High-resolution MRI vessel wall enhancement in moyamoya disease: risk factors and clinical outcomes.

OBJECTIVES: Intracranial vessel wall enhancement (VWE) on high-resolution magnetic resonance imaging (HRMRI) is associated with the progression and poor prognosis of moyamoya disease (MMD). This study assessed potential risk factors for VWE in MMD. METHODS: We evaluated MMD patients using HRMRI and traditional angiography examinations. The participants were divided into VWE and non-VWE groups based on HRMRI. Logistic regression was performed to compare the risk factors for VWE in MMD. The incidence of cerebrovascular events of the different subgroups according to risk factors was compared using Kaplan-Meier survival and Cox regression. RESULTS: We included 283 MMD patients, 84 of whom had VWE on HRMRI. The VWE group had higher modified Rankin Scale scores at admission (p = 0.014) and a higher incidence of ischaemia and haemorrhage (p = 0.002) than did the non-VWE group. Risk factors for VWE included the ring finger protein 213 (RNF213) p.R4810K variant (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.08-3.76, p = 0.028), hyperhomocysteinaemia (HHcy) (OR 5.08, 95% CI 2.34-11.05, p < 0.001), and smoking history (OR 3.49, 95% CI 1.08-11.31, p = 0.037). During the follow-up of 63.9 ± 13.2 months (median 65 months), 18 recurrent stroke events occurred. Cox regression showed that VWE and the RNF213 p.R4810K variant were risk factors for stroke. CONCLUSION: The RNF213 p.R4810K variant is strongly associated with VWE and poor prognosis in MMD. HHcy and smoking are independent risk factors for VWE. CLINICAL RELEVANCE STATEMENT: Vessel wall enhancement in moyamoya disease is closely associated with poor prognosis, especially related to the ring finger protein 213 p.R4810K variant, hyperhomocysteinaemia, and smoking, providing crucial risk assessment information for the clinic. KEY POINTS: • The baseline presence of vessel wall enhancement is significantly associated with poor prognosis in moyamoya disease. • The ring finger protein 213 p.R4810K variant is strongly associated with vessel wall enhancement and poor prognosis in moyamoya disease. • Hyperhomocysteinaemia and smoking are independent risk factors for vessel wall enhancement in moyamoya disease.

Intraoperative Computed Tomography (CT) for Treating Giant Carotid Intracavernous Aneurysms.

BACKGROUND Giant carotid intracavernous aneurysm refers to those lesions larger than 2.5 cm and derived from a cavernous segment, accounting for about 30% of all intracranial tumors. Dynamic CT perfusion imaging (PCT) is a common method recently employed to evaluate cerebral perfusion. This study investigated the efficacy and clinical application of intraoperative CT in the surgery for giant symptomatic carotid intracavernous aneurysm. MATERIAL AND METHODS A retrospective analysis was performed on 23 cases with giant symptomatic carotid intracavernous aneurysm. BTO testing was performed before surgery. Differential treatments were performed based on the condition of aneurysm, and some patients received intraoperative PCT. Postoperative anti-coagulation was given with DSA or CTA follow-up examinations at 3-6 months, 1 year, and 2 years after surgery. RESULTS A total of 17 patients received aneurysm isolation coupled with high-flow bypass surgery. Among those, 9 developed early-onset neurological function after surgery, with gradual recover within 6 months. One coma patient died 25 months after discharge. One patient had aneurysm isolation with clapping of anterior communicating artery, and the other 5 cases received artery clapping only. In those patients, 4 had improvement at early phase, while 1 patient had numbness of the oculomotor nerve. Six patients received surgery in the CT room, including 5 cases with single proximal ligation of the internal carotid artery plus 1 aneurysm isolation combined with high-flow bypass surgery. CONCLUSIONS Intraoperative PCT can provide objective evidence and effective evaluation of cerebral perfusion.

Surgical management of recurrent aneurysms after coiling treatment.

