Portable ultrasound-guided keyhole evacuation of intracerebral hemorrhage: a detailed case report highlighting technical nuances.

Intracerebral hemorrhage (ICH) is a common neurosurgical emergency that is associated with high morbidity and mortality. Minimally invasive or endoscopic hematoma evacuation has emerged in recent years as a viable alternative to conventional large craniotomies. However, accurate trajectory planning and placement of the tubular retractor remains a challenge. We describe a novel technique for handheld portable ultrasound-guided minimally invasive endoscopic evacuation of supratentorial hematomas. A 64-year-old male diagnosed right hematoma (48.5 mL) at the basal ganglia was treated with emergent ultrasound-guided endoscopic transtubular evacuation through a small craniotomy. Ultrasound-guidance facilitated optimal placement of the tubular retractor into the long axis of the hematoma, and allowed for near-total evacuation, reducing iatrogenic tissue damage by mitigating the need for wanding or repositioning of the retractor. The emergence of a new generation of small portable phased array ultrasound probes with improved resolution and clarity has broadened ultrasound's clinical applications.

Chinese guideline on the application of anti-seizure medications in the perioperative period of supratentorial craniocerebral surgery.

Seizures are a common symptom of craniocerebral diseases, and epilepsy is one of the comorbidities of craniocerebral diseases. However, how to rationally use anti-seizure medications (ASMs) in the perioperative period of craniocerebral surgery to control or avoid seizures and reduce their associated harm is a problem. The China Association Against Epilepsy (CAAE) united with the Trauma Group of the Chinese Neurosurgery Society, Glioma Professional Committee of the Chinese Anti-Cancer Association, Neuro-Oncology Branch of the Chinese Neuroscience Society, and Neurotraumatic Group of Chinese Trauma Society, and selected experts for consultancy regarding outcomes from evidence-based medicine in domestic and foreign literature. These experts referred to the existing research evidence, drug characteristics, Chinese FDA-approved indications, and expert experience, and finished the current guideline on the application of ASMs during the perioperative period of craniocerebral surgery, aiming to guide relevant clinical practice. This guideline consists of six sections: application scope of guideline, concepts of craniocerebral surgery-related seizures and epilepsy, postoperative application of ASMs in patients without seizures before surgery, application of ASMs in patients with seizures associated with lesions before surgery, emergency treatment of postoperative seizures, and 16 recommendations.

Histone Demethylase KDM4A Inhibition Represses Neuroinflammation and Improves Functional Recovery in Ischemic Stroke.

BACKGROUND: Epigenetic regulation concerning histone lysine methylation and demethylation play a crucial role in cerebral ischemic injury. Dysregulation of histone methylation modifiers has been identified in cerebral ischemia. However, the function and the underlying mechanisms of histone demethylase KDM4A on neuroinflammation and functional recovery in ischemic stroke remains unclear. METHODS: In the present study, the rat model of transient middle cerebral artery occlusion (MCAO) was established, and the expression level of KDM4A was assessed in brain tissues. KDM4A inhibition was carried out by intrathecal injection with Lv-shKDM4A, and then pro-inflammatory cytokines and neurological functional tests were assessed. RESULTS: We demonstrated that rats subjected to MCAO showed a markedly increased expression of KDM4A, pro-inflammatory cytokines IL-1ß and TNF-α, and vascular endothelial growth factor (VEGF), whereas KDM4A inhibition repressed the expression of IL-1ß, TNF-α and VEGF both in MCAO and oxygen-glucose deprivation (OGD) models. Furthermore, KDM4A inhibition showed a marked improvement in spatial learning and sensorimotor function, as suggested by mNSS and foot-fault test, respectively. Mechanistically, KDM4A inhibition repressed NF-κB signaling activation in microglia as indicated by decreased expression and nuclear translocation of p65 in vitro and in vivo. The effects of KDM4A overexpression on exacerbating neuroinflammation was inhibited by additional treatment of NF-κB inhibitor (JSH-23). CONCLUSION: The current results demonstrated KDM4A inhibition improves functional recovery in ischemic stroke by repressing NF-κB activation and subsequent neuroinflammation.

