Minimally invasive surgeries for spontaneous hypertensive intracerebral hemorrhage (MISICH): a multicenter randomized controlled trial.

BACKGROUND: Intracerebral hemorrhage (ICH) is a common stroke type with high morbidity and mortality. There are mainly three surgical methods for treating ICH. Unfortunately, thus far, no specific surgical method has been proven to be the most effective. We carried out this study to investigate whether minimally invasive surgeries with endoscopic surgery or stereotactic aspiration (frameless navigated aspiration) will improve functional outcomes in patients with supratentorial ICH compared with small-bone flap craniotomy. METHODS: In this parallel-group multicenter randomized controlled trial conducted at 16 centers, patients with supratentorial hypertensive ICH were randomized to receive endoscopic surgery, stereotactic aspiration, or craniotomy at a 1:1:1 ratio from July 2016 to June 2022. The follow-up duration was 6 months. Patients were randomized to receive endoscopic evacuation, stereotactic aspiration, or small-bone flap craniotomy. The primary outcome was favorable functional outcome, defined as the proportion of patients who achieved a modified Rankin scale (mRS) score of 0-2 at the 6-month follow-up. RESULTS: A total of 733 patients were randomly allocated to three groups: 243 to the endoscopy group, 247 to the aspiration group, and 243 to the craniotomy group. Finally, 721 patients (239 in the endoscopy group, 246 in the aspiration group, and 236 in the craniotomy group) received treatment and were included in the intention-to-treat analysis. Primary efficacy analysis revealed that 73 of 219 (33.3%) in the endoscopy group, 72 of 220 (32.7%) in the aspiration group, and 47 of 212 (22.2%) in the craniotomy group achieved favorable functional outcome at the 6-month follow-up (P = .017). We got similar results in subgroup analysis of deep hemorrhages, while in lobar hemorrhages the prognostic outcome was similar among three groups. Old age, deep hematoma location, large hematoma volume, low preoperative GCS score, craniotomy, and intracranial infection were associated with greater odds of unfavorable outcomes. The mean hospitalization expenses were ¥92,420 in the endoscopy group, ¥77,351 in the aspiration group, and ¥100,947 in the craniotomy group (P = .000). CONCLUSIONS: Compared with small bone flap craniotomy, endoscopic surgery and stereotactic aspiration improved the long-term outcome of hypertensive ICH, especially deep hemorrhages. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02811614.

Reorganization of the structural connectome during vision recovery in pituitary adenoma patients post-transsphenoidal surgery.

Pituitary adenomas (PAs) can exert pressure on the optic apparatus, leading to visual impairment. A subset of patients may observe a swift improvement in their vision following surgery. Nevertheless, the alterations in the structural connectome during the early postoperative period remain largely unexplored. The research employed probabilistic tractography, graph theoretical analysis, and statistical methods on preoperative and postoperative structural magnetic resonance imaging and diffusion tensor images from 13 PA patients. Postoperative analysis revealed an increase in global and local efficiency, signifying improved network capacity for parallel information transfer and fault tolerance, respectively. Enhanced clustering coefficient and reduced shortest path length were also observed, suggesting a more regular network organization and shortened communication steps within the brain network. Furthermore, alterations in node graphical properties were detected, implying a restructuring of the network's control points, possibly contributing to more efficient visual processing. These findings propose that rapid vision recovery post-surgery may be associated with significant reorganization of the brain's structural connectome, enhancing the efficiency and adaptability of the network, thereby facilitating improved visual processing.

Hyperhomocysteinemia increases the risk of vertebrobasilar dissecting aneurysm among the male Han Chinese population: a retrospective case-control study.

