The utility of combined neuroendoscopic- and laparoscopic-assisted ventriculo- peritoneal shunt as a treatment for patients with communicating hydrocephalus.

BACKGROUND: Ventriculo-peritoneal shunt (VPS) is one of the routine methods used to treat communicating hydrocephalus. OBJECTIVE: To sum up the clinical effectiveness of ventriculo-peritoneal shunt (VPS), assisted with neuroendoscopy and laparoscopy, for the treatment of patients with communicating hydrocephalus. METHODS: From January 2010 to 2014, we performed VPS surgery on 209 patients with communicating hydrocephalus, using neuroendoscopy and laparoscopy, which helped to implant the shunt catheter in a suitable position in the ventricles and abdominal cavity, respectively. The subsequent survival following the surgery was analyzed using Kaplan-Meier analysis. RESULTS: A total of 209 patients received 255 VPSs or revisions and all the operations were successfully completed. Open operation or oraniotomy was not needed for any technical complications, while 46 revisions were performed. After the operations, 203 patients with communicating hydrocephalus exhibited improvement of symptoms following surgery. The follow-up period ranged from one month to four years; the shunt surgery efficiencies were 91.0%, 86.7%, 83.9%, and 82.0% in the first, second, third, and fourth years, respectively. CONCLUSION: For ventriculo-peritoneal shunt, laparoscopy and neuroendoscopy can help to implant shunt catheter in a suitable position, in the ventricles or abdominal cavity, respectively. Hence, the combination of the two techniques can reduce the failure rate of VPS, and has an obvious impact on survival following the surgery.

Analysis of 137 Patients Who Underwent Endoscopic Transsphenoidal Pituitary Adenoma Resection Under High-Field Intraoperative Magnetic Resonance Imaging Navigation.

BACKGROUND: Pure endoscopic resection has become the most popular surgical approach for pituitary adenoma. Intraoperative magnetic resonance imaging (iMRI) systems have been in use for endoscopic resection of pituitary adenomas. This study aimed to evaluate the effectiveness of iMRI and neuroimaging navigation techniques during endoscopic endonasal transsphenoidal surgery of pituitary adenomas. METHODS: Data from 137 patients who underwent resection of endoscopic pituitary adenoma under 1.5T iMRI navigation were collected and analyzed. RESULTS: Of patients, 92 underwent complete resection and 45 had residual tumor on real-time iMRI. Twenty-three patients underwent further surgery, and total resection was achieved in 19. Extent of total resection increased from 67.15% to 81.02%. iMRI revealed 3 patients with bleeding in the surgical area, which was successfully treated during the surgery. Review images obtained 3 months after surgery showed 26 patients with residual tumor; 14 patients had the same volume as intraoperatively, and 12 patients had a volume less than that observed intraoperatively. Residual tumor volume in the suprasellar region was less than that seen intraoperatively in 11 of 15 (73.3%) patients. CONCLUSIONS: The use of iMRI and neuronavigation not only leads to a higher rate of tumor resection but also helps in detecting and removing hematomas in the surgical area. Follow-up examinations of extent of residual tumor at 3 months postoperatively were consistent with intraoperative results. Residual tumor volume in the suprasellar region was usually less than that observed intraoperatively.

Optimizing the Extent of Resection and Minimizing the Morbidity in Insular High-Grade Glioma Surgery by High-Field Intraoperative MRI Guidance.