Risk factors and clinical features of paroxysmal sympathetic hyperactivity after spontaneous intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Paroxysmal sympathetic hyperactivity (PSH) is a rare complication of spontaneous intracerebral hemorrhage (ICH).We aimed to evaluate the risk factors and clinical features for PSH after ICH. METHODS: From January 1, 2013 to April 1, 2018, patients with ICH were consecutively included in this observational study. Baseline characteristics were compared in patients with and without PSH. Multivariate logistic regression analysis was used to determine the risk factors associated with PSH development. Clinical features of patients with PSH were also analyzed. RESULTS: There were 548 patients with ICH included and a total of 15 (2.7%) patients were identified with PSH. In univariate analysis, PSH development was associated with the following: previous hemorrhagic stroke, pupils abnormity, admission Glasgow Coma Scale (GCS) score, hematoma volume, liver function abnormity, neutrophil count and early tracheostomy. Multivariate logistic regression analysis showed that a significantly increased risk of PSH was found in patients with previous hemorrhagic stroke (odds ratio [OR], 4.176; 95% confidence interval [CI], 1.111-15.698), admission GCS score (OR, 0.703; 95% CI, 0.548-0.902) and early tracheostomy (OR, 8.317; 95%CI, 1.755-39.412).The most common symptoms of PSH were hyperthermia (80%) and hyperhidrosis (80%).The median Intensive Care Unit stays and Glasgow Outcome Scale at discharge were 34 (19-46) and 2 (1.5-3), respectively. CONCLUSIONS: PSH is characterized by a cluster of symptoms and abnormal vital signs, which may lead to poor outcomes in ICH. The present study suggests that previous hemorrhagic stroke, admission GCS score and early tracheostomy may be the significant risk factors for PSH after ICH.

The role of long noncoding RNA in traumatic brain injury.

Traumatic brain injury (TBI), a mainly lethal and highly debilitating condition, is increasing worldwide. However, the underlying mechanism has not been fully elucidated and effective therapy is needed. Long noncoding RNAs (lncRNAs), which form a major class of noncoding RNAs, have emerged as novel targets for regulating physiological functions and mediating numerous neurological diseases. Notably, gene expression profile analyses have demonstrated aberrant changes in lncRNA expression in the cerebral cortex and hippocampus of rats, mice and human after TBI. lncRNAs may be associated with multiple pathophysiological processes following TBI and might play a crucial role in complications of TBI, such as traumatic optic neuropathy due to the regulation of specific signaling pathways. Some lncRNAs have also been found to be therapeutic targets for motor and cognitive recovery after TBI. lncRNAs may be promising biomarkers for TBI diagnosis, treatment, and prognosis prediction. However, further research isneeded to clarify the underlying mechanisms and therapeutic effects of lncRNAs on TBI. We review the current progress of studies on lncRNAs in TBI to draw more attention to their roles in this debilitating condition.

Prognostic Significance of MicroRNAs in Glioma: A Systematic Review and Meta-Analysis.

PURPOSE: Different microRNAs (miRs) have been demonstrated to relate with the outcome of glioma patients, while the conclusions are inconsistent. We perform a meta-analysis to clarify the relationship between different miRs and prognosis of glioma. METHODS: Related studies were retrieved from PubMed, Embase, and Cochrane Library. Pooled hazard ratios (HRs) of different miRs expression for survival and 95% confidence intervals (CIs) were calculated using random-effects model. RESULTS: A total of 15 miRs with 4708 glioma patients were ultimately included. Increased expression of miR-15b (HR, 1.584; 95% CI, 1.199-2.092), 21 (HR, 1.591; 95% CI, 1.278-1.981), 148a (HR, 1.122; 95% CI, 1.023-1.231), 196 (HR, 1.877; 95% CI, 1.033-3.411), 210 (HR, 1.251; 95% CI, 1.010-1.550), and 221 (HR, 1.269; 95% CI, 1.054-1.527) or decreased expression of miR-106a (HR, 0.809; 95% CI, 0.655-0.998) and 124 (HR, 0.833; 95% CI, 0.729-0.952) was correlated with poor outcome of glioma patients. CONCLUSIONS: miR-15b, 21, 148a, 196, 210, 221, 106a, and 124 are valuable biomarkers for the prognosis of glioma which might be used in clinical settings.

Effect of oxidative stress in rostral ventrolateral medulla on sympathetic hyperactivity after traumatic brain injury.

