Spinal cord injury effectively ameliorated by neuroprotective effects of rosmarinic acid.

OBJECTIVE: Pathophysiology of spinal cord injury (SCI) causes primary and secondary effects leading to loss of neuronal function. The aim of the present study was to investigate the role of rosmarinic acid (RA) in protection against SCI. METHODS: The experimental study was carried out in male wistar rats categorized into three groups. Group I - sham operated rats; Group II - SCI; Group III - SCI followed by RA treatment (10 mg/kg). The spinal tissues after treatment schedule were analyzed for oxidative stress status through determination of reactive oxygen species (ROS), lipid peroxidation, protein damage (carbonyl and sulfhydryl contents), and antioxidant enzyme activities. The expression of oxidative stress factors NF-κB and Nrf-2 was determined by Western blot analysis. Further pro-inflammatory cytokines (TNF-α, IL-6, MCP-1, and IL-1ß) were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: The results show that treatment with RA significantly enhances the antioxidant status and decrease the oxidative stress in wistar rats post-SCI. RA effectively ameliorated inflammatory mechanisms by downregulation of NF-κB and pro-inflammatory cytokines post-SCI. CONCLUSION: The study demonstrates for the first time on the role of RA in protecting the spinal cord from injury and demonstrates its neuroprotection in wistar rats.

Posterior C1-C2 screw and rod instrument for reduction and fixation of basilar invagination with atlantoaxial dislocation.

PURPOSE: To report the surgical technique and preliminary clinical results for the treatment of basilar invagination (BI) with atlantoaxial dislocation (AAD) by posterior C1-C2 pedicle screw and rod instrument. METHODS: Between July 2012 and August 2013, 33 patients who had BI with AAD underwent surgery at our institution. Pre and postoperative three-dimensional computed tomographic (CT) scans were performed to assess the degree of dislocation. Magnetic resonance (MR) imaging was used to evaluate the compression of the medulla oblongata. For all patients, reduction of the AAD was conducted by two steps: fastening nuts and rods was performed to achieve the horizontal reduction. Distraction between C1 and C2 screws was performed to obtain the vertical reduction. RESULTS: No neurovascular injury occurred during surgery. Follow-up ranged from 6 to 15 months (mean 10.38 months) in 32 patients. Post-operative three-dimensional CT showed that complete horizontal reduction was obtained in 30/33 (90.9%), and complete vertical reduction was obtained in 31/33 (93.9%). The repeated three-dimensional CT and MR image demonstrated that bony fusion and the decompression of the medulla oblongata were obtained in all patients. Clinical symptoms improved significantly 3 months after surgery. CONCLUSIONS: This C1-C2 pedicle screw and rod instrument is a promising technique for the treatment of BI with AAD.

Operative management of trigeminal neuromas: an analysis of a surgical experience with 55 cases.

BACKGROUND: The trigeminal schwannoma is the second most common intracranial schwannoma. Their proximity to the critical skull base neural and vascular structures increases the complexity of surgical treatment. The aim of this study was to better understand the surgical approaches and the prognosis, as well as to assess the optimum therapeutic schedule. METHODS: This was a retrospective study of 55 patients with trigeminal schwannomas who visited our department between Jan 2007 and Jan 2012. We analyzed the clinical and radiological presentation, tumor characteristics, surgical approaches, the prognosis. RESULTS: The patients were 30 women and 25 men of mean age 36 years (range, 6-66 years) who received postoperative neurological and neuroradiological follow-up. The tumor was located in the middle fossa (type A) in 13 cases, in the posterior fossa (type B) in ten cases, in the middle and posterior fossae (type C) in 21 cases, and in the branches of the trigeminal nerve (type D) in 11 cases. The most common symptom was facial hypesthesia or numbness in 36 patients (65 %) . Total and nearly total tumor resection was achieved in 51 cases (93 %). Three patients (5 %) had worsening of preexisting deficits and there was no perioperative mortality. With an average follow-up period of 35 months, facial hypesthesia persisted in 26 patients (72 %),and improved in ten patients (28 %). Facial pain was relieved in 11 patients (100 %). There has been a recurrence in one case (2 %) and all patients resumed independent and social reintegration. CONCLUSION: This study demonstrates radical surgery with excellent neurological outcomes is the primary treatment of trigeminal schwannomas. Appropriate selection of surgical approach according to tumor types is highly important and necessary. The preoperative facial pain could be relieved, hypesthesia frequently remains or could even be worsened after surgery.

