Efficacy of microsurgical management and gamma knife radiosurgery on brain stem cavernous malformations / 中华神经医学杂志

Objective To explore the efficacy ofmicrosurgery and gamma knife treatment on brainstem cavernous malformations.Methods Retrospective analysis was performed on the clinical data of 15 patients with brainstem cavernous malformations treated by microsurgery and 22 patients by gamma knife in our hospital from January 2002 to December 2011.The clinical symptom improvement,scores of Glasgow Outcome Scale,scores of Karnofsky Performance Scale and scores of National Institutes of Health Stroke Scale before and after treatment were observed and compared between the two groups.Results Patients in the micro-surgery group enjoyed the following results:one patient with pontine lesion had residual postoperation; no re-bleeding or death was noted; two had irreversible neurological dysfunction; clinical symptoms improved in 11 patients (73.3％); the postoperative scores of Glasgow Outcome Scale and Karnofsky Performance Scale increased 0.20 and 6.6 as compared with the preoperative ones; The postoperative scores of National Institutes of Health Stroke Scale decreased 1.20 as compared with the preoperative ones.Patients in Gamma Knife group enjoyed the following results:the lesions of two patients increased due to re-bleeding; three had perifocal brain edema; no death was noted;the clinical symptoms improved in 9 patients (40.9％); the postoperative scores of Glasgow Outcome Scale and Karnofsky Performance Scale increased 0.05 and 1.82 as compared with the preoperative ones; the postoperative scores of National Institutes of Health Stroke Scale decreased 0.82 as compared with the preoperative ones.Conclusion Micro-surgery may be more effective than Gamma Knife in treating brainstem cavernous malformations; however,patients with non-surgical conditions or refusing surgery could choose Gamma Knife treatment; gamma knife treatment should be cautiously chosen.

Brain mappings in non-fluent late Chinese-English bilinguals / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the distribution characteristics of language areas in Chinese-English non-fluent late bilinguals.</p><p><b>METHODS</b>Six Chinese-English bilinguals with eloquent tumors underwent awake-surgeries. The activated areas of BOLD-fMRI were obtained as the patients performed pure naming, verb generation, and abstract/concrete judgment tasks. Direct cortical stimulation(DCS) as the golden standard of language mapping were performed during awake-surgeries on the exposed cortical areas. BOLD-fMRI results of 3 language tasks were compared with DCS results. The statistical method was McNemer.</p><p><b>RESULTS</b>Sixteen positive sites(22.5%) were comfirmed out of 71 stimulations. There were 3 specific language sites, in which 2 sites were specific English sites and 1 site was specific Chinese site. When activated areas of BOLD-fMRI were compared with the DCS results, verb generation task had the highest concordance rate 40.9% (95%CI:30.2%-52.5%) . There were significant differences between the results of BOLD-fMRI and DCS of all 3 bilingual tasks(P < 0.017).</p><p><b>CONCLUSIONS</b>There are specific language areas in Chinese-English non-fluent late bilinguals. The BOLD-fMRI language mapping could not substitute DCS in the context of mapping language areas in bilinguals.</p>

Three core techniques in surgery of neuroepithelial tumors in eloquent areas: awake anaesthesia, intraoperative direct electrical stimulation and ultrasonography / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The goal of surgery in the treatment of intrinsic cerebral tumors is to resect the maximum tumor volume, and to spare the eloquent areas. However, it is difficult to discover the eloquent areas intraoperatively due to individual anatomo-functional variability both for sensori-motor and language functions. Consequently, the surgery of intrinsic cerebral tumors frequently results in poor extent of resection or permanent postoperative deficits, or both, and remains a difficult problem for neurosurgeons.</p><p><b>METHODS</b>From January 2003 to January 2010, 112 patients with neuroepithelial tumors in/close to the eloquent areas were operated on under awake anesthesia with the intraoperative direct electrical stimulation for functional mapping of the eloquent areas. The extent of the tumors was verified by intraoperative ultrasonography. The maximal resection of the tumors and minimal damage of the eloquent areas were the surgical goal of all patients.</p><p><b>RESULTS</b>Totally 356 cortical sites in 99 patients were detected for motor response by intraoperative direct electrical stimulation, 50 sites in 16 patients for sensory, 72 sites in 48 patients for language. Sixty-six patients (58.9%) achieved total resection, 34 (30.4%) subtotal and 12 (10.7%) partial. Fifty-eight patients (51.8%) had no postoperative deficit, while 37 patients (33.0%) had transitory postoperative paralysis, 26 patients (23.2%) with transitory postoperative language disturbance and 3 patients (2.7%) with permanent neurological deficits. No patient complained of pain recollection following operation.</p><p><b>CONCLUSIONS</b>Awake anesthesia, intraoperative direct electrical stimulation and ultrasonography are three core techniques for the resection of intrinsic cerebral tumors near the eloquent areas. This new concept allows an improvement in the quality of surgery for neuroepithelial tumors in/adjacent to eloquent areas.</p>