OBJECTIVE: Aneurysms that recur after coiling treatment are difficult to manage. The microsurgical technique in these cases differs significantly from that in regular aneurysm clipping. We present our experience in surgical management of aneurysms that recurred more than 1 month after coiling in a series of 19 patients. MATERIALS AND METHODS: Between January 2004 and December 2014, 1437 patients were treated surgically for intracranial aneurysms in our institution. We performed a retrospective review of the clinical records, operation videos, and cerebral angiograms. We focused on patients in whom the initial aneurysm was treated by coiling, but the results were incomplete or the aneurysm recurred. RESULTS: Nineteen patients underwent surgical clipping for recurrent aneurysm more than 1 month after initial coiling treatment. The sex ratio (male:female) was 0.9, and the average age was 51.3 years (range 35-72 years). One aneurysm was classified as giant (≥ 25 mm), two as large (10-25 mm), and 18 as small (≤ 10 mm). A good outcome (Glasgow Outcome Scale 4 or 5) was observed in 16 of 19 patients (84.2%). CONCLUSION: Microsurgical clipping can be safe and effective in the management of previously coiled residual and recurrent aneurysms.

The Management of Symptomatic Cerebral Developmental Venous Anomalies: A Clinical Experience of 43 Cases.

BACKGROUND Developmental venous anomalies (DVAs) are rare vascular diseases becoming more frequently diagnosed. Most patients with DVAs have no clinical symptoms with the exception of a few patients with epilepsy, intracranial hemorrhage, or neuro-function deficit. There is still controversy with respect to treatment strategies for symptomatic DVAs. MATERIAL AND METHODS Forty-three cases of symptomatic DVAs from January 2006 to October 2015 were retrospectively reviewed and the imaging characteristics of DVAs by CT, MRI, and DSA and the treatment modalities for DVAs were studied. RESULTS Typical imaging characteristics of symptomatic DVAs were wedge or umbrella-shaped collections of dilated medullary veins converging in an enlarged subependymal or transcortical collecting vein, draining to the superficial or deep vein system. Based on location and draining vein features, symptomatic DVAs were tentatively classified into six different subtypes. Of the 43 cases, 19 were treated by surgical methods and 24 were treated conservatively. CONCLUSIONS We concluded that the rate of accompanying abnormalities in cases of symptomatic DVAs was high. Intracerebral hemorrhage was usually attributed to associated CMs or AVMs. The associated lesions and the branches responsible for bleeding could be resected while preserving the collecting vein as far as possible.

Intraoperative Perfusion Computed Tomography in Carotid Endarterectomy: Initial Experience in 16 Cases.

BACKGROUND This study aimed to evaluate the changes in perfusion computed tomography (PCT) parameters in carotid endarterectomy (CEA), and to discuss the use of intraoperative PCT in CEA. MATERIAL AND METHODS Sixteen patients with carotid stenosis who also underwent CEA with intraoperative CT were recruited in this study. We calculated quantitative data on cerebral blood flow (CBF), cerebral blood volume (CBV), time to peak (TTP), and the relative parameter values, including relative CBF (rCBF), relative CBV (rCBV), and relative TTP (rTTP). The role of PCT was assessed and compared to conventional monitoring methods. RESULTS There were no significant differences in any of the parameters in the anterior cerebral artery (ACA) territory (P>0.05). In the middle cerebral artery (MCA) territory, the CBF and CBV increased and TTP decreased in the operated side during CEA; the rCBF and rCBV increased and the rTTP decreased significantly (P<0.05). In 16 patients, CT parameters were improved, SSEP was normal, and MDU was abnormal. In 3 patients, CBF increased by more than 70% during CEA. Relative PCT parameters are sensitive indicators for detecting early cerebral hemodynamic changes during CEA. Cerebral hemodynamics changed significantly in the MCA territory during CEA. CONCLUSIONS Intraoperative PCT could be an important adjuvant monitoring method in CEA.

Microsurgical management of posterior cerebral artery aneurysms: A report of thirty cases in modern era.