[Individualized treatment of the atlantoaxial dislocation in craniovertebral junction abnormalities].

OBJECTIVES: To analyze the clinical characteristics of the atlantoaxial dislocation (AAD) in craniovertebral junction (CVJ) abnormalities and to study the setup of its surgery strategy. METHODS: From April 2009 to November 2011, 56 patients of AAD and CVJ abnormalities including 22 male and 34 female patients who had received surgery were analyzed. There were 2 cases of reducible AAD and 54 cases of irreducible AAD. The age of the patients ranged from 9 to 56 years (mean 34 years). Among them, 14 cases achieved reduction/partial reduction via direct posterior fixation, 41 cases had transoral anterior deconpression and occipito-cervical/C1-C2 fusion and 1 case had the posterior odontoidectomy and spinal fusion. RESULTS: Fifty-three cases had a follow-up between 6 months and 36 months (mean 20 months) and 3 cases lost follow-up (had improvement at discharge). Seven cases had complications as follows: 1 case had irreversible spinal cord injury and muscle weakness of extremities, 2 cases had cerebrospinal leak, 2 cases had pulmonary infection, 1 case had local granuloma hyperplasia and 1 case had delayed healing of the incision. The later 6 cases all got recovery after reasonable treatments. The grades of Nurick at last follow-up were as follows: 6 cases (11.3%) improved by 3 grades, 30 cases (56.6%) improved by 2 grades, 13 cases (24.5%) improved by 1 grade, 3 cases (5.7%) without change, 1 case (1.9%) get worse. CONCLUSIONS: Reducible AAD could achieve direct reduction and fixation via posterior pathways. Irreducible AAD needs individualized treatment. To choose the direct reduction and fixation or transoral odontoidectomy and posterior fixation and fusion should consider the pathogenetic condition, the image data and personal clinical experience.

[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.

[Trans-extradural approach to resect trigeminal schwannomas involving the cavernous sinus region].

OBJECTIVE: To investigate the techniques and effect of extradural approach for the resection of trigeminal schwannomas involving the cavernous sinus. METHODS: Twenty-three patients (range 26-63 years, mean age 46.2 years) with trigeminal schwannomas involving the cavernous sinus treated by middle fossa extradural approach were retrospectively analyzed. Frontotemporal orbitozygomatic extradural approach was performed in 2 patients. Frontotemporal zygomatic extradural approach was carried out in 21 patients. The first follow-up visit was on the 3rd month after surgery, and if residual was observed on enhanced MRI, then the patient was followed up every 6 months; otherwise, the patient was followed up every 8-12 months. RESULTS: The length of hospital stay after surgery was 7-13 days (mean 8.5 days). Two tumors originated from the ophthalmic branch, 2 from the maxillary branch, 5 from the mandibular branch and 14 from the gasserian ganglion. Total resection was achieved in 21 of the 23 patients (91.3%) and subtotal resection in the other 2 patients. All the patients were followed up from 3 months to 4 years. Median follow-up time was 19 months. The most common symptom was facial hypoesthesia, occurring in 18 patients. This symptom improved in 10 patients and worsened in 8 patients after surgery. New postoperative facial hypoesthesia was observed in 2 patients. Facial pain was observed in 3 patients and subsided after surgery. Two patients had loss of hearing, this symptom improved in 1 patient and worsened in 1 patient after surgery. Diplopia was observed in 6 patients. In 1 of these 6 patients, diplopia resulted from palsy of the oculomotor nerve. In the other 5 patients, diplopia resulted from palsy of the abducens nerve. This symptom improved postoperatively in all these 6 patients. New postoperative atrophy of the temporalis muscle was observed in 3 patients. There was no operation-related mortality. Tumor recurrence was only found in 1 patient after 24 months and was treated by Gamma knife. CONCLUSIONS: The middle fossa extradural approach may be an ideal option for the resection of trigeminal schwannomas involving the cavernous sinus. This approach produces no further impairment, less complication, and is less likely to injured the trigeminal nerve, abducens nerve, trochlear nerve and internal carotid artery.