OBJECT: Vertebrobasilar dissecting aneurysms (VBDAs) are known to have a poor natural history with high rates of re-bleeding and mortality. There is a strong relation between hyperhomocysteinemia (HHcy) and cerebrovascular disease; we perform a retrospective study within the male of Chinese Han population to explore the association between HHcy and VBDAs. METHODS: Eighty-eight male patients with VBDA and Eighty-one male control subjects were evaluated for their serum total homocysteine levels. With multiple logistic regression analysis, the association between HHcy and the risk of VBDAs was estimated. Interaction and stratified analyses were conducted according to age, BMI, smoking status, drinking status, and chronic disease histories. The two-piecewise linear regression model examined the threshold effect. RESULTS: The multivariate logistic regression analyses revealed a significant association between HHcy and VBDAs (odds ratio (OR) = 2.62; 95% confidence interval (CI), 1.02-6.71) after adjusting for classical vascular risk factors. The relationship was stable in all subgroup analysis. The interactive role was not found in the association between HHcy and VBDAs for the potential risk factor. CONCLUSIONS: In summary, our study provides evidence that HHcy can increases the risk of VBDAs in the male Han Chinese population. Further researches with appropriate study designs including sex differences and aneurysm types are needed to verify this association.

Real-time augmented reality application in presurgical planning and lesion scalp localization by a smartphone.

OBJECTIVE: A smartphone augmented reality (AR) application (app) was explored for clinical use in presurgical planning and lesion scalp localization. METHODS: We programmed an AR App on a smartphone. The accuracy of the AR app was tested on a 3D-printed head model, using the Euclidean distance of displacement of virtual objects. For clinical validation, 14 patients with brain tumors were included in the study. Preoperative MRI images were used to generate 3D models for AR contents. The 3D models were then transferred to the smartphone AR app. Tumor scalp localization was marked, and a surgical corridor was planned on the patient's head by viewing AR images on the smartphone screen. Standard neuronavigation was applied to evaluate the accuracy of the smartphone. Max-margin distance (MMD) and area overlap ratio (AOR) were measured to quantitatively validate the clinical accuracy of the smartphone AR technique. RESULTS: In model validation, the total mean Euclidean distance of virtual object displacement using the smartphone AR app was 4.7 ± 2.3 mm. In clinical validation, the mean duration of AR app usage was 168.5 ± 73.9 s. The total mean MMD was 6.7 ± 3.7 mm, and total mean AOR was 79%. CONCLUSIONS: The smartphone AR app provides a new way of experience to observe intracranial anatomy in situ, and it makes surgical planning more intuitive and efficient. Localization accuracy is satisfactory with lesions larger than 15 mm.

Fusion of subarachnoid hemorrhage data and computed tomography angiography data is helpful to identify the rupture source in patients with multiple intracranial aneurysms.

Determining the rupture source is imperative in patient with aneurysmal subarachnoid hemorrhage (SAH). About one third of SAH cases with multiple intracranial aneurysms cannot be certain of the rupture source according to the hemorrhage pattern. This study aims to identify of the rupture source in patients with multiple intracranial aneurysms by fusing SAH data and computed tomography angiography (CTA) data. This retrospective study included 52 aneurysmal SAH patients with multiple intracranial aneurysms. In the 52 patients, 36 had definitive hemorrhage patterns on computed tomography imaging. And the other 16 patients had non-definitive hemorrhage patterns, which were bewildered for us to determine the ruptured aneurysms. Fusion of SAH data and CTA data was performed to demonstrate the spatial relationship between the SAH with each aneurysm by using the 3D Slicer software. For the patients with definitive bleed patterns, all of the suspected ruptured aneurysms were confirmed to be accurate according to the surgical records. Interestingly, the suspected rupture sources were correct in 14 of 16 patients with non-definitive hemorrhage patterns. For all 52 patients with multiple intracranial aneurysms, the ruptured aneurysms were identified in 50 cases (96.2%). In conclusion, fusion of SAH data and CTA data can precisely demonstrate the spatial relationship between the SAH with each aneurysm, which is helpful to determine the ruptured aneurysm in patients with multiple intracranial aneurysms.

Identification of genomic alterations in oesophageal squamous cell cancer.