OBJECTIVE: We reviewed a series of 30 cases of posterior cerebral artery (PCA) aneurysms to examine the outcomes of microsurgical techniques, which is an important alternative to endovascular interventions in localities where access to the latter renders practical difficulty. We also aimed to introduce the initial experience about the clinical application of intraoperative computed tomography (CT) in treatment of PCA aneurysm. METHODS: Thirty patients with PCA aneurysm treated using microsurgery in our department between January 1996 and July 2014 were reviewed retrospectively. RESULTS: The case series included 13 females and 17 males with a mean age of 44 years, ranging from 8 to 78 years. Eighteen aneurysms were ruptured, five aneurysms caused a direct mass effect, and the remaining seven aneurysms were found incidentally. Most aneurysms were located in the P1 segment or the P1-P2 junction of the PCA (63%). Eighteen aneurysms (60%) were large or giant in size (≥ 10 mm). Seventeen aneurysms were directly clipped, six trapped, one wrapped, one electrocoagulated and resected, and five trapped or proximal clipped with a bypass. Intraoperative perfusion CT (PCT) and CT angiography (CTA) were applied to provide immediate information regarding cerebral hemodynamics and anatomy of vessels in six patients. Twenty-six patients (87%) showed good clinical outcomes according to the modified Rankin Scale score (≤ 2) at the mean clinical follow-up period of 34 (range: 1-78) months, including the patients using intraoperative CT, and one (3%) patient was dead. CONCLUSION: Microsurgical therapy for patients with PCA aneurysms can have a positive outcome with correctly selected techniques. Personalized microsurgical treatment paradigms are determined by the anatomical location, shape and size of the PCA aneurysm, and the clinical features of the patient. Intraoperative PCT and CTA can improve the efficacy of the surgical treatment.

[Surgical treatment of multiple intracranial aneurysms].

OBJECTIVE: To discuss the surgical strategies and analyze the clinical outcomes of multiple intracranial aneurysms (MIA). METHODS: The clinical data of 49 MIA patients surgically treated between January 2009 and December 2013 was analyzed retrospectively. Among the 49 patients, 12 patients were male and 37 were female, mean age (49 ± 11) years. Thirty-five patients had ruptured aneurysms, and 14 had unruptured aneurysms. Treatment strategies included one-stage operation (MIA were treated in one-stage with an unilateral approach), two-stage treatment (MIA were treated stage by stage) and partial treatment (only ruptured aneurysm was treated). Postoperative CT angiograms (CTA) or digital subtraction angiograms (DSA) were reviewed and the Glasgow Outcome Scale (GOS) scores were evaluated during follow-up period. RESULTS: Thirty-two patients (65.3%) underwent one-stage operation, 9 patients (18.4%) underwent two-stage treatment, and 8 patients (16.3%) underwent partial treatment. Forty-seven patients were followed up 4-49 months, mean (22 ± 7) months. Postoperative CTA or DSA showed no aneurysm recurrence. According to the GOS scores, 41 patients (83.7%) with good outcomes (GOS 4, 5), 6 patients (12.2%) were disabled (GOS 2, 3) and 2 patients (4.1%) were dead (GOS 1). CONCLUSION: Selecting the right patients for surgery and making personalized surgical strategies based on the characteristics of patients and aneurysms could improve the surgical outcomes of MIA.

[Surgical managements of peripheral intracranial aneurysms].