[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.

[Surgical treatment of large or giant cavernous sinus hemangiomas via epidural approach].

OBJECTIVE: To summarize the curative effect of surgically treated large or giant cavernous sinus hemangiomas (CSH) via epidural approach. METHODS: From June 1999 to June 2011, 19 cases of CSH including 15 female and 4 male patients, ranging from 26 to 70 years (mean 45.3 years) were retrospectively reviewed. Ptosis/ocular motility disorders (10 cases), headache/ophthalmalgia (7 cases), decreased visual acuity (7 cases) and facial hyperesthesia (4 cases) were the most common presenting complaints. The epidural approach was taken and the tumor dissection was performed at the interval between trochlear nerve and ophthalmic nerve and the interval between ophthalmic nerve and maxillary nerve. The curative effect was followed up regularly. RESULTS: Gross total resection was attained in 13 cases, near-total resection in 4 cases, subtotal resection in 1 case and partial resection in 1 case. The follow-up period was between 6-144 months (mean 41.5 months). The results of last follow-up were as follows: among the 10 patients with ptosis/ocular motility disorders, complete remission was achieved in 5, improvement in 2, no change in 2 and lost follow-up in 1. Facial hypoesthesia symptom got complete remission in 2 patients and partial remission in the other 2 patients. The other symptoms mentioned above were all relieved. One patient got complication with impairment of vision and ocular motility disorders. CONCLUSIONS: Combined with skilled skull base techniques, surgical treatment of large or giant CSH via epidural approach is an effective method and the preservation of cranial nerves could be attained to an acceptable level.

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.

[Functional neuro-navigation and intraoperative magnetic resonance imaging for the resection of gliomas involving eloquent language structures].

OBJECTIVES: To explore the clinical value of functional neuro-navigation and high-field-strength intraoperative magnetic resonance imaging (iMRI) for the resection of intracerebral gliomas involving eloquent language structures. METHODS: From April 2009 to April 2010, 48 patients with intracerebral gliomas involving eloquent language structures, were operated with functional neuro-navigation and iMRI. Blood oxygen level dependent functional MRI (BOLD-fMRI) was used to depict both Broca and Wernicke cortex, while diffusion tensor imaging (DTI) based fiber tracking was used to delineate arcuate fasciculus. The reconstructed language structures were integrated into a navigation system, so that intra-operative microscopic-based functional neuro-navigation could be achieved. iMRI was used to update the images for both language structures and residual tumors. All patients were evaluated for language function pre-operatively and post-operatively upon short-term and long-term follow-up. RESULTS: In all patients, functional neuro-navigation and iMRI were successfully achieved. In 38 cases (79.2%), gross total resection was accomplished, while in the rest 10 cases (20.8%), subtotal resection was achieved. Only 1 case (2.1%) developed long-term (more than 3 months) new language function deficits at post-operative follow-up. No peri-operative mortality was recorded. CONCLUSIONS: With functional neuro-navigation and iMRI, the eloquent structures for language can be precisely located, while the resection size can be accurately evaluated intra-operatively. This technique is safe and helpful for preservation of language function.

[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.

[Evaluation of carotid angiography and stenting for patients with contralateral carotid occlusion].