Oesophageal cancer is one of the most aggressive cancers and is the sixth leading cause of cancer death worldwide. Approximately 70% of global oesophageal cancer cases occur in China, with oesophageal squamous cell carcinoma (ESCC) being the histopathological form in the vast majority of cases (>90%). Currently, there are limited clinical approaches for the early diagnosis and treatment of ESCC, resulting in a 10% five-year survival rate for patients. However, the full repertoire of genomic events leading to the pathogenesis of ESCC remains unclear. Here we describe a comprehensive genomic analysis of 158 ESCC cases, as part of the International Cancer Genome Consortium research project. We conducted whole-genome sequencing in 17 ESCC cases and whole-exome sequencing in 71 cases, of which 53 cases, plus an additional 70 ESCC cases not used in the whole-genome and whole-exome sequencing, were subjected to array comparative genomic hybridization analysis. We identified eight significantly mutated genes, of which six are well known tumour-associated genes (TP53, RB1, CDKN2A, PIK3CA, NOTCH1, NFE2L2), and two have not previously been described in ESCC (ADAM29 and FAM135B). Notably, FAM135B is identified as a novel cancer-implicated gene as assayed for its ability to promote malignancy of ESCC cells. Additionally, MIR548K, a microRNA encoded in the amplified 11q13.3-13.4 region, is characterized as a novel oncogene, and functional assays demonstrate that MIR548K enhances malignant phenotypes of ESCC cells. Moreover, we have found that several important histone regulator genes (MLL2 (also called KMT2D), ASH1L, MLL3 (KMT2C), SETD1B, CREBBP and EP300) are frequently altered in ESCC. Pathway assessment reveals that somatic aberrations are mainly involved in the Wnt, cell cycle and Notch pathways. Genomic analyses suggest that ESCC and head and neck squamous cell carcinoma share some common pathogenic mechanisms, and ESCC development is associated with alcohol drinking. This study has explored novel biological markers and tumorigenic pathways that would greatly improve therapeutic strategies for ESCC.

Hyperhomocysteinemia is an independent risk factor for intracranial aneurysms: a case-control study in a Chinese Han population.

Intracranial aneurysms (IAs) are common lesions in the brain. There is a strong relation between hyperhomocysteinemia (HHcy) and cerebrovascular disease; we perform a retrospective study within the Chinese Han population to explore the association between HHcy and IAs. Two hundred six patients with IAs and 206 control subjects were evaluated for their serum total homocysteine levels. With multiple logistic regression analysis, the association between HHcy and the risk of IAs was estimated. Interaction and stratified analyses were conducted according to age, sex, BMI, smoking status, drinking status, and chronic disease histories. The threshold effect was examined by the two-piecewise linear regression model. The multivariate logistic regression analyses revealed a significant association between HHcy and IAs (odds ratio (OR) = 1.68; 95% confidence interval (CI), 1.02-2.75) after adjusting for classical vascular risk factors. And a 2% higher risk of IAs was observed, which was associated with a 1-µmol/L increase in serum total homocysteine level. The interaction analysis showed that age played an interactive role in the association between HHcy and IAs. In summary, our study provides evidence that HHcy is an independent risk factor for IAs in the Chinese Han population, especially in the elderly subgroup. Taking all the findings into consideration, longitudinal studies and clinical trials of homocysteine-lowering therapy via dietary or medical intervention are needed to assess the causal nature of these relationships.

Diagnostic performance of apparent diffusion coefficient parameters for glioma grading.

This study was to evaluate the diagnostic performance of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) parameters derived from diffusion tensor imaging in the differentiation between grade II and III gliomas. The records of 60 patients (30 women, 30 men; mean age, 45.4 years) suspected of having gliomas who underwent an ADC image-guided stereotactic biopsy were retrospectively reviewed. The values of FA and ADC were measured, and the sensitivity, specificity, accuracy and area under the curve (AUC) of those parameters were calculated based on the receiver operating characteristic curve analysis. A predictive diagnostic equation was also constructed and evaluated. Significant differences in minimum ADC values were found in the quantitative analysis between the grade III and II glioma groups. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), accuracy and AUC for identifying grade III and II gliomas at the optimum cut-off value of 0.895 × 10-3 mm2/s of minimum ADC were 81.0, 89.1, 77.3, 91.1, 86.6 and 0.87, respectively. The predictive diagnostic equation was superior to the single minimum ADC indicator with a sensitivity of 90.5%, a specificity of 84.8%, a PPV of 73.1%, an NPV of 95.1%, and an accuracy of 86.6%, respectively. The study provides evidence that minimum ADC values have a superior diagnostic performance in differentiating grade III and II gliomas, and the predictive diagnostic equation may be helpful in the differentiation.