OBJECTIVE: To explore the clinical characteristics and treatment strategies of peripheral intracranial aneurysms. METHODS: A total of 24 patients of peripheral aneurysms from October 2008 to October 2011 were retrospectively analyzed. There were 11 females and 13 males with a mean age of 46 (38-38) years. Of the 24 patients, 11 were female and 13 were male, mean age was 46 years (ranged 38-68). The distributions of the lesions included 12 peripheral anterior cerebral artery (n = 12), aneurysms, 3 peripheral middle cerebral artery (n = 3) aneurysms, 2 peripheral posterior cerebral artery (n = 2) aneurysms, 1 peripheral superior cerebellar artery (n = 1) aneurysm, 2 anterior inferior cerebellar artery (n = 2) aneurysms, 2 posterior inferior cerebellar artery (n = 2) aneurysms, and 2 medial posterior choroidal artery (n = 2) aneurysm. Eight procedures were performed by under neuro-navigation, and another 2 under were performed by intraoperative magnetic resonance imaging (MRI) and navigation. The procedures included Sixteen peripheral aneurysms were simple y clipping (n = 16)ed, 4 were clipping plus reconstruction of ed and parent arteries (n = 4) reconstructed, resection (n = 2) and resection plus reanastomosis 2 were resected, 1 was resected and of parent artery (n = 1) and EC-IC bypass (n = 1) was reanastomosed, and 1 was trapped with EC-IC bypass. RESULTS: At discharge, 20 of them out of the 24 patients had a Glasgow Outcome Scale (GOS) score of 5, and another 4 patients had yielded a score of 4. Two oculomotor nerve palsies occurred postoperatively and , with both improved in during a 3-month follow-ing up period. One patient case had postoperative partial visual field defect. CONCLUSIONS: The Peripheral intracranial aneurysms are a rare in clinical practices kind of entity. Precise intraoperative localization of the lesions is the of key importance for management to the procedure. Different treatment strategies should be taken based on their diverse different characteristics of the aneurysm.

[Diagnostic value of magnetic resonance spectroscopy and intraoperative magnetic resonance imaging in the treatment of brain abscesses].

OBJECTIVE: To evaluate the diagnostic value of magnetic resonance spectroscopy (MRS) and the role of intraoperative magnetic resonance imaging (iMRI) in the treatment of brain abscesses by aspiration and drainage. METHODS: From November 2009 to June 2013, Forty-one brain abscess patients were evaluated. MRS was employed to acquire the metabolic information and assist in the differential diagnosis of brain abscesses showing lactate cytosolic amino acids (AAs) with/without succinate, acetate, alanine and glycine on MRS. Diffusion-weighted imaging (DWI) was also helpful. Eleven single deep-seated abscesses underwent aspiration and drainage with 1.5 T iMRI and neuronavigation system. RESULTS: Forty-one brain abscesses were all diagnosed correctly. Ten single deep-seated abscesses underwent aspiration and drainage with 1.5 T iMRI and neuronavigation system successfully with just one puncture. One deep-seated abscess with thick-walled was punctured thrice before achieving success because of aspirated needle sidesliping. All 11 deep-seated abscess cases were cured and were also confirmed by follow-up. None of them suffered from significant complications, such as intracranial bleeding or new neurological deficit. CONCLUSION: MRS may acquire the metabolic information, confirm the presence of AAs with/without succinate, acetate, alanine and glycine and assist in the differential diagnosis of brain abscesses. iMRI system can help detect aspirated needle sidesliping and correct it in time to improve the cure rate, especially for single deep-seated brain abscess with a thick wall.

[Individualized surgical treatment of complex middle cerebral artery aneurysms].

OBJECTIVE: To summarize individualized surgical treatment strategies for complex middle cerebral artery (MCA) aneurysms. METHODS: Twenty patients with complex MCA aneurysms treated by microsurgery in Chinese People's Liberation Army General Hospital between December 2009 and November 2012 were retrospectively analyzed. There were 12 male and 8 female patients, with a mean age of 43 years (range: 14-58 years). Giant aneurysms (size > 2.5 cm) were found in 6 cases, wide-neck aneurysms in 7 cases and serpentine ones in 3 patients. Important perforators were involved in aneurysm neck in 2 cases. Important branches originated from aneurysms in 6 patients. Two patients harbored recurrent aneurysms after coiling. Individualized surgical strategies were planned according to preoperative imaging. A frontotemporal approach was routinely used. Intraoperative somatosensory evoked potential monitoring, indocyanine green videoangiography and microvascular Doppler ultrasonography were regularly used. A postoperative digital subtraction angiography (DSA) or computed tomography angiography (CTA) was performed to verify the efficacy of treatment and patency of bypass vessels. RESULTS: Of the 20 cases, 7 aneurysms were clipped with clipping and reconstruction of parent artery with multiple clips, 3 M1 segment aneurysms were proximally occluded with extra-intracranial high-flow revascularization, 2 aneurysms were treated with aneurysmectomy with superficial temporal artery to middle cerebral artery low-flow revascularization, 1 aneurysm was treated with aneurysmectomy with superficial temporal artery to middle cerebral artery low-flow revascularization and branch side-to-side anastomosis, 2 aneurysms were treated with aneurysmectomy and re-anastomosis of parent artery, 1 aneurysm was treated with aneurysmectomy and re-anastomosis of parent artery and reinplantation of lenticulostriate artery, 3 bilateral MCA aneurysms were clipped by unilateral approach, and 1 was trapped. Nineteen patients were favorable with Glasgow Outcome Scale score 4-5 at discharge, and 1 patient died of cardiac infarction one week after surgery. The mean clinical follow-up was 20 months (range: 6-39 months). During follow-up, no bleeding occurred. DSA or CTA confirmed absence of aneurysm in 14 cases and residual neck in 2 patients. The other 3 patients were lost to follow-up. CONCLUSIONS: Individualized, multi-modality surgical treatment strategies are effective and safe solution for treatment of complex MCA aneurysms. Revascularization remains imperative surgical technique.