OBJECTIVE: To discuss the efficiency and safety of carotid angioplasty stenting (CAS) in patients with contralateral carotid artery occlusion. METHODS: From January 2001 to January 2010, 56 carotid artery stenosis patients with contralateral carotid artery occlusion were performed CAS and the feature and results of these cases were analyzed retrospectively. All the cases were confirmed to be carotid artery stenosis with contralateral carotid artery occlusion by digital subtraction angiography (DSA). The diameter stenosis rate was 72% ± 15%. CAS were performed with distal protection device in 56 cases. RESULTS: The technique success rate of CAS were 100% in all the 56 patients with contralateral carotid artery occlusion and post-procedure stenosis rate descended to 13% ± 8%, and the symptoms of cerebral ischemia were all improved. Only 1 case occurred remote hemorrhage in the position of previous cerebral infarction in the side of CAS after the procedure, and recovered with light neurological deficit after the craniotomy to remove the hematoma. No ischemic complications or death occurred. During the following up of 6 months to 3 years, no cerebral ischemic symptoms reoccurred. The rechecking results of color Doppler of 47 cases and DSA of 2 cases showed no restenosis in-stent. CONCLUSIONS: CAS is safe and effective for the patients with contralateral carotid artery occlusion. Critical election of the case, operation of skilled doctors and scrupulous post procedure general management can decrease the rate of complication.

[High-field intraoperative magnetic resonance imaging suite with neuronavigation system: implementation and preliminary experience in the pituitary adenoma operation with transsphenoidal approach].

OBJECTIVES: To review the preliminary clinical experience with high-field-strength intraoperative magnetic resonance imaging (iMRI) suite with neuronavigation system in the pituitary adenoma operation with transsphenoidal approach. METHODS: From March 2009 to December 2010, 31 patients [range, 29 - 76 years, mean age (47 ± 11) years]of pituitary adenoma were operated with transsphenoidal approach and intraoperatively with a movable 1.5 T high-field-strength iMRI suite in combination with neuronavigation system. Tumor size was 1.8 - 7.3 cm, mean (3.5 ± 1.2) cm. Twenty-five cases were non-functional pituitary adenoma, 4 cases were prolactin-secreting pituitary adenoma, 2 cases were growth hormone-secreting pituitary adenoma. Thirty patients' resection with transnasal transsphenoidal approach were performed, one patient with transoral transsphenoidal approach was performed. RESULTS: In 12 cases of 30 patients who planed to totally remove tumor, iMRI had revealed residual lesions and resulted in the change of the surgical strategy, 2 invasive cavernous sinus cases no further resection of the tumor because of internal carotid artery encasement, the other 10 cases resected further, eventually. Finally, 8 cases were totally removed. The ratio of total removal tumor was enhanced to 86.7% (26/30) from 60.0% (18/30). There was no perioperative mortality. CONCLUSIONS: High-field-strength iMRI suite with neuronavigation system provides valuable information of tumor resection that allows intraoperative modification of the surgical strategy. It could be very helpful to maximize the resection of the pituitary adenoma and minimize the injury to neurological function.

[Implementation and preliminary experience of high-field intraoperative magnetic resonance imaging in the endoscopic chordoma operation with transsphenoidal or transoral approach].

OBJECTIVE: To review the preliminary clinical experience with high-field-strength intra-operative magnetic resonance imaging (iMRI) in the endoscopic chordoma operation with transsphenoidal or transoral approach. METHODS: From January 2009 to December 2010, 23 patients [range, 29 - 64 years, mean age (42 ± 3) years] of chordoma were operated with endoscopic transsphenoidal or transoral approach and examined intraoperatively with a movable 1.5 T iMRI magnet. Tumor size range was 2.0 - 5.7 cm, mean (3.5 ± 0.8) cm. A navigation system based on iMRI was used in 20 cases. RESULTS: iMRI scan were performed in each operation from 1 time to 5 times. Neuronavigation system were used in 20 operations and the data renewed in 12 cases by the information from iMRI. In 15 of 23 patients, iMRI had revealed residual lesions and resulted in 12 cases further treatment, eventually, 9 tumors were totally removed and 3 tumors were further removed. The ratio of total removal tumor was enhanced to 73.9% (17/23) from 34.8% (8/23). Among 15 cases of partial chordoma removal detected by scanning in operation, 9 were huge chordoma. The residual of huge chordoma detected by scanning in operation was 9/11, and other chordoma contributed to 6/12. There were no iMRI related safety issue or accident recorded in this study. CONCLUSIONS: High-field-strength iMRI provide high-quality images of tumor resection that allows intraoperative modification of the surgical strategy. Combined with the navigation system, iMRI is helpful to maximize the resection of the chordoma and benefit for the safety of endoscopic operation.