Role of magnetic resonance spectroscopy to differentiate high-grade gliomas from metastases.

This study is to measure the diagnostic examination quality of magnetic resonance spectroscopy in differentiating high-grade gliomas from metastases. PubMed, Embase, and Chinese Biomedical databases were systematically searched for relevant studies published through 10 July 2016. Based on the data from eligible studies, heterogeneity and threshold effect tests were performed; pooled sensitivity, specificity, and areas under summary receiver-operating characteristic curve of magnetic resonance spectroscopy were calculated. Finally, seven studies with a total of 261 patients were included. Quantitative synthesis of studies showed that pooled sensitivity/specificity of Cho/NAA and Cho/Cr ratio in peritumoral region was 0.85 (95% confidence interval: 0.79-0.90)/0.93 (95% confidence interval: 0.80-0.99) and 0.86 (95% confidence interval: 0.76-0.92)/0.86 (95% confidence interval: 0.73-0.94). The area under the curve of the summary receiver-operating characteristic curve was 0.95 and 0.90. Pooled sensitivity, specificity, and area under the curve of magnetic resonance spectroscopy to identify high-grade gliomas from metastases were 0.85 (95% confidence interval: 0.79-0.90), 0.84 (95% confidence interval: 0.75-0.90), and 0.90, respectively. We concluded that magnetic resonance spectroscopy demonstrated moderate diagnostic performance in distinguishing high-grade gliomas from metastases. Furthermore, Cho/NAA ratio showed higher specificity and higher value of area under the curve than Cho/Cr ratio in peritumoral region. We suggest that Cho/NAA ratio of peritumoral region should be used to improve diagnostic accuracy of magnetic resonance spectroscopy for differentiating high-grade gliomas from metastases.

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.

MSX1 inhibits cell migration and invasion through regulating the Wnt/ß-catenin pathway in glioblastoma.

Glioblastoma is a type of primary brain tumor with poor prognosis. The hallmark phenotype of glioblastoma is its aggressive invasion. Understanding the molecular mechanism of the invasion behavior of glioblastoma is essential for the development of effective treatment of the disease. In our present study, we found that the expression levels of a homeobox transcription factor, MSX1, were significantly reduced in glioblastoma compared to normal brain tissues. The levels of MSX1 in glioblastoma tissues were also correlated with the survival of the patients. In cultured glioblastoma cells, MSX1 was a negative regulator of cell migration and invasion. Loss of MSX1 enhanced cell migration and induced mesenchymal transition as characterized by the downregulation of E-cadherin and the upregulation of N-cadherin. Overexpression of MSX1 on the other hand led to the inhibition of both cell migration and mesenchymal transition. We also found that MSX1 was able to inhibit the Wnt/ß-catenin signaling pathway, and that the ability to regulate the Wnt/ß-catenin signaling pathway is critical for MSX1 to suppress glioblastoma cell migration and invasion.

The diagnostic performance of magnetic resonance spectroscopy in differentiating high-from low-grade gliomas: A systematic review and meta-analysis.

