[Evaluation of the single stage treatment of intracranial or extracranial artery stenosis combined with intracranial aneurysm:experience from a single center].

Objective: To investigate the strategy and the clinical effect of single stage treatment for intracranial or extracranial artery stenosis with intracranial aneurysm. Methods: The clinical data of 15 patients with intracranial aneurysms and extracranial or intracranial artery stenosis treated by one-stage endovascular therapy at Department of Neurosurgery of Peking University First Hospital from April 2013 to September 2018 were analyzed,respectively.There were 6 males and 9 females,aged (63.9±9.1)years (range:43 to 79 years).Fifteen arterial stenosis were found, including 8 in anterior circulatiion and 7 in posterior circulation, and the stenosis rates ranged from 75% to 95%. There were 17 aneurysms, among which 11 in the anterior circulation and 6 in the posterior.The maximal diameter was (5.3±1.2)mm (range:3 to 7 mm).All patients were treated with stenting and embolization at one stage. The operation choices, perioperative and postoperative symptoms,imaging data and complications were recorded. Results: Stents were successfully implanted into arterial stenosis of 15 cases, reducing the stenosis rates to less than 30%.Among the 17 aneurysms,10 cases were treated by coil embolization alone,7 cases by stenting and coil embolization. Eventually all the 17 aneurysms reached complete embolization.One patient had mild symptoms of the cerebral infarction during the perioperative period,and the rest had not shown surgical complications.The follow-up time was (43.8±8.2)months (range:24 to 85 months). All the patients underwent digital subtraction angiography 6 to 12 months after operation.Among them,2 cases had asymptomatic in-stent restenosis,and no recurrence was found in aneurysms.Up to the last follow-up,no patients had showed new symptoms or signs of intracranial hemorrhage or ischemic stroke. Conclusions: For patients suffered from both stenosis and aneurysms,individualized treatment should be made based on the location and severity of the vascular stenosis and aneurysms.With careful preoperative evaluation and surgical planning,the single stage endovascular treatment for intracranial or extracranial artery stenosis combined with intracranial aneurysm is safe,feasible and effective for selected patients.

[Evaluation of intravascular therapy for cerebral ischemic tandem stenosis].

Objective: To investigate the efficacy and the safety of intravascular therapy for cerebrovascular ischemic tandem stenosis. Methods: Clinical data of 35 patients with symptomatic anterior circulation and posterior circulation tandem stenosis who received intravascular therapy for two sites of stenosis at the same time at Department of Neurosurgery of Peking University First Hospital from January 2013 to December 2018 were analyzed retrospectively. There were 27 males and 8 females,aged (65.6±9.4)years (range:47 to 81 years).There were 14 cases of anterior circulation tandem stenosis and 21 of posterior circulation tandem stenosis.The medical records were collected with emphasis on postoperative symptoms,imaging manifestations and modified Rankin scale(mRS) scores. Results: Sixty-eight stents were implants in to 35 patients,including 49 extracranial implants and 19 intracranial implants.The surgical success rate was 100%.The perioperative death rate was 0,and 1 patient(1/35,2.9%) had cerebral hemorrhage.All patients were followed up for 18 months.During 3 to 12 months after the intervention,1 case(1/35,2.9%) had stent restenosis,and 4 cases(4/35,11.4%) had persisted symptoms such as dizziness and weakness in limbs.All patients'mRS scores were ≤2. No new stroke occurred. During 12 to 18 months after the intervention,3 cases had in-stent restenosis,increasing the rate to 11.4% (4/35). The mRS scores of 32 patients(32/35,91.4%) were ≤2. Conclusion: Intravascular therapy for patients with symptomatic tandem stenosis is a feasible and safe procedure with good short-term outcomes.

[Exploration on endovascular treatment for symptomatic occlusion of the intracranial vertebral arteries in early non-acute stage].

Objective: To examine the clinical efficacy of endovascular treatment on symptomatic occlusion of intracranial vertebral artery (ICVA) in early non-acute stage. Methods: Nine consecutive patients who presented with aggressive ischemic events in the early non-acute stage of ICVA occlusion from January 2014 to December 2019 and received endovascular treatment at Department of Neurosurgery, Peking University First Hospital were retrospectively reviewed.There were 7 males and 2 females, aged 63.4 years old(range: 52 to 72 years).The average preoperative modified Rankin scale(mRS) was 4.3(range: 4 to 5), the National Institute of Health stroke scale(NIHSS) was 12.3(range: 8 to 18). Among them, 2 patients received a single stage endovascular treatment, and the other 7 patients received staged endovascular treatment.The strategy of staged treatment was as follows: firstly, the occlusion part was passed through by a micro-guidewire and dilated with balloons to maintain the blood flow above Thrombolysis In Cerebral Infarction grade 2b. Then, the intravascular large load thrombus was eliminated by the fibrinolytic system and strengthened antiplatelet drugs. After that, a second stage of angioplasty with stenting was performed on the severe residual stenosis part.The complications and the recanalization rate were collected, and the National NIHSS and mRS after endovascular treatment and in follow-up period were recorded. Results: In the 2 cases received single stage endovascular treatment, although revascularization was achieved lastly, one patient suffered embolus translocation and the other suffered re-occlusion after mechanical thrombectomy during the operation, respectively.Technical success was achieved in 6 of the 7 patients received staged endovascular treatment.On discharge, the average NIHSS scores was 5.7(range: 3 to 4) of the patients. Three months after operation,the average mRS was 1.6(range:0 to 3) and it was 0.9(range: 0 to 2) at the latest follow-up, which were better than preoperative status. Conclusions: Staged endovascular treatment might be a safe, efficient, viable option in carefully selected patients with symptomatic ICVA occlusion in early non-acute stage. It needs to be confirmed by further investigation, preferably in a large controlled setting.