[The clinical diagnosis and treatment of blood-blister-like cerebral aneurysms in supra-clinoid segment of internal carotid artery].

OBJECTIVE: To study the clinical characteristics, surgical principles and treatment options of blood-blister-like cerebral aneurysms in supra-clinoid segment of internal carotid artery. METHODS: Twelve blood-blister-like aneurysms were retrospectively studied including 4 open-surgery cases and 8 endovascular-treated cases from November 2008 to December 2012. Patients comprised 8 female and 4 male patients, whose mean age was 46.6 (range 38-56) years. Eleven patients presented with severe headache as the primary symptom, and 1 patient was found with aneurysm incidentally. Preoperative Hunt-Hess graded 0 in 1 patient, graded I in 5 patients, graded II in 4 patients, and graded III in 2 patients. By DSA examinations, 4 blood-blister-like aneurysms located in anterior wall and 8 in medial-anterior wall of supra-clinoid segment of internal carotid artery. Open surgical treatment included direct clipping, trapping, or wrapping and interventional treatment included stent-assisted coiling or simple stent placement. Intra-operative electroencephalogram and somatosensory evoked potentials monitoring was regularly used. Microvascular Doppler ultrasonography and indocyanine green videoangiography were used to assess blood flow in parent and branch vessels. The patients were followed up at 6 months by CT angiography (CTA) examination in outpatient clinic. RESULTS: For 4 open surgeries, 2 aneurysms were directly clipped, 1 was trapped and 1 was wrapped. The patient underwent trapping paralyzed postoperatively. For endovascular treatment, 6 patients were coiled assisted with stents and 2 patients were treated with simple stent placement. All the patients were followed with a mean follow-up time of 16 months (range, 6-61 months). At 6 months follow-up, 3 out of 4 surgical treated patients had good outcome and 1 was moderately severe disabled by modified Rankin scale; 1 patient underwent wrapping recurred and was transferred to endovascular treatment. Of the 6 patients treated with stent-assisted coiling, 4 patients were recurrent and coil replacements were performed. Two patients with simple stent placement had no recurrences. CONCLUSIONS: Blood-blister-like aneurysm is a special type of complex cerebral aneurysm. Comprehensive understanding of blood-blister-like aneurysm is the key to successful treatment.Open surgery is difficult procedure with high risk and complications while stent-assisted coiling has a high recurrent rate. To date, neither is the safe and effective treatment option.

[The surgery of giant symptomatic cavernous sinus aneurysms].