OBJECTIVE: Magnetic resonance spectroscopy (MRS) is a powerful tool for preoperative grading of gliomas. We performed a meta-analysis to evaluate the diagnostic performance of MRS in differentiating high-grade gliomas (HGGs) from low-grade gliomas (LGGs). METHODS: PubMed and Embase databases were systematically searched for relevant studies of glioma grading assessed by MRS through 27 March 2015. Based on the data from eligible studies, pooled sensitivity, specificity, diagnostic odds ratio and areas under summary receiver operating characteristic curve (SROC) of different metabolite ratios were obtained. RESULTS: Thirty articles comprising a total sample size of 1228 patients were included in our meta-analysis. Quantitative synthesis of studies showed that the pooled sensitivity/specificity of Cho/Cr, Cho/NAA and NAA/Cr ratios was 0.75/0.60, 0.80/0.76 and 0.71/0.70, respectively. The area under the curve (AUC) of the SROC was 0.83, 0.87 and 0.78, respectively. CONCLUSIONS: MRS demonstrated moderate diagnostic performance in distinguishing HGGs from LGGs using tumoural metabolite ratios including Cho/Cr, Cho/NAA and NAA/Cr. Although there was no significant difference in AUC between Cho/Cr and Cho/NAA groups, Cho/NAA ratio showed higher sensitivity and specificity than Cho/Cr ratio and NAA/Cr ratio. We suggest that MRS should combine other advanced imaging techniques to improve diagnostic accuracy in differentiating HGGs from LGGs. KEY POINTS: • MRS has moderate diagnostic performance in distinguishing HGGs from LGGs. • There is no significant difference in AUC between Cho/Cr and Cho/NAA ratios. • Cho/NAA ratio is superior to NAA/Cr ratio. • Cho/NAA ratio shows higher sensitivity and specificity than Cho/Cr and NAA/Cr ratios. • MRS should combine other advanced imaging techniques to improve diagnostic accuracy.

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.

ATP Induces Disruption of Tight Junction Proteins via IL-1 Beta-Dependent MMP-9 Activation of Human Blood-Brain Barrier In Vitro.

Disruption of blood-brain barrier (BBB) follows brain trauma or central nervous system (CNS) stress. However, the mechanisms leading to this process or the underlying neural plasticity are not clearly known. We hypothesized that ATP/P2X7R signaling regulates the integrity of BBB. Activation of P2X7 receptor (P2X7R) by ATP induces the release of interleukin-1ß (IL-1ß), which in turn enhances the activity of matrix metalloproteinase-9 (MMP-9). Degradation of tight junction proteins (TJPs) such as ZO-1 and occludin occurs, which finally contributes to disruption of BBB. A contact coculture system using human astrocytes and hCMEC/D3, an immortalized human brain endothelial cell line, was used to mimic BBB in vitro. Permeability was used to evaluate changes in the integrity of TJPs. ELISA, Western blot, and immunofluorescent staining procedures were used. Our data demonstrated that exposure to the photoreactive ATP analog, 3'-O-(4-benzoyl)benzoyl adenosine 5'-triphosphate (BzATP), induced a significant decrease in ZO-1 and occludin expression. Meanwhile, the decrease of ZO-1 and occludin was significantly attenuated by P2X7R inhibitors, as well as IL-1R and MMP antagonists. Further, the induction of IL-1ß and MMP-9 was closely linked to ATP/P2X7R-associated BBB leakage. In conclusion, our study explored the mechanism of ATP/P2X7R signaling in the disruption of BBB following brain trauma/stress injury, especially focusing on the relationship with IL-1ß and MMP-9.

Facial and Cochlear Nerve Complications following Microsurgical Resection of Vestibular Schwannomas in a Series of 221 Cases.

BACKGROUND: Despite improvements in microsurgical technique and the use of intraoperative electrophysiological monitoring, the potential for facial and cochlear nerve injury remains a possibility in the resection of vestibular schwannomas (VS). We reviewed a series of 221 cases of VS resected via a retrosigmoid approach at our institution from October 2008 to April 2014 and determined the incidence of postoperative facial and cochlear deficits. MATERIAL AND METHODS: A total of 221 patients - 105 (47.5%) male and 116 (52.5%) female - with a mean age of 46.1 years (range 29-73 years), with VS ≥3 cm (n=183, 82.8%) and <3 cm (n=38, 17.2%) underwent surgical resection via a retrosigmoid approach and were evaluated for postoperative facial and cochlear nerve deficits. RESULTS: Near-total resection (>95% removal) was achieved in 199 cases (90%) and subtotal resection (>90% removal) in 22 cases (10%). At 6 month follow-up, House-Brackmann grades I-III were observed in 183 cases (82.8%), grade IV in 16 cases (7.2%), and grade V in 22 cases (10%). Of the 10 patients that had preoperative functional hearing, 3 (33%) retained hearing postoperatively. Cerebrospinal fluid leakage occurred in 6 patients (2.7%), lower cranial nerve palsies in 9 patients (4.1%), and intracranial hematomas 3 cases (1.4%). CONCLUSIONS: The observed incidence of persistent postoperative nerve deficits is very low. Meticulous microsurgical dissection of and around the facial and cochlear nerves with the aid of intraoperative electrophysiological nerve monitoring in the retrosigmoid approach allows for near-total resection of medium and large VS with the possibility of preservation of facial and cochlear nerve function.

