas. The approximate approach and proper exposure regions of jugular foramen tumour were discussed in this paper. METHODS: Fourteen cases of jugular foramen neurinomas were diagnosed by CT, MRI, DSA and 3D-CT reconstruction preoperatively. The tumours were resected by far lateral infra-temporal approach. The classification and relative operative approaches were discussed. RESULTS: Among 14 patients, total removal were achieved in 8 cases, subtotal removal in 4 cases and partial removal in the other 2 cases. All patients got good recovering. No serious complications correlating the approaches occurred except one case of facial paralysis. CONCLUSION: The far later infratentorial approach was suggested to be more suitable for surgery upon neurinomas of jugular foramen.

Loss of heterozygosity on chromosome 22 in sporadic schwannoma and its relation to the proliferation of tumor cells.

BACKGROUND: Schwannoma is the tumor arising mainly from the cranial and spinal nerves. Bilateral vestibular schwannoma is the hallmark of neurofibromatosis type 2 (NF2). The NF2 gene has been cloned with comprehensive analysis of its mutations in schwannoma. However, most studies focused on vestibular schwannoma. There are differences in proliferation of tumor cell and ultrastructure between vestibular and spinal schwannomas. It is unknown whether genetic alterations in vestibular schwannoma are different from those in non-vestibular schwannoma. We analyzed the loss of heterozygosity (LOH) on chromosome 22 in patients with sporadic schwannoma including vestibular and spinal schwannomas and correlated this genetic alteration with tumor proliferation. METHODS: In 54 unrelated patients without clinical NF1 or NF2, 36 patients had sporadic vestibular schwannoma, and 18 dorsal spinal root schwannoma. Four highly polymorphic linkage to NF2 gene microsatellite DNA markers (D22S264, D22S268, D22S280, CRYB2) were used to analyze LOH. The proliferative index was evaluated by Ki-67 and proliferative cell nuclear antigen (PCNA) immunostaining. Student's t test was used to analyze the difference of the proliferative index between schwannoma with LOH and that without LOH. The difference of the frequency of LOH in vestibular and spinal schwannomas was investigated by the chi-square test. RESULTS: Twenty-three schwannomas (42.6%, 23/54) showed allele loss. The frequency of LOH in vestibular schwannoma was significantly higher than that in spinal schwannoma (chi2 = 5.14, P < 0.05). The proliferative index of schwannoma with LOH was significantly higher than that without LOH (tki-67 = 2.97, P = 0.0045; tPCNA = 2.93, P = 0.0051). CONCLUSIONS: LOH on chromosome 22 is a frequent event in the tumorigenesis of sporadic schwannoma. And, there is a correlation between LOH on chromosome 22 and proliferative activity in schwannoma. The frequency of LOH in vestibular schwannoma is significantly different from that in spinal schwannoma.

Improved capsulotomy for refractory Tourette's syndrome.

The effects of bilateral anterior capsulotomy were analyzed in 12 patients with Tourette's syndrome (TS). All of the patients underwent bilateral anterior capsulotomy. In 7 patients, the target was the anterior one third of the anterior limb of the capsula interna, while in 5 patients, the posterior one third of this structure was targeted. Radiofrequency thermolesions were created at 80 degrees C for 60 s. These surgeries resulted in a reduction in TS symptoms (motor and vocal tics and/or obsessive-compulsive behavior) of >50% in all patients, regardless of the target. A comparison of the two lesion sites suggests that patients with lesions of the posterior one third of the anterior limb have a greater reduction in TS symptoms (>80%) than patients receiving lesions of the anterior one third of the anterior limb (>50%). No severe, permanent side effects were observed in any patient.