[Microsurgical treatment of paraclinoid aneurysms].

Objective: To explore the microsurgical treatment of paraclinoid aneurysms and evaluate its safety and efficacy. Methods: The data of 21 patients with 22 paraclinoid aneurysms receiving craniotomy between Jan. 2010 and Dec. 2017 in Peking University First Hospital were retrospectively analyzed. According to the Barami K classification, 2 aneurysms were type Ⅰa, 6 type Ⅰb,7 typeⅡ,6 type Ⅲa,1 type Ⅳ. Out of the 17 cases of saccular aneurysms, 16 aneurysms were clipped and one aneurysm was trapped following high-flow EC-IC bypass. Out of the 5 cases of blood blister like aneurysms, 2 aneurysms were wrap-clipped, 2 aneurysms were trapped following high-flow EC-IC bypass and 1 aneurysm was trapped following STA-MCA bypass. The patients were reexamined with CT angiography (CTA) or digital subtraction angiography (DSA) and followed up in outpatient or by phone call. Results: Seventeen patients with 18 paraclinoid aneurysms had received aneurysm clipping. Aneurysmal neck remnant was found in 2 cases, parent artery stenosis was found in 2 cases. In all of the four bypass cases, graft artery patency was confirmed and no recurrence of aneurysm was observed. The obliteration rate of the paraclinoid aneurysm was 91%(20/22). Eight cases with preoperative vision defect had recovered to some extent. New vision defect occurred in two cases. At discharge, 12 patients scored with Glasgow outcome scale 5, 6 patients scored 4, 2 patients scored 3, and one patient scored 1. Conclusion: Microsurgical treatment for paraclinoid aneurysm is a safe and effective method with high aneurysm obliteration rate and low aneurysm recurrence rate, and is thus a reasonable and effective complementary method for endovascular treatment.

[Trigemino-cardiac reflex in skull base surgery].

OBJECTIVE: To explore the mechanism, clinical features, and prognosis of Trigemino-cardiac reflex (TCR) during skull base operations. METHODS: A retrospective analysis was performed on 291 patients with skull base disease from Jan. 2009 to Oct. 2015 in Peking University First Hospital. By reviewing the patients' operative data and anaesthetic electrical record, and we picked out all the patients who suffered from TCR during the operation and analyzed their surgical procedures, clinical features, influence factors, and prognosis. TCR was defined as a drop in mean arterial blood pressure (MABP) and the heart rate (HR) of more than 20% to the baseline values before the stimulus and coinciding with the manipulation of the trigeminal nerve. RESULTS: In all the 291 patients receiving skull base surgery, 9 patients suffering TCR for 19 times during the operation were found. These 9 cases included three acoustice schwannomas, one trigeminal schwannoma, one petroclival meningioma, one epidermoid cyst in cerebellopontine angle, one cavernous sinus cavernous hemangioma, one pituitary adenoma, and one trigeminal neuralgia. The trigger of TCR was related to manipulation, retraction, and stimulation of the trunk or branches of trigeminal nerve. The baseline heart rate was 62-119/min [mean (79.4±14.6) /min] and dropped about 29.0%-66.4% (mean 44.3%) to 22-60 /min [mean (44.2±9.6) /min] after TCR. The baseline mean arterial blood pressure was 75-103 mmHg [mean (87.5±7.8) mmHg] and dropped about 23.4%-47.2% (mean 37.3%) to 45-67 mmHg [mean (54.9±6.3) mmHg] after TCR. During the 19 times of TCR, heart rate and blood pressure could return to baseline in a short time while stopping manipulation (8 times), using atropine (8 times, dose 0.5-1.0 mg, mean 0.69 mg), using ephedrine hydrochloride (one time, 15 mg), using epinephrine (one time, 1 mg), and using dopamine (one time, 2 mg). TCR also could be triggered again by a second stimulation. There was no relative cardiologic complication or neurological deficit in the postoperative 24 hours. CONCLUSION: TCR is a short neural reflex with a drop in blood pressure and heart rate coinciding with the manipulation of the trigeminal nerve in skull base surgery. Correct recognition, intensive observation, and essential management of TCR will lead to a good prognosis.

Treatment of traumatic dislocation of the mandibular condyle into the cranial fossa: development of a probable treatment algorithm.

This study summarizes our experience of treating three rare cases of traumatic superior dislocation of the mandibular condyle into the cranial fossa and provides a potential treatment algorithm. Between the years 2002 and 2012, three patients with traumatic superior dislocation of the mandibular condyle into the cranial fossa were admitted to our department. After evaluating the interval from injury to treatment, the associated facial injuries including neurological complications, and the computed tomography imaging findings, an individualized treatment plan was developed for each patient. One patient underwent closed reduction under general anaesthesia. Two patients underwent open reduction with craniotomy and glenoid fossa reconstruction. All three patients were followed up for 1 year. Mouth opening and occlusal function recovered well, but all patients had mandibular deviation during mouth opening. Closed reduction under general anaesthesia, open surgical reduction with craniotomy, and mandibular condylotomy are the three main treatment methods for traumatic superior dislocation of the mandibular condyle into the cranial fossa. The treatment method should be selected on the basis of the interval from injury to treatment, associated facial injuries including neurological complications, and computed tomography imaging findings.