Paraventricular or centrum ovale cavernous hemangioma involving the pyramidal tract in children: intraoperative MRI and functional neuronavigation-guided resection.

OBJECTIVES: In this study, we investigated whether visualization of the pyramidal tract and intraoperative MRI combined with functional navigation was helpful in the resection of paraventricular or centrum ovale cavernous hemangioma in children. METHODS: Twelve patients with cavernous hemangioma located in the paraventricular area or in the centrum ovale adjacent to the pyramidal tract were prospectively enrolled in the study. The pyramidal tract of all patients was visualized preoperatively, and all patients underwent tailored craniotomy with white matter trajectory to resect the lesion, with the help of intraoperative MRI and microscope-based functional neuronavigation. RESULTS: In our study, of the total of 12 patients (nine males and three females), five patients had lesions on the left side, and seven had lesions located in the right hemisphere. The lesion volume varied from 0.2 to 11.45 cm(3). In seven cases, the distance of the lesion from the pyramidal tract was 0-5 mm (the 0-5 mm group), and five cases were in the 5-10 mm group. The 3D visualization of the lesion and the pyramidal tract helped the surgeon design the optimal surgical approach and trajectory. Intraoperative functional neuronavigation allowed them to obtain access to the lesion accurately and precisely. All lesions had been removed totally at the end of the surgery. Compared with the preoperative level, muscle strength at 2 weeks had decreased in six cases, was unchanged in four cases, and improved in two cases; at 3 months, it was improved in five cases, unchanged in six cases, and decreased in one case. CONCLUSIONS: Pyramidal tract visualization and intraoperative MRI combined with functional neuronavigation can aid in safe removal of paraventricular or centrum ovale cavernous hemangioma involving the pyramidal tract.

Impact of intraoperative magnetic resonance imaging and functional neuronavigation on surgical outcome in patients with gliomas involving language areas.

Balancing the benefit of extensive tumor resection with the consequence of potential postoperative language deficits remains a challenge in glioma surgery involving language areas. This study is designed to evaluate the impact of intraoperative magnetic resonance imaging (iMRI) and functional neuronavigation on surgical outcome in patients with gliomas involving language areas. Two hundred seventeen patients were prospectively enrolled, 124 in the study group underwent iMRI and functional neuronavigation-guided microsurgery and 93 in the control group underwent conventional navigation-guided microsurgery. Extent of tumor volume resection (EoR) and rate of gross total resection (rGTR) were calculated perioperatively. Aphasia quotient (AQ) was assessed to evaluate the change of language function perioperatively and at 6-month follow-up. Survival outcome for glioblastoma, including progression-free survival (PFS) and overall survival (OS), were recorded. In 198 glioma patients (112 in the study group and 86 in the control group), EoR (95.50 versus 89.85%, p < 0.001) and rGTR (69.60 versus 47.70%, p = 0.002) were significantly higher in the study group, and language functions were also better at 6-month follow-up in the study group (87.47 versus 78.73, p = 0.001). Furthermore, postoperative new aphasia occurred in 34.8% of the control group, whereas it occurred only in 2.3% of the study group (p < 0.001). In addition, PFS (12.5 versus 6.6 m, p = 0.003) and OS (19.6 versus 13.0 m, p < 0.001) for patients with glioblastomas were dramatically prolonged in the study group than in the control group. These results indicated that iMRI and functional neuronavigation may help maximize tumor resection, minimize language deficits in patients with gliomas involving language areas, and improve survival time for patients with glioblastomas.