OBJECTIVE: To evaluate the management and outcomes in patients with giant symptomatic cavernous sinus aneurysms who underwent aneurysms trapping with bypass, proximal carotid occlusion and aneurysms trapping. METHODS: Twenty-three patients with giant symptomatic cavernous sinus aneurysms underwent surgery between February 2007 and March 2013, 3 cases were male and 20 cases were female patients, the age of the patients ranged between 24 and 68 years, mean age was 54.7 years. The pre-operative digital subtraction angiography (DSA) and ballon occlusion test (BOT) were performed to confirm the diagnosis and identify hemodynamic reserve with carotid occlusion, and the aneurysms trapping with bypass, aneurysms trapping and proximal occlusion of the internal carotid artery were performed according to BOT results. During the surgery, the neurophysiological monitoring and the intraoperative CT perfusion were used. The follow-up by DSA or CT angiography were made. RESULTS: Seventeen patients underwent aneurysms trapping with bypass, 1 underwent aneurysms trapping and 5 underwent proximal occlusion of the internal carotid artery. After surgery, symptom improved in 4 cases, did not change in 10 cases, and new neural function deficit developed in 9 cases. The follow-up period were 3 months to 75 months. Two patients were lost. The Glasgow Outcome Scale of last follow-up were 5 in 19 patients, 3 in 1 patient and 1 in 1 patient. CONCLUSIONS: The aneurysms trapping with bypass and proximal occlusion of the internal carotid artery are effective and reliable procedure for treatment of giant symptomatic cavernous sinus aneurysms in selected patients after evaluation of the pre-operative BOT, intra-operative neurophysiological monitoring and the intraoperative CT perfusion.

[Surgical management of intracranial mirror aneurysms].

OBJECTIVE: To study the clinical characteristics and treatment strategies of mirror aneurysms. METHODS: Nineteen patients with 20 pairs of mirror aneurysms from November 2007 to November 2012 were retrospectively analysed. Among the 19 patients, 13 were female and 6 were male, mean age was 56 years (ranged 32-75 years). Distribution of the lesions included 11 bilateral posterior communicating artery aneurysms (one with a pair of anterior choroidal artery aneurysm), 4 bilateral middle cerebral artery aneurysms, 3 bilateral paraclinoidal aneurysms, and 1 bilateral pericallosal-callosomarginal artery aneurysm. Surgical strategies were selected according to location of hemorrhage, Hunt-Hess grade, location and size of aneurysm, etc. RESULTS: Four mirror aneurysms were clipped at one stage, 3 mirror aneurysms were clipped at two stages, 2 were treated with combination of clipping and coiling and remaining 10 were clipped unilaterally. At discharge, 15 out of 19 patients had a Glasgow Outcome Scale score of 5, 4 patients had a score of 4. The mean clinical follow-up was 18.6 months (range 3-50 months). Two patients had oculomotor nerve palsy postoperatively. At 3-month follow-up, 1 improved and 1 unchanged. In 10 patients with unilateral clipping, contralateral aneurysms were unruptured, small ( < 5 mm) and regular. No remnant or recurrence of aneurysm were found in other 9 patients whose bilateral aneurysms had been treated. CONCLUSIONS: The mirror aneurysms are rare kinds of multiple aneurysms. The aneurysm responsible for hemorrhage should be treated with first priority. The contralateral unruptured aneurysm could be observed, clipped or coiled in one stage, or treated in two separate stages.

Clinical study of renal artery cold perfusion combined with laparoscopic nephron retention in the treatment of complex renal angiomyolipoma.

Objective: The aim of this study is to summarize the surgical experience of renal artery cold perfusion combined with laparoscopic nephron preserving surgery for the treatment of complex renal angiomyolipoma and to evaluate the safety and feasibility of this surgical protocol. Materials and methods: Clinical data of nine patients who received renal artery cold perfusion combined with laparoscopic nephron preserving surgery for complex renal angiomyolipoma in our hospital from February 2017 to August 2020 were retrospectively analyzed. The study parameters included imaging findings, total renal function before and after surgery, glomerular filtration rate (GFR) of affected kidney before and after surgery, and related complications. Results: Eight of the nine patients successfully completed the operation, one patient was intolerant to renal artery balloon implantation, and the success rate of the operation was 88.89%. The mean maximum tumor diameter was 6.8 cm, and RENAL score was 7 points. Postoperative total renal function and GFR of the affected kidney had no significant changes compared with that before surgery, and imaging examination showed no tumor residue or recurrence. Conclusion: This surgical procedure is safe and feasible for complex renal angiomyolipoma and can be used as a surgical option for renal hamartoma. The long-term effect needs to be confirmed by further studies.