[The analysis of intracranial aneurysms undergoing surgical treatment].

OBJECTIVE: To study the surgical principles and treatment options of intracranial aneurysms. METHODS: One hundred and thirty nine patients with intracranial aneurysms were retrospectively studied, including 80 open-surgery cases and 59 endovascular-treated cases from January to December in 2009. Open surgical methods included clipping, trapping or wrapping and interventional methods included simple coiling or stent-assisted coiling. Intra-operative electroencephalogram and somatosensory evoked potentials monitoring were regularly used. Microvascular doppler ultrasonography and indocyanine green videoangiography were used to assess blood flow in parent and branch vessels. RESULTS: Seventy-three aneurysms were directly clipped, 6 were trapped and 1 was wrapped. Thirty-three aneurysms were coiled and 26 were coiled assisted with stents. At discharge, 71 of the 80(88.8%) surgical treated patients had Glasgow Outcome Scale score of 4 or 5 points, 3 points in 6 patients (7.5%), 2 points in 1 patient (1.2%), and 1 point in 2 patients (2.5%). Fifty-four out of 59 cases underwent endovascular treatment scored 4 or 5 points (91.5%) and 3 points in 5 patients (8.5%). CONCLUSIONS: Surgical clipping and endovascular coiling are two major treatment choices for intracranial aneurysms. The treatment option should be individualized based on the patients' specific conditions, which could have a safe, effective and durable outcome.

[Cause and treatment for intracranial hemorrhage during the perioperative period of carotid artery stenting].

OBJECTIVES: To discuss the possible cause of intracranial hemorrhage and treatment after carotid artery stenting (CAS) in patients with carotid artery stenosis. METHODS: From January 2003 to August 2009, 403 patients with carotid artery stenosis that were performed CAS, intracranial hemorrhage occurred in 5 cases after the procedure. We analyzed the feature of these cases and perioperative management retrospectively to summarize the possible cause of intracranial hemorrhage and preventive measure. RESULTS: Cerebral hemorrhage were found 30 min after CAS in 2 cases, 5 days in 2 cases and 3 days in 1 case. One patient was treated conservatively whose hemorrhage was about 2 ml, one was performed draining of ventricle and the other three cases were all performed craniotomy to remove the hematoma and to depress. The position of hemorrhage were all in the side of carotid artery stenosis, and in 2 cases of them the hemorrhage were at the region of previous cerebral infarction. One patient was cured conservatively, the one who was performed draining of ventricle died. Among the other three cases performed craniotomy, one recovered with light neurological deficit and two died of multiple organ failure. CONCLUSION: Intracranial hemorrhage is the most serious complication of CAS of carotid artery, and general measure should be taken to prevent it from occurring.

[Diagnosis and surgical treatment of tight carotid stenosis].

OBJECTIVE: To explore the specialty of diagnosis and surgery of tight carotid stenosis. METHOD: From January 2000 to December 2009, 53 patients with tight carotid stenosis (> 95%) were operated on. All 53 patients had tight carotid stenosis more than 95% on one side in whom 28 had contralateral carotid stenosis or occlusion. The clinical and imaging data as well as surgical outcomes of the patients were retrospectively analyzed. RESULTS: Forty-five patients had postoperatively done well without any complications. There were 3 cases of hemodynamic instability and one case of cardiac ischemia which resolved in one to two days. One patient developed mild hoarseness. One complicated with bacteremia due to deep vein catheter insertion. Two patients experienced brain hemorrhage. None of this series occurred perioperative brain ischemia. CONCLUSIONS: Tight carotid stenosis indicates a need for expeditious carotid endarterectomy with very low rates of brain ischemia. Intraoperative shunting is seldom necessary. Postoperative hyperperfusion syndrome and brain hemorrhage should be worried. Micro-endarterectomy can effectively prevent from restenosis.