Sympathetic hyperactivity occurs in a subgroup of patients after traumatic brain injury (TBI). The rostral ventrolateral medulla (RVLM) is a key region for the activity of sympathetic nervous system. Oxidative stress in the RVLM is proved to be responsible for the increased level of sympathetic activity in animal models of hypertension and heart failure. In this study, we investigated whether oxidative stress in the RVLM contributed to the development of sympathetic hyperactivity after TBI in rats. Model of diffuse axonal injury was induced using Sprague-Dawley rats, and level of mean arterial pressure (MAP) and plasma Norepinephrine (NE) was measured to evaluate the sympathetic activity. For the assessment of oxidative stress, expression of reactive oxygen species (ROS), malondialdehyde (MDA), and superoxide dismutase (SOD) in the RVLM was determined. Microinjection of Tempol into the RVLM was performed to determine the effect of oxidative stress on sympathetic hyperactivity. According to the results, TBI led to elevated MAP and plasma NE in rats. It also induced a significantly increased level of ROS, MDA production and decreased level of SOD in the RVLM. The sympathetic activity, ROS, and MDA in the RVLM decreased significantly after microinjection of Tempol. Therefore, the present results suggested that oxidative stress in the RVLM was involved in the development of sympathetic hyperactivity following TBI.

miR-448-3p controls intracranial aneurysm by regulating KLF5 expression.

microRNAs (miRNAs) control several processes known to be involved in progression of aneurysm. Here, intracranial aneurysms (IAs) were surgically induced in Sprague-Dawley rats, and we found that miR-448-3p was downregulated and KLF5 was upregulated in IA rats. We identified Klf5 as a direct target of miR-448-3p in smooth muscle cells (SMCs). In addition, aneurysms size and the lumen area of the aneurysms were smaller 4 weeks after IA induction in the miR-448-3p-treated group. miR-448-3p treatment protected the wall thickness ratio and suppressed macrophage infiltration after IA induction. IAs caused a significant increase in KLF5 expression and were alleviated by miR-448-3p. Moreover, the anti-inflammatory effect of miR-448-3p was verified in lipopolysaccharide -stimulated RAW 264.7 macrophage cells. The expression levels of KLF5, MMP2, and MMP9 levels were elevated by LPS, and were attenuated by miR-448-3p. These data suggest that miR-448-3p plays the inhibitory role in IA progression, indicating that miR-448-3p overexpression is crucial for preventing the development of IA through downregulation of macrophage-mediated inflammation.

Aortic valve calcification and risk of stroke: A systematic review and meta-analysis.

Aortic valve calcification (AVC) is common among aged population and reported to be associated with the risk of stroke. However, the conclusions are inconsistent among studies. We performed a rigorous meta-analysis to unravel the AVC-stroke relationship. Embase, PubMed and Cochrane library were retrieved for related cohort studies investigating the correlations between AVC and risk of stroke. The language was limited to English. We selected risk ratio (RR) and 95% confidence intervals (CIs) as the effect size. Random-effects model was used in the data synthesis. A total of 7 cohort studies were identified in our meta-analysis with 21,395 participants and 1025 strokes. We detected statistically significant correlation between AVC and stroke (RR, 1.20; 95% CI, 1.02-1.40, P = 0.02) with low heterogeneity (I2 = 6.9%, P = 0.375). Statistically significant results were detected only in the subgroup of "+" degree of adjustment (P = 0.04). Therefore, a definite relationship between AVC and risk of stroke couldn't be decided based on current available data, and more large scale prospective studies were needed to verify the AVC-stroke relationship.

CCNG2 Overexpression Mediated by AKT Inhibits Tumor Cell Proliferation in Human Astrocytoma Cells.

The cyclin family protein CCNG2 has an important inhibitory role in cancer initiation and progression, but the exact mechanism is still unknown. In this study, we examined the relationship between CCNG2 and the malignancy of astrocytomas and whether the AKT pathway, which is upregulated in astrocytomas, may inhibit CCNG2 expression. CCNG2 expression was found to be negatively associated with the pathological grade and proliferative activity of astrocytomas, as the highest expression was found in control brain tissue (N = 31), whereas the lowest expression was in high-grade glioma tissue (N = 31). Additionally, CCNG2 overexpression in glioma cell lines, T98G and U251 inhibited proliferation and arrested cells in the G0/G1 phase. Moreover, CCNG2 overexpression could increase glioma cells apoptosis. In contrast, AKT activity increased in glioma cells that had low CCNG2 expression. Expression of CCNG2 was higher in cells treated with the AKT kinase inhibitor MK-2206 indicating that the presence of phosphorylated AKT may inhibit the expression of CCNG2. Inhibition of AKT also led to decreased colony formation in T98G and U251 cells and knocked down of CCNG2 reversed the result. Finally, overexpression of CCNG2 in glioma cells reduced tumor volume in a murine model. To conclude, low expression of CCNG2 correlated with the severity astrocytoma and CCNG2 overexpression could induce apoptosis and inhibit proliferation. Inhibition of AKT activity increased the expression of CCNG2. The present study highlights the regulatory consequences of CCNG2 expression and AKT activity in astrocytoma tumorigenesis and the potential use of CCNG2 in anticancer treatment.