Expressions of microtubule-associated protein 1 light chain 3B and autophagy-related gene Beclin 1 and their clinical significance in astrocytic tumors / 中华神经医学杂志

Objective To investigate the expressions of microtubule -associated protein 1 (MAP1) light chain 3B (LC3B) and autophagy-related gene Beclin1 in astrocytic tumors, and explore their correlations with the pathological features and clinical manifestations of astrocytic tumors to further reveal their roles in tumorigenesis and development of astrocytic tumors. Methods Sixty-two specimens with different-grade astrocytic tumors, including 4 with grade Ⅰ (pilocytic astrocytoma), 23 with grade Ⅱ (astrocytoma), 12 with grade Ⅲ (anaplastic astrocytoma) and 23 with grade Ⅳ (glioblastoma multiforme), were selected in our study. Immunohistochemistry was employed to detect the expression of Beclin1; the expressions of MAP 1-LC3B and Beclin1 were detected by Western blotting.The correlations between expressions of MAP 1-LC3B and Beclin 1 and both the pathological features and clinical manifestations of astrocytic tumors were analyzed. Results Immunohistochemistry showed decreased Beclin1 expression in the astrocytic tumors following the increase of tumor grades (P＜0.05).Western blotting indicated that the expressions of Beclin1 in tumors with different grades and these patients with different life cycles were significantly different (P＜0.05) and the average optical density ratio of Beclin1 in high-grade astrocytic tumors (grade Ⅲ/Ⅳ) was obviously lower than that in low-grade astrocytic tumors (grade Ⅰ/Ⅱ, P＜0.05). The expressions of LC3B-Ⅰ showed significant differences in different-grade astrocytic tumors, and the expression of LC3B-Ⅰ of grade Ⅳ tumor was statistically lower than that of grade Ⅰ, Ⅱ and Ⅲ tumors(P＜0.05). The expressions of LC3B-Ⅱ and Beclin 1 were negatively correlated to the pathological grade of the tumors (r=-0.334, P=0.007; r=-0.448, P=0.000), but positively correlated to the survival time(r=0.285, P=0.027; r=0.359, P=0.005). The expressions of LC3B-Ⅱ and Beclin 1 had a positive correlation (r=0.272, P=0.035). Conclusion Expressions of LC3B-Ⅱ and Beclin1 are down-regulated in glioblastoma multiforme; the decrease of autophagic capacity may relate to the tumorigenesis and development of astrocytic tumors.

Surgical strategy of a Chinese-English-French multilingual patient with tumor in eloquent area / 中华神经医学杂志