Intraoperative high-field magnetic resonance imaging combined with functional neuronavigation in resection of low-grade temporal lobe tumors.

BACKGROUND: The aim of this study is to investigate the role of intraoperative MR imaging in temporal lobe low-grade glioma (LGG) surgery and to report the surgical outcome in our series with regard to seizures, neurological defects, and quality of life. METHODS: Patients with temporal lobe contrast-nonenhancing gliomas who presented with seizures in the course of their disease were enrolled in our prospective study. We non-randomly assigned patients to undergo intraoperative magnetic resonance imaging (iMRI)-guided surgery or conventional surgery. Extent of resection (EOR) and surgical outcomes were compared between the two groups. RESULTS: Forty-one patients were allocated in the iMRI group, and 14 were in the conventional group. Comparable EOR was achieved for the two groups (p = 0.634) although preoperative tumor volumes were significantly larger for the iMRI group. Seizure outcome tended to be better for the iMRI group (Engel class I achieved for 89.7% (35/39) vs 75% (9/12)) although this difference was not statistically different. Newly developed neurological deficits were observed in four patients (10.3%) and two patients (16.7%), respectively (p = 0.928). Free of seizures and neurological morbidity led to a return-to-work or return-to-school rate of 84.6% (33/39) vs 75% (9/12), respectively (p = 0.741). CONCLUSIONS: Our study provided evidence that iMRI was a safe and useful tool in temporal lobe LGG surgery. Optimal extent of resection contributed to favorable seizure outcome in our series with low morbidity rate, which led to a high return-to-work rate.

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.

[Intraoperative high-field magnetic resonance imaging combined with functional neuronavigation in resection of low-grade temporal lobe tumors involving optic radiation].

OBJECTIVE: To investigate the clinical value of high-field-strength intraoperative magnetic resonance imaging (iMRI) combined with optic radiation neuro-navigation for the resection of temporal lobe low-grade gliomas. METHODS: From April 2009 to September 2013, 65 patients with temporal lobe low-grade gliomas (WHO grade II) involving optic radiation were operated with iMRI and functional neuro-navigation. Diffusion tensor imaging (DTI) based fiber tracking was used to delineate optic radiation. The reconstructed optic radiations were integrated into a navigation system, in order to achieve intraoperative microscopic-based functional neuro-navigation. iMRI was used to update the images for both optic radiations and residual tumors. Volumetric analyses were performed using 3D Slicer for pre- and intra-operative tumor volumes in all cases. All patients were evaluated for visual field deficits preoperatively and postoperatively. The Student t test was used to evaluate the average rate of extent of resection between groups. Spearman rank correlation analysis was used to assess correlations between predictors and epilepsy prognosis. RESULTS: Preoperative tumor volumes were (78±40) cm3. In 29 cases, iMRI scan detected residual tumor that could be further resected, and extent of resection were increased from 76.2% to 92.7% (t=7.314, P<0.01). In 19 cases (29.2%), gross total resection was accomplished, and iMRI contributed directly to 8 of these cases. Postsurgical follow-up period varied from 13 months to 59 months, mean (33±13) months. Tumor progression were observed in 3 patients, newly developed or deteriorated visual field defects occurred in 4 patients (6.2%). For patients with pre-operative seizures, Engel Class I were achieved for 89.7% of them. Spearman rank correlation analysis revealed that seizure outcome (Engel Class) was related to increased excision of ratio (r=-0.452, P=0.004, 95% CI: -0.636--0.261) and larger tumors (r=0.391, P=0.014, 95% CI: 0.178-0.484). CONCLUSIONS: With iMRI and functional neuro-navigation, the optic radiation can be accurately located, while extent of resection can be evaluated intra-operatively. This technique is safe and helpful for preservation of visual field for the resection of temporal lobe low-grade gliomas involving optic radiation.