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.

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.

[Endoscopic treatment strategy of obstructive hydrocephalus induced by pineal region tumors].

OBJECTIVE: To explore the efficacies of endoscopic third ventriculostomy (ETV) and tumor biopsy in surgical treatment of obstructive hydrocephalus induced by pineal region tumors. METHODS: For 65 patients of obstructive hydrocephalus induced by pineal region tumors, endoscopic third ventriculostomy (ETV) and tumor biopsy were performed from 2012 to 2014. Tumor specimens were harvested and analyzed histopathologically. According to pathological diagnosis, appropriate treatment strategies were followed. RESULTS: Sixty-five patients underwent successfully ETV and pineal region tumor biopsy. And the histological diagnosis yield rate was 98.5% (64/65). PEB chemotherapy (cisplatin+etoposide+bleomycin) and radiotherapy were offered for germ cell tumors (n = 37) and pineal blastomas (n = 6). The therapy effective rate of germ cell tumors was 91.7% (33/36). A total of 56.9% (37/65) patients benefited without traditional craniotomy or shunt. CONCLUSION: For pineal region tumor induced non-communicating hydrocephalus, ETV and endoscopic tumor biopsy can relieve hydrocephalus while obtaining pathological diagnosis at a relative low risk. Most patients of germ cell tumors and pineoblastomas may avoid craniotomy and shunt. It will become a routine treatment for pineal region tumors with non-communicating hydrocephalus.

[Value of virtual endoscopy in diagnosis and treatment for hydrocephalus after failed shunt].

OBJECTIVE: To investigate the value of virtual endoscopy in diagnosis and treatment of hydrocephalus after failed shunt. METHODS: we performed magnetic resonance imaging (MRI) 3D-SPACE sequence scanning for 76 patients suffering from hydrocephalus after failed shunt. Based on the DICOM data of 3D-SPACE sequence, we three-dimensionally reconstructed the ventricles and simulated virtual endoscopy with 3D-Slicer software. Surgical strategy was made after evaluation of virtual endoscopy images. RESULTS: Virtual endoscopy based on 3D-SPACE images was helpful to depict the aqueduct or foramen of Monro obstructions, and confirm the reason of shunt failure. Finally, there were 56 hydrocephalus patients (73.7%) were treated with endoscopic assisted third ventricle fistula (ETV), without shunt catheter insertion. CONCLUSION: For patients suffering from shunt failure of hydrocephalus, virtual endoscopy has high diagnostic yield rate for providing more detailed anatomical information than conventional MR imaging. Hence, this advanced imaging method is helpful for surgical treatment strategy decision making.

[Treatment for giant pituitary adenomas through transcranial approach in a series of 112 consecutive patients].

OBJECTIVE: To investigate the clinical features, surgical transcranial approaches and outcomes of giant pituitary adenomas. METHODS: A series of 112 consecutive cases of giant pituitary adenomas underwent microsurgery through transcranial approaches at People' s Liberation Army General Hospital were retrospectively analyzed. Of the 112 patients, 58 were male and 54 were female, with age ranging from 3 to 72 years(mean age 44. 3 years). There were 91 non-functioning adenomas and 21 hormone-secreting adenomas. The maximum tumor diameter varied from 4. 0 to 7. 2 cm, with mean diameter of 4. 8 cm. Unilateral subfrontal approach was chosen in 16 cases, pterional approach in 41 cases, anterior interhemispheric approach in 34 cases, transcallosal-interforniceal approach in 6 cases, transcortical- transventricular approach in 5 cases, combined approach in 6 cases and other approaches in 4 cases. Postoperative MRI and endocrine function were re-examined routinely to evaluate the therapeutic efficacy. Staged operation through transsphenoidal approach or adjuvant treatments including medical and radiation therapies were administered in patients with hormone-secreting adenomas when hormonal excess persisted after surgery and in patients with non-functioning adenomas who had postoperative MRI evidence of residual tumor. RESULTS: Total removal of the lesion was achieved in 57 cases (50. 9%) , 26 patients (23. 2%) underwent subtotal resection, and 29 patients (25. 9%) underwent partial removal. Postoperative mortality occurred in 3 patients (2. 7%). Major surgical morbidity occurred in 38 patients (33. 9%). Vision was preserved or improved in 98 patients (87. 5%). The postsurgical follow-up period varied from 3 to 64 months (mean 19. 5 months) . Nineteen of the 21 patients with hormone-secreting adenomas were considered to be in hormonal remission, and 87. 2% of the cases were capable of normal work and life and 8 patients suffered recurrence during the followed-up period. CONCLUSIONS: Selection of appropriate transcranial approaches is the key to successful microsurgery for giant pituitary adenomas according to the morphological characteristics presented in image examinations and clinical symptoms. Staged transsphenoidal operation and/or adjuvant therapies including medical and radiation therapies offer the best chances to control the residual tumors after the maximal surgical removal of giant adenomas through transcranial approaches.