[Carotid angioplasty and stenting for stenosis of extracranial carotid artery].

OBJECTIVE: To evaluate the operation method and prevention from complications of extracranial carotid stenosis. METHODS: Three cases of carotid angioplasty and stenting for 271 patients with extracranial carotid stenosis were performed from October 2001 to June 2008. Before the operation, take Clopidogrel for 75 mg/d, Aspirin Delayed-Release Capsules for 100 200 mg/d, Simvastatin for 40 mg 1/night, for 5 - 10 d. Then treat continuous vein infusion Heparin 50 mg/d for 2 d. After the operation, continue antiplatelet and reduce blood fat therapy. RESULTS: All 300 carotid stenting were successfully accomplished. DSA showed that the diameter of stenosed segment of carotid artery was markedly enlarged, and all clinical ischemia signs were improved remarkably. Seven cases suffered from complications in one week after operation and one died. Following up 3 - 24 months in 226 patients, restenosis were found in 5 cases, among which 45 patients were evaluated at follow-up by means of ultrasonic examination for 36 months or so, no restenosis was found. No ischemic attack occurred at follow-up. CONCLUSIONS: The satisfactory effect and safety are achieved in the therapy of carotid stenosis by carotid angioplasty and stenting. Correct intraoperative treatment and skilled techniques are the key points of success.

[The strategy of management for bilateral carotid atherosclerotic stenosis].

OBJECTIVE: To evaluate the indication, time and strategy of surgery for patients with bilateral carotid atherosclerotic stenosis. METHODS: Seventy-four patients with bilateral carotid atherosclecrotic stenosis were admitted to our hospital from February 1987 to December 2007. In 34 patients who presented with unilateral symptoms and underwent ipsilateral carotid endarterectomy (CEA), contralateral CEA or carotid artery stenting (CAS) was performed in 8 because of severe stenosis (> 70%) or unstable plaque. Thirty-eight patients presented with bilateral symptoms. Among them, 15 underwent CEA on both sides, 3 were performed CEA on one side and CAS on the other side, while 20 underwent unilateral CEA only. In 2 asymptomatic patients, CEA was also performed. RESULTS: Ninety-three cases of CEA were performed in 74 patients. Sixty-eight patients were uneventful after operation. Neurological deficits deteriorated in 2 patients. Four patients developed cardiac ischemia, cerebral hemorrhage and hoarseness respectively. Sixty-seven patients were followed-up for 4.9 years. No cerebral ischemia relevant to operated carotid artery developed in 63 patients. CONCLUSIONS: If the indication is obvious, CEA should be performed no matter how contralateral carotid artery is. The strategy of therapy is individual. Whether using shunt depends on intra-operative monitoring.

Surgical management of large and giant intracavernous and paraclinoid aneurysms.

BACKGROUND: Due to their location, large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons. We identified characteristics, surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients. METHODS: The pterional approach was routinely used. The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression. Paraclinoid aneurysms were directly clipped, intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft. Intraoperative electroencephalogram (EEG) and somatosensory evoked potential (SSEP) monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries. Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels. Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms. Postoperative digital subtraction angiography (DSA) was performed in 33 of the 36 patients. RESULTS: Thirty-two paraclinoid aneurysms were directly clipped, 1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascularization. Except for two patients who died in the early postoperative stage, 34 patients' follow-up was 6 - 65 months (mean 10 months) and a Glasgow Outcome Scale score of 4 to 5 at discharge. At the 6-month follow-up examination, Rankin Outcome Scale scores were 0 to 2 in 32 patients. EEG and SSEP monitoring changed in six patients. Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected. Three posterior wall aneurysms were clipped. CONCLUSIONS: Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms. The temporary parent vessel occlusion, retrograde suction decompression, endoaneurysmectomy, parent vessel reconstruction, vascular anastomosis, electrophysiological monitoring, Doppler ultrasonography and endoscopy are essential techniques in the treatment of the large and giant intracavernous and paraclinoid aneurysms.