AIM: The result of surgical resection for insular high-grade glioma (HGG) is disappointing due to the complex anatomy of insula and aggressive growth of HGG. The use of intraoperative magnetic resonance imaging (iMRI) was reported to improve the results of glioma surgery. The authors aimed to evaluate the impact of high-field iMRI and functional neuronavigation on the surgical resection of insular HGG. MATERIAL AND METHODS: Between July 2010 and July 2014, 51 insular HGG patients underwent operations guided by combined high-field iMRI and functional neuronavigation. Twenty-two insular HGG patients underwent conventional neuronavigation operations were assessed as the control group. Preoperative and postoperative tumor volumetric scan analysis, Karnofsky performance score (KPS) and follow-up results were reviewed retrospectively. RESULTS: Residual tumor was detected by the iMRI in 42 patients, and residual tumor of 37 patients was further resected in the iMRI-assisted group. The median extent of resection (EOR) increased significantly from 79% (58%?100%) to [96% (86%? 100%), p < 0.001]. The median EOR of iMRI-assisted group [96% (86%?100%)] was significantly higher than that of conventional neuronavigation group [84% (69%?100%); p=0.031]. Mean residual tumor volume of iMRI-assisted group [0.6 (0.0-5.2) cm3] was significantly smaller than that of conventional neuronavigation group [3.8 (0.0-12.1) cm3; p=0.003]. KPS within 3 days after surgery reduced and KPS at 3 months after surgery improved for both groups. KPS of iMRI-assisted group [90(70-100)] was significantly higher than that of control group [80(60-100); p=0.021] at 3 months after surgery. The median progression-free survival (PFS) of iMRI-assisted group [18(9-42) months] was better than that of control group [15(3-32) months; p=0.010]. The median overall survival (OS) of iMRI-assisted group [28(14-49) months] was better than that of control group [18 (7-38) months; p=0.035]. CONCLUSION: Combined high-field iMRI and functional neuronavigation optimize the extent of resection and minimize the morbidity in insular HGG surgery. Aggressive resection of insular HGG is predictive of improved OS and PFS.

Image-guided endoscopic surgery for spontaneous supratentorial intracerebral hematoma.

OBJECTIVE Endoscopic removal of intracerebral hematomas is becoming increasingly common, but there is no standard technique. The authors explored the use of a simple image-guided endoscopic method for removal of spontaneous supratentorial hematomas. METHODS Virtual reality technology based on a hospital picture archiving and communications systems (PACS) was used in 3D hematoma visualization and surgical planning. Augmented reality based on an Android smartphone app, Sina neurosurgical assist, allowed a projection of the hematoma to be seen on the patient's scalp to facilitate selection of the best trajectory to the center of the hematoma. A obturator and transparent sheath were used to establish a working channel, and an endoscope and a metal suction apparatus were used to remove the hematoma. RESULTS A total of 25 patients were included in the study, including 18 with putamen hemorrhages and 7 with lobar cerebral hemorrhages. Virtual reality combined with augmented reality helped in achieving the desired position with the obturator and sheath. The median time from the initial surgical incision to completion of closure was 50 minutes (range 40-70 minutes). The actual endoscopic operating time was 30 (range 15-50) minutes. The median blood loss was 80 (range 40-150) ml. No patient experienced postoperative rebleeding. The average hematoma evacuation rate was 97%. The mean (± SD) preoperative Glasgow Coma Scale (GCS) score was 6.7 ± 3.2; 1 week after hematoma evacuation the mean GCS score had improved to 11.9 ± 3.1 (p < 0.01). CONCLUSIONS Virtual reality using hospital PACS and augmented reality with a smartphone app helped precisely localize hematomas and plan the appropriate endoscopic approach. A transparent sheath helped establish a surgical channel, and an endoscope enabled observation of the hematoma's location to achieve satisfactory hematoma removal.

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.

Impact of Virtual and Augmented Reality Based on Intraoperative Magnetic Resonance Imaging and Functional Neuronavigation in Glioma Surgery Involving Eloquent Areas.

BACKGROUND: The utility of virtual and augmented reality based on functional neuronavigation and intraoperative magnetic resonance imaging (MRI) for glioma surgery has not been previously investigated. METHODS: The study population consisted of 79 glioma patients and 55 control subjects. Preoperatively, the lesion and related eloquent structures were visualized by diffusion tensor tractography and blood oxygen level-dependent functional MRI. Intraoperatively, microscope-based functional neuronavigation was used to integrate the reconstructed eloquent structure and the real head and brain, which enabled safe resection of the lesion. Intraoperative MRI was used to verify brain shift during the surgical process and provided quality control during surgery. The control group underwent surgery guided by anatomic neuronavigation. RESULTS: Virtual and augmented reality protocols based on functional neuronavigation and intraoperative MRI provided useful information for performing tailored and optimized surgery. Complete resection was achieved in 55 of 79 (69.6%) glioma patients and 20 of 55 (36.4%) control subjects, with average resection rates of 95.2% ± 8.5% and 84.9% ± 15.7%, respectively. Both the complete resection rate and average extent of resection differed significantly between the 2 groups (P < 0.01). Postoperatively, the rate of preservation of neural functions (motor, visual field, and language) was lower in controls than in glioma patients at 2 weeks and 3 months (P < 0.01). CONCLUSION: Combining virtual and augmented reality based on functional neuronavigation and intraoperative MRI can facilitate resection of gliomas involving eloquent areas.