Objective To explore the localization of brain functional area in a Chinese-English-French multilingual patient with low-grade glioma and study the surgical method of low-grade glioma in the eloquent area using awake craniotomy and direct cortical electrical stimulation. Methods A cerebral operation was performed in a Chinese multilingual patient with low-grade glioma in the eloquent region, who spoke Mandarin, English and French. Based on semantic, speech and reading test of Chinese, English and French, functional MRI (fMRI) was conducted to map the Chinese-English-French eloquent cerebral cortex before operation. The patient received microsurgery for tumor resection with monitoring of Chinese, English and French multilingual eloquent areas under awake anesthesia, and the surgical program was guided by cortical-subcortical direct electrical stimulation, with tumor locating by B-mode ultrasound in the operation. Results Chinese, English and French eloquent cerebral cortexes were found by fMRI. All eloquent areas were located in the inferior-anterior region near the tumor, namely the posterior part of left middle-inferior frontal gyrus and superior temperal gyrus. But cortical direct electrical stimulation identified that Chinese eloquent cerebral cortex was not totally coincided with English and French eloquent cerebral cortexes, which were in the unique cortical area in the posterior part of the upper temporal gyrus; these results were different from those of fMRI. Transient supplementary motor area syndrome in the left middle-frontal gyrus was observed by subcortical direct stimulation; subtotal resection of the tumor was achieved. The patient suffered from multilingual motor aphasia of all 3 languages for 3 months. Then his Chinese recovered first, followed by English and French. After 1 year follow-up, the patient went back to his work free of aphasia of all 3 languages and had normal life with free of epilepsy. Conclusion Mapping eloquent areas using fMRI based on multilingual mission and multilingual monitoring under a waking state of the patient makes it possibe to remove the tumor in the multilingual eloquent area. Protection of mother tongue is the precondition of this kind of surgery. Linguistic function may be recovered after the maximal resection of the tumor.

Application of T2 reversed MR image in neurosurgical operations / 中华神经医学杂志

Objective To evaluate and discuss the usage of T2 reversed magnetic resonance (MR) image in neurosurgical operations. Methods T2 MR image was integrated in neuronavigation and then it was reversed. The T2 reversed image was used in image-guided neurosurgical operations in 36 cases to localize central sulcus and precentral gyrus. In 13 cases of a brain functional area tumor, the results of localization of central sulcus by somatosensory evoked potential (SEP) and precentral gyrus hand-knob by direct electrical stimulation (DES) were compared with those of reversed T2 guided navigation. Results The sulcus, gyms, brain surface vein, suture, pacchionian corpuscles, sinus, and brain edema were conspicuous in T2 reversed image. The reversed T2 image-guided navigation results of the central sulcus and the hand-knob were consistent with those of electrical examination completely. Conclusion The T2 reversed image is reliable in localizing sulcus and gyrus. It could substitute for SEP in localizing the central sulcus and provide more image information in neuronavigation.

Changes in metabotropic glutamate receptor 4 expression and the effects of L-2-amino-4-phosphonobutyrate in a rodent model of diffuse brain injury / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To examine the changes in the expression of mGluR4 after diffuse brain injury (DBI) and to determine the role of its specific agonist L-2-amino-4-phosphonobutyrate (L-AP4) in vivo.</p><p><b>METHODS</b>A total of 161 male SD rats were randomized into the following groups. Group A included normal control, sham-operated control and DBI group. DBI was produced according to Marmarou's diffuse head injury model. mRNA expression of mGluR4 was detected by hybridization in situ. Group B included DBI alone, DBI treated with normal saline and DBI treated with L-AP4. All DBI rats were trained in a series of performance tests, following which they were subjected to DBI. At 1 and 12 hours, animals were injected intraventricularly with L-AP4 (100 mmol/L, 10 microl) or normal saline. Motor and cognitive performances were tested at 1, 3, 7, 14 days after injury and the damaged neurons were also detected.</p><p><b>RESULTS</b>There was no significant difference between normal control group and sham-operated group in the expression of mGluR4 (P>0.05). The animals exposed to DBI showed significantly increased expression of mRNA of mGluR4 compared with the sham-operated animals 1 h after injury (P<0.05). At 6 hours, the evolution of neuronal expression of mGluR4 in the trauma alone group was relatively static. Compared with saline-treated control animals, rats treated with L-AP4 showed an effective result of decreased number of damaged neurons and better motor and cognitive performances.</p><p><b>CONCLUSIONS</b>Increased expression of mGluR4 is important in the pathophysiological process of DBI and its specific agonist L-AP4 can provide remarkable neuroprotection against DBI not only at the histopathological level but also in the motor and cognitive performance.</p>