The surgical strategy and technical nuances of in situ side-to-side bypass for the management of complex intracranial aneurysms.

Background: Despite continuous advances in microsurgical and endovascular techniques, the treatment of complex aneurysms remains challenging. Aneurysms that are dilemmatic for conventional clipping or endovascular coiling often require bypass as part of a strategy to reduce the risk of ischemic complications. In anatomically favorable sites, the intracranial-intracranial in situ bypass may be an appealing choice. This article details the surgical strategies, operative nuances, and clinical outcomes of this technique with a consecutive series in our department. Methods: A retrospective review of a prospectively maintained neurosurgical patient database was performed to identify all patients treated with side-to-side in situ bypass from January 2016 to June 2022. In total, 12 consecutive patients, including 12 aneurysms, were identified and included in the series. The medical records, surgical videos, neuroimaging studies, and follow-up clinic notes were reviewed for every patient. Results: Of the 12 aneurysms, there were 5 middle cerebral artery aneurysms, 4 anterior cerebral artery aneurysms, and 3 posterior inferior cerebellar artery aneurysms. The morphology of the aneurysms was fusiform in 8 patients and saccular in the remaining 4 patients. There were 3 patients presented with subarachnoid hemorrhage. The treatment modality was simple in situ bypass in 8 cases and in situ bypass combined with other modalities in 4 cases. Bypass patency was confirmed in all cases by intraoperative micro-doppler probe and (or) infrared indocyanine green (ICG) video angiography intraoperatively and with digital subtraction angiography (DSA) or computed tomography angiography (CTA) postoperatively. None of the patients developed a clinically manifested stroke due to the procedure though a callosomarginal artery was intentionally removed in one patient. The median follow-up period was 16.2 months (6-36). All patients had achieved improved or unchanged modified Rankin scale scores at the final follow-ups. Conclusion: Cerebral revascularization technique remains an essential skill for the treatment of complex aneurysms. The in situ bypass is one of the most effective techniques to revascularize efferent territory when vital artery sacrifice or occlusion is unavoidable. The configuration of in situ bypass should be carefully tailored to each case, with consideration of variations in anatomy and pathology of the complex aneurysms.

[Microsurgery assisted by intraoperative magnetic resonance imaging and neuronavigation for small lesions in deep brain].

OBJECTIVE: To explore the practicability of resecting small lesions in deep brain by intraoperative magnetic resonance imaging (iMRI) and neuronavigator-assisted microsurgery and its clinical efficacies. METHODS: A total of 42 cases with small lesions in deep brain underwent intraoperative MRI and neuronavigator-assisted microsurgery. The drifting of neuronavigation was corrected by images acquired from intraoperative MR rescanning. RESULTS: All lesions were successfully identified and 40 cases totally removed without mortality. Only 3 cases developed new neurological deficits post-operatively while 2 of them returned to normal neurological functions after a follow-up duration of 3 months to 2 years. CONCLUSION: The application of intraoperative MRI can effectively correct the drifting of neuronavigation and enhance the accuracy of microsurgical neuronavigation for small lesions in deep brain.

Case report: Gemcitabine intravesical hyperthermic infusion combined with tislelizumab in muscle invasive bladder urothelium carcinoma.

Background: Muscle invasive bladder urothelium carcinoma is a common urinary tract tumor. With the deepening of research, more and more treatment methods are applied in clinical practice, extending the life of patients. Among them, the clinical application of chemotherapeutic intravesical hyperthermia and tumor immunotherapy provides new ideas for our treatment. Case report: An 81-year-old female patient was diagnosed with stage T2N0M0 bladder cancer in our hospital. Because the patient and her family were keen to preserve her bladder, they declined surgery and opted for combined chemotherapy. After informed consent from the patient and her family, she received cisplatin combined with gemcitabine intravesical hyperthermic infusion. But the side effects of cisplatin made her intolerable to chemotherapy. With their informed consent we changed her to intravenous tislelizumab in combination with gemcitabine intravesical hyperthermic infusion to continue her treatment. During the subsequent follow-up visits, we found a surprising effect of the treatment. Conclusion: Gemcitabine intravesical hyperthermia therapy combined with intravenous tislelizumab in the treatment of muscle invasive bladder urothelium carcinoma may provide a new possible therapeutic strategy of some patients who are inoperable or refuse surgery.