Cognitive Function After Carotid Endarterectomy: Early Decline and Later Recovery.

AIM: To prospectively study neurocognitive performance following carotid endarterectomy (CEA) in various follow-up periods, taking into account the potential confounding factors. MATERIAL AND METHODS: Thirty-six patients with carotid artery stenosis received CEA (group A). Thirty-one patients underwent surgery for femoropopliteal occlusive disease served as controls (group B). Neuropsychological testing and brain magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) was repeated preoperatively, within 3 days and at 3 months after surgery. RESULTS: No patient had DWI evidence of procedure-related cerebral ischemia. Preoperative baseline scores of groups A and B were not statistically different in mini mental state examination (MMSE) or clock drawing task (CDT) score. MMSE and CDT scores were significantly reduced for patients in group A (p < 0.01) within 3 days after CEA. Differences of MMSE score (p=0.48) and CDT score (p=0.26) between baseline and 3 months after surgery in group A were not statistically significant. No statistically significant change of MMSE score and CDT score in group B was observed at 3 days and 3 months after the surgery. Degree of internal carotid artery (ICA) stenosis (p=0.029) and duration of ICA clamping (p=0.031) were significantly higher in patients with cognitive impairment immediately after CEA than in those without that. CONCLUSION: Our study demonstrated cognitive decline for the patients with unilateral carotid stenosis at early stage after CEA and a restorative effect at 3 months after CEA. Postoperative early cognitive impairment might be associated with intraoperative temporary hypoperfusion and postoperative hyperperfusion, not the microembolic event.

Indirect Revascularization for Non-Moyamoya Disease Anterior Circulation Arterial Steno-occlusion: Clinical Features, Surgical Treatment, and Medium-Term Outcomes in Adults.

BACKGROUND: Symptomatic anterior arterial steno-occlusion is often associated with neurofunctional deficits or a high risk of recurrent stroke or both. Although both medical and endovascular treatments are useful and suitable, few studies have investigated the continued use of indirect encephaloduroarteriosynangiosis (EDAS) bypass in patients with non-moyamoya disease ischemia. We retrospectively investigated clinical features, surgical treatments, and medium-term outcomes of indirect revascularization for patients with non-moyamoya disease anterior circulation arterial steno-occlusion in China. METHODS: EDAS without burr holes was performed in 51 adult patients with cerebral ischemic events and diagnosed nonmoyamoya anterior circulation arterial steno-occlusion. Preoperative, postoperative, and follow-up neurologic status was evaluated using the National Institutes of Health Stroke Scale; changes on angiography and perfusion-weighted magnetic resonance imaging were evaluated. RESULTS: Unilateral EDAS was performed in 48 patients, and bilateral EDAS was performed in 3 patients. Four patients experienced complications before hospital discharge; only 23 patients underwent follow-up angiograms. Of the 51 patients, 44 (86.3%) exhibited improved muscle strength; 21 of 23 patients (91.3%) with follow-up angiography data exhibited evidence of new visible branches from the superficial temporal artery or middle meningeal artery or both. Preoperative and postoperative perfusion-weighted magnetic resonance imaging was performed for 5 patients. Despite clinical improvement in all patients, only 2 exhibited hemodynamic improvement. CONCLUSIONS: Indirect revascularization may be safe and effective for improving blood flow to the ischemic region following nonmoyamoya anterior circulation arterial steno-occlusion, especially in patients with residual postinfarction neurologic deficits. Our study demonstrates that improvements in ischemic symptoms after EDAS correspond to neovascularization from the superficial temporal artery or middle meningeal artery in ischemic brain areas.

Operative Management of Intraventricular Central Neurocytomas: An Analysis of a Surgical Experience with 32 Cases.