[Combined application of neuroendoscope and laparoscope in ventriculo-peritoneal shunt for treatment of communicating hydrocephalus].

OBJECTIVE: To summarize the clinical efficacy of ventriculo-peritoneal shunt (VPS) assisted by neuroendoscopy and laparoscopy for treatment of communicating hydrocephalus. METHODS: From January 2010 to January 2014, 209 cases (male 93, female 116) who suffered communicating hydrocephalus performed VPS with neuroendoscopy and laparoscopy in Department of Neurosurgery of People's Liberation Army General Hospital. The age of the patients were from 7 months to 79 years (mean 38.1 years), average duration were 20 days to 4 years (mean (2.4 ± 0.7) months). Neuroendoscopy and laparoscopy were used to help respectively to place shunt catheter to better position, both in the ventricle and peritoneal cavity. The effect of subsequent shunt system survival was analyzed with Kaplan-Meier survival analysis. RESULTS: There were 209 patients received 255 times of VPS. All operations were successfully completed. No craniotomy or open operation were needed for technical-related complications. Forty-six revisions were performed in all patients. After the operation, 203 patients with hydrocephalus improved at different level after surgery. Thirteen cases occurred intracranial hypotension syndrome and improved after the pressure adjusted. All patients were followed up for 1 month to 4 years, with a median follow-up time of 2.1 years, while the shunt system efficiencies were 91.0%, 86.7%, 83.9% and 82.0% respectively from the end of the 1st year to the end of the 4th year. CONCLUSIONS: For VPS, neuroendoscopy and laparoscopy can respectively help to place shunt catheter to better position, both in the ventricle and peritoneal cavity. Hence, the combination of these two modalities can reduce the failure rate of shunt catheter insertion and has significant impact on shunt system survival.

[Magnetic resonance three dimensional sampling perfection with application optimized contrasts using different flip angle evolution sequence for obstructive hydrocephalus: impact on diagnosis and surgical strategy modification].

OBJECTIVE: To investigate the value of magnetic resonance three dimensional sampling perfection with application optimized contrasts using different flip angle evolution (3D-SPACE) sequences in diagnosis and surgical strategy modification for obstructive hydrocephalus. METHODS: From March 2013 to July 2014, there were 152 cases admitted in People's Liberation Army General Hospital suffered from hydrocephalus, including 88 male patients and 64 female patients aging from 8 months to 79 years. All patients were performed magnetic resonance T2WI and 3D-SPACE sequence scanning before operation. Surgical strategy was made after evaluation of 3D-SPACE sequence. Non-communicating hydrocephalus was treated with endoscopic third ventriculostomy (ETV) and communicating hydrocephalus was treated with ventriculo-peritoneal shunt. According to MR images of direct observation to site of obstruction to determine the detection rate. MRI 3D-SPACE and cranial CT examination were performed in regular follow-up studies. RESULTS: The relevance ratio of 3D-SPACE for the diagnosis of non-communicating hydrocephalus was 98.3% (114/116), while the relevance ratio of conventional T2-weighted MRI was 72.4% (84/116). Among the 152 patients, there were 36 cases with cerebral aqueduct film obstruction, 22 cases with space-occupying lesions in pineal region, posterior part of the third ventricle, or space-occupying lesions in quadrigeminal bodies area, 10 cases with Dandy-Walker symptom, 18 cases with cyst of the anterior pool of the bridge, 16 cases with cysticercosis, 4 cases with cyst of lateral ventricle, 2 cases with cyst of fourth ventricle, 2 cases with space-occupying lesion in foramen ofmonro, 2 cases with foramen ofmonro atresia, 4 cases with craniopharyngioma, 36 cases with communicating hydrocephalus. There were 112 hydrocephalus cases (73.7%) were treated with ETV, without shunt catheter insertion in follow-up study from 1 to 18 months (average (14±9) months). CONCLUSIONS: For obstructive hydrocephalus, MRI 3D-SPACE sequence image has high diagnostic yield rate for providing more detailed anatomical information than conventional MRI. Hence, the advanced imaging methods are helpful for surgical treatment strategy decision making.

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.

Intraoperative computed tomography with an integrated navigation system in stabilization surgery for complex craniovertebral junction malformation.