Revascularization for complex cerebral aneurysms.

BACKGROUND AND PURPOSE: Complex cerebral aneurysms may require indirect treatment with revascularization. This manuscript describes various surgical revascularization techniques together with clinical outcomes. METHODS: Thirty-two consecutive patients with complex cerebral aneurysm were managed from November 2005 to October 2008. Techniques used for revascularization were high-flow bypass, low-flow bypass, branch artery reimplantion, and primary reanastomosis. Physiologic and anatomic monitoring technologies, including electroencephalography, somatosensory evoked potential monitoring, microvascular doppler ultrasonography, and/or indocyanine green videoangiography were used intraoperatively to assess both brain physiology and vascular anatomy. Patient outcome was determined using the Glasgow Outcome Scale at discharge and at a mean of 12 months post operation (range 6-25 months). RESULTS: Two cervical carotid aneurysms (6%) were resected followed by primary reanastomosis, 21 aneurysms (66%) were trapped following saphenous vein high-flow bypasses, five (16%) were clipped after superficial temporal or occipital artery low-flow bypasses, and four (12%) middle cerebral branch arteries were reimplanted. Of the 32 patients at discharge, 29 (91%) had a Glasgow Outcome Scale of four or five, two (6%) had severe disability, and one (3%) died. CONCLUSION: Cerebral revascularization remains an effective and reliable procedure for treatment of complex cerebral aneurysms. Low morbidity and mortality rates reflect the maturity of patient selection and surgical technique in the management of these lesions.

[Extracranial-intracranial revascularization techniques in the treatment of complex aneurysms and prevention and management of occlusion of bypass vessels].

OBJECTIVES: To study the revascularization techniques in the treatment of intracranial complex aneurysms and occlusive reasons of bypass vessel. METHODS: The 20 complex intracranial aneurysms who underwent saphenous bypass treatment from November 2006 to November 2008 were retrospectively analyzed and the occlusive reasons were studied. Of the 20 patients, 12 were female and 8 were male, mean age was 54.5 years (ranged 27 - 65 years). The distribution of the lesions included 13 cavernous sinus aneurysms, 4 para-clinoid aneurysms, 2 supraclinoid aneurysms, and 1 basilar trunk aneurysm. Four aneurysms were giant (diameter > 25 mm), 12 aneurysms were large (15 - 25 mm), and 4 aneurysms were medium (10 - 15 mm) size. RESULTS: One saphenous vein was occluded intraoperatively and one saphenous vein was occluded postoperatively. At discharge, 18 out of the 20 patients had Glasgow Outcome Scale (GOS) score of 4 or 5, 2 patients had score of 3, and 1 patient had score of 1. At 6 months follow up, 18 of 19 survivors had GOS score of 4 or 5 and 1 patient had score of 3. CONCLUSIONS: Extracranial-intracranial revascularization technique is a safe and effective method in the treatment of complex aneurysms. Mechanical and hemodynamic factors are two leading reasons for occlusion of bypass vessels. Long-term bypass vessels patent rate still needs further observation.

Independent syntactic representation identified in left front-temporal cortex during Chinese sentence comprehension.

It has been well established that syntactic representation is independent of semantic representation in Indo-European languages, but it is unclear whether this is the case in Chinese. The present functional magnetic resonance imaging (fMRI) study adopted a syntactic priming paradigm to investigate the neural basis of Chinese syntactic representation. A passive sentence was preceded by either a passive or an active sentence without repeating a verb or a pattern of agent-patient animacy, thus constructing primed and unprimed sentence pairs based on sentence structure. The fMRI data were collected from 22 native Chinese speakers while they were reading the sentences. Priming-related activation suppression was found in the left temporal pole, left inferior frontal gyrus and left precentral gyrus. The results are the strongest neuroimaging evidence to date that syntactic representation is independent of semantic representation in Chinese, in line with Indo-European languages.