AIM: To better understand the clinical characteristics of central neurocytoma (CN), as well as to assess the optimum therapeutic schedule. MATERIAL AND METHODS: This was a retrospective study of 32 patients with CN who visited our department between January 2008 and January 2013. We analyzed the clinical and radiological presentations, tumor characteristics, surgical strategies, and the prognosis. RESULTS: We performed operation guided by combined intraoperative magnetic resonance imaging (iMRI) and neuronavigation in 25 patients. The iMRI detected residual tumor in 9 cases, and further resection was performed in 5 cases. Total and nearly total tumor resection was achieved in 29 cases (91%). There was no significant difference between transcortical and transcallosal approaches in complications. Two cases (6%) with recurrence received respectively repeat salvage surgery and radiosurgery at 46 and 50 months after surgery. Thirty patients (94%) had excellent functional outcome (Karnofsky Performance Score ≥80) and 28 patients (88%) resumed their occupations. CONCLUSION: Our study demonstrates radical surgery with excellent neurological outcomes is the primary treatment of CN. The techniques of resection guided by combined iMRI and neuronavigation seems to enable a higher complete resection rate and reduce the morbidity rate during surgery. We suggest careful clinical observation after initial surgery, and repeat salvage surgery or radiosurgery for recurrent CN.

[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.

[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.

[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.

Upregulation of neuroglobin expression and changes in serum redox indices in a rat model of middle cerebral artery occlusion.

Neuroglobin (NGB) is a recently identified protein, which is localized in the neurons and retinal cells of the central and peripheral nervous systems in vertebrates. It is hypothesized to function as a scavenger for reactive oxygen species, or as a stress-responsive sensor for signal transduction in hypoxic-ischemic brain insults. However, the mechanism underlying the physiological function of this protein remains to be elucidated. In the present study, the profiling of changes in the serum redox index of morphological features of the hippocampus and cortex, and of the expression of NGB and hypoxia-inducible factor-1α (HIF-1α), are described in a rat middle cerebral artery occlusion (MCAO) model. The necrotic zone of the rat neural tissues increased in size with increasing reperfusion time, and different brain slices exhibited necrosis in different regions. The number of NGB-positive hippocampal and cortical cells, as well as NGB and HIF-1α transcript and protein levels in the ischemic cortex, increased with increasing reperfusion time. NGB and HIF-1α mRNA and protein levels peaked in the group that received reperfusion at 32 h after MCAO. These findings indicated that HIF-1α may be involved in ischemic pathology in an MCAO model and that NGB expression may be upregulated. Serum superoxide dismutase (SOD) activity decreased and serum malondialdehyde (MDA) levels increased with increasing reperfusion time, indicating that the redox potential increased following MCAO. Serum SOD and MDA measurements may, therefore, be useful as biomarkers for the early detection of ischemic injury in a clinical setting.

Multimodal treatment and management strategies for intracranial hemangiopericytoma.

Intracranial hemangiopericytoma (HPC) is a rare malignant meningothelial tumor. The authors retrospectively reviewed the long-term clinical outcomes of patients with HPC with regard to treatment modalities and histopathological grades. Eighteen women and 20 men (mean age 38.5 years, range, 18-62 years) were observed over an average follow-up period of 61 months (range, 15-133 months) between 2003 and 2013. The initial treatment modalities included total tumor resection followed by conventional radiotherapy (RT) (n=27), and subtotal tumor resection followed by stereotactic radiosurgery (n=11). One patient (3%) had permanent neurological deficits, and six patients (16%) died. Thirteen patients (34%) suffered recurrence. One year, 5 year, and 10 year recurrence-free survival rates were 100%, 70%, and 39%, respectively. Five patients (13%) developed metastasis. One year, 5 year, and 10 year metastasis-free survival rates were 100%, 89%, 74%, respectively. Low grade tumors were associated with longer overall survival, recurrence-free interval and metastasis-free interval (log-rank, p<0.05). Radical resection with RT was associated with longer overall survival and recurrence-free interval (log-rank, p<0.05), but had no effect on the metastasis-free interval (log-rank, p=0.245). Thus, radical surgery followed by adjuvant RT is the primary treatment of HPC, but recurrence and metastasis remain a common treatment outcome regardless of initial strategy. It is necessary to maintain long-term follow-up and serial imaging for all patients with intracranial HPC after treatment, regardless of extent of resection.

[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.

[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.