STUDY DESIGN: This study was designed to report our preliminary experience with stabilization procedures for complex craniovertebral junction malformation (CVJM) using intraoperative computed tomography (iCT) with an integrated neuronavigation system (NNS). OBJECTIVE: To evaluate the workflow, feasibility and clinical outcome of stabilization procedures using iCT image-guided navigation for complex CVJM. SUMMARY OF BACKGROUND DATA: The stabilization procedures in CVJM are complex because of the area's intricate geometry and bony structures, its critical relationship to neurovascular structures and the intricate biomechanical issues involved. METHODS: A sliding gantry 40-slice computed tomography scanner was installed in a preexisting operating room. The images were transferred directly from the scanner to the NNS using an automated registration system. On the basis of the analysis of intraoperative computed tomographic images, 23 cases (11 males, 12 females) with complicated CVJM underwent navigated stabilization procedures to allow more control over screw placement. The age of these patients were 19-52 years (mean: 33.5 y). We performed C1-C2 transarticular screw fixation in 6 patients to produce atlantoaxial arthrodesis with better reliability. Because of a high-riding transverse foramen on at least 1 side of the C2 vertebra and an anomalous vertebral artery position, 7 patients underwent C1 lateral mass and C2 pedicle screw fixation. Ten additional patients were treated with individualized occipitocervical fixation surgery from the hypoplasia of C1 or constraints due to C2 bone structure. RESULTS: In total, 108 screws were inserted into 23 patients using navigational assistance. The screws comprised 20 C1 lateral mass screws, 26 C2, 14 C3, or 4 C4 pedicle screws, 32 occipital screws, and 12 C1-C2 transarticular screws. There were no vascular or neural complications except for pedicle perforations that were detected in 2 (1.9%) patients and were corrected intraoperatively without any persistent nerves or vessel damage. The overall accuracy of the image guidance system was 98.1%. The duration of interruption during the surgical process for the iCT was 8±1.5 minutes. All patients were clinically evaluated using Nurick grade criteria and for neurological deficits 3 months after surgery. Twenty-one patients (91.3%) improved by at least 1 Nurick grade, whereas the grade remained unchanged in 2 (8.7%) patients. Craniovertebral stability and solid bone fusion was achieved in all patients. NNS was found to correlate well with the intraoperative findings, and the recalibration was uneventful in all cases and had an accuracy of 1.8 mm (range, 0.6-2.2 mm). CONCLUSIONS: iCT scanning with integrated NNS was found to be both feasible and beneficial in the stabilization procedures for complex CVJM. In this unusual patient population, the technique seemed to be of value for negotiating complex anatomy and for achieving more control over screw placement.

[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.

[Treatment of fixed atlantoaxial dislocation and basilar invagination with C1-2 screw and rod reduction and fixation technique].

OBJECTIVE: To introduce a novel technique of reducing fixed atlantoaxial dislocation (FAAD) and basilar invagination (BI) with C1-C2 screw and rod system. METHODS: From January 2009 to December 2011, 26 patients of FAAD and BI were reduced successfully with an insertion of C1 lateral mass and C2 pedicle/pars screw and rod system. The cohort had 17 females and 9 males. And their most common presenting symptoms were extremity muscle weakness, restricted neck movement and paresthesia. RESULTS: All of them achieved effective reduction. Among them, 18 attained complete reduction and 8 partial reduction (over 60% extent of reduction). The mean atlanto-dental interval (ADI) value was 2.1 mm postoperatively versus 8.8 mm preoperatively (t = 21.1, P < 0.01) . All of them had relieved compression of dura and medulla oblongata and cervical cord. All clinical symptoms improved. One case had pulmonary infection while another case delayed healing of incision. Both recovered well after symptomatic treatments. Bony fusion reached 100% during a mean follow-up period of 22 months. CONCLUSION: The C1-C2 screw and rod system may achieve effective reduction and fixation for FAAD and BI. Capable of preserving atlanto-occipital joints in patients without atlas assimilation, this procedure provide more solid immobilization than occipitocervical fusion in those with atlas assimilation.

[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.

[Anterior interhemispheric approach for giant sellar region tumors in a series of 110 consecutive patients].

OBJECTIVE: To explore the techniques and efficacies of surgical resection of giant sellar region tumors via anterior interhemispheric approach. METHODS: A series of 110 consecutive cases of giant sellar region tumors undergoing microsurgery through an anterior interhemispheric approach at our hospital were retrospectively analyzed. Their mean age was 35.6 (3-72) years. There were craniopharyngioma (n = 57), pituitary adenoma (n = 33), hypothalamic glioma (n = 5), meningioma (n = 4) and other lesions (n = 11). The maximal tumor diameter varied from 4.0 to 8.2 cm with a mean diameter of 4.8 cm. Active measurements were taken for managing blood sodium disorder and diabetes insipidus. During the follow-ups, the patients were monitored for residual or recurrent tumor by hormonal assessment (in cases of functioning adenomas) and postoperative contrast magnetic resonance imaging (MRI) performed 1-3 months after surgery. RESULTS: Total lesion removal was achieved in 76 cases (69.1%). Twenty patients (18.2%) underwent subtotal resection and 14 (12.7%) had partial removal. No surgery-related mortality occurred. Visual acuity was preserved or improved in 97 patients (88.2%) within 1 week after surgery. The major postoperative complications included diabetes insipidus (n = 76, 69.1%), permanent diabetes insipidus (n = 23, 20.9%), electrolyte disorder (n = 62, 56.4%), seizures (n = 7, 6.4%), brain damage (3 cerebral contusions and 5 hematomas) (n = 8, 7.3%) and infarction(n = 2, 1.8%). During a median post-surgical follow-up period of 26 (3-96) months, 11 patients had recurrence. And 35 cases (31.8%) of endocrinological deficit received hormonal replacement after surgery. CONCLUSION: The interhemispheric approach is feasible for removing giant sellar region tumors without significant sequels. Active postoperative managements of diabetes insipidus and electrolyte disorder may accelerate early patient recovery.

[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.

[Clinical analysis of the technique of puncture and drainage guided by neuronavigation in treatment of brain abscesses].

OBJECTIVE: To study the techniques and efficacy of neuronavigation-guided puncture and drainage in the treatment of brain abscesses. METHODS: From February 2006 to December 2012, 31 patients with brain abscesses treated by the technique of neuronavigation-guided puncture and drainage were retrospectively analyzed. There were 27 male and 4 female patients, age ranged from 10 months to 69 years, average (34 ± 19) years.Single brain abscesses were found in 26 patients, multiple abscesses in 5 patients. The abscesses were located in eloquent regions in 19 patients. The mean diameter of the abscess was 4.1 cm (2.5-6.7 cm). The first follow-up visit was on the first month after surgery, and if residual was observed on enhanced MRI, then the patient was followed up every 3 months until the abscess disappeared completely. After residual absorbed, the patient was followed up every year. RESULTS: Incisions of all patients were healed well and no infection. The length of hospital stay after surgery was 6-42 days, mean (14 ± 9) days. Bacterial culture of pus was performed regularly including aerobic, anaerobic and fungal culture after surgery. Thirteen patients had positive culture whereas the other 18 patients had negative culture. The duration of antibiotic use was 18-42 days, mean (22 ± 5) days. All the patients were followed up for 3 months to 3 years. Twenty-nine patients recovered well postoperatively, 1 case died 2 months after operation.One case was performed the second drainage after 10 days from the first surgery.Eighteen patients showed the improvement of neurological status within the first day following surgery, 4 patients got improvement in the next day, 1 patient with hemiplegia showed improvement in 10 days postoperatively, 1 patient with aphasia recovered gradually after 1 month, 1 patient with hemiplegia showed deterioration temporarily after surgery, and recovered gradually after 15 days. CONCLUSION: The technique of puncture and drainage guided by neuronavigation has many advantages to treat brain abscesses, such as small trauma, short operation time, high accuracy and safety, simple surgical procedures and good prognosis.

[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.

[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.

[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.

Neuroprotective effects of neuroglobin after mechanical injury.

Neuroglobin (NGB) is a recently discovered globin, which is widely expressed in vertebrates central and peripheral nervous systems. Previous studies have shown that NGB is important in protecting neurons from hypoxic/ischemic brain injuries. However, there are no reports on the neuroprotective effects of NGB after mechanical injury. Currently, we showed that the NGB expression level in neurons increased continuously from 2 h after injury, and reached a peak at 16 h (p<0.01), after which it decreased sharply. NGB that was overexpressed in mechanically injured B104 cells showed significant neuroprotective effects. Lactate dehydrogenase (LDH) activity decreased and cell survival rates increased (p<0.01, n=5). In the rat model of focal brain trauma, the NGB expression increased sharply at 1 h, after which it increased continuously until it reached a peak at 6 h, and then gradually decreased (p<0.01, n=5). Furthermore, moderate and severe injury resulted in significantly higher NGB levels than did mild injury (p<0.01, n=5). Our results indicate that NGB exerts significant neuroprotective effects after mechanical injury, and thus has important implications for the prognosis and cure of traumatic brain injury.