Clinical features and management of nonfunctioning giant pituitary adenomas causing hydrocephalus.

We evaluated the features of clinically nonfunctioning giant pituitary adenomas (NFGPAs) causing hydrocephalus to highlight the timing of hydrocephalus management and surgical approaches. A total of 24 patients with NFGPAs and hydrocephalus were included. Eighteen patients underwent endoscopic transsphenoidal surgery. Ten patients received pterional surgery, including 6 patients as first treatment and 4 cases with recurrence after transsphenoidal approach. Gross total resection was achieved in 10 patients, including 6 cases (6/18, 33.3%) with endoscopic transsphenoidal surgery and 4 cases (4/10, 40%) with pterional surgery. All patients were divided into preoperative EVD group and non-preopoerative EVD group. The proportion of patients receiving postoperative EVD or shunt was significantly higher in non-preoperative EVD group than that in preoperative EVD group (9/15 vs. 1/9, P = 0.033). Visual impairment score (VIS) was evaluated for each patient. We detected significant vision improvement according to the preoperative and postoperative VIS (median, interquartile range: 62, 48.25-77 vs. 36.5, 0-50.75, P < 0.001). Conclusively, for patients with NFGPAs and hydrocephalus, preoperative EVD might reduce the need for a second shunt or EVD. Surgical approach should be decided based on the clinicoradiological features and surgeons' experience for individualized treatment, and endoscopic transsphenoidal resection of pituitary adenomas was suggested for most NFGPAs.

Clinical management of traumatic superior orbital fissure and orbital apex syndromes.

OBJECTIVES: Both traumatic orbital apex syndrome (OAS) and traumatic superior orbital fissure syndrome (SFOS) are rare conditions after craniofacial injury. Few types of researches investigate the difference in clinical characteristics and outcome between them. We describe clinical features and cranial nerves functional recovery of traumatic OAS or SOFS and to discuss surgical decompression of these patients. PATIENTS AND METHODS: A retrospective study was performed of 15 patients diagnosed with traumatic OAS and 39 patients with traumatic SOFS from July 2010 to July 2017 in our hospital. The initial status and functional recovery of cranial nerve were evaluated based on visual perception and extraocular muscle movement. The average follow-up period was 11.8 months. RESULTS: 41 males' and 13 females' patients with a mean age of 38.3 years were included. 12 patients were diagnosed with internal carotid artery injury. In the OAS group, there is no visual recovery of those 10 totally blindness patients and only 5 functional recovery patients at 6-months follow up. No visual dysfunction occurred in the SOFS group. Cranial nerves Ⅲ, Ⅳ, and Ⅵ function recovery were better in the SOFS group than in the OAS group. CONCLUSION: Patients with OAS might undergo more severe cranial nerves injury and worse functional recovery. Due to the occurrence of internal carotid artery injury, CTA or DSA are recommended. Surgical decompression should be considered when there is evidence of optical canal fracture or bone fragment impingement of the superior orbital fissure.

Lateral Ventricular Volume Asymmetry Predicts Poor Outcome After Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Midline shift (MLS) has been a known predictor for prognosis after spontaneous intracerebral hemorrhage (ICH), whereas it is secondary to lateral ventricular compression. In this study, we investigated whether lateral ventricular volume (LVV) asymmetry caused by ventricular compression was independently associated with poor outcome of ICH. METHODS: We retrospectively studied clinical patients with spontaneous ICH from January 2010 to January 2017. LVV was calculated using slicer software. LVV ratio (LVR) was then determined to quantitatively evaluate LVV asymmetry, and its relationship with poor outcome was tested by logistic regression model. Receiver operating characteristic (ROC) curve analysis was performed to identify the optimized baseline LVR cutoff point to predict poor outcome. RESULTS: 188 patients were included, of whom 41% (77/188) experienced a poor outcome. Multivariate logistic regression analysis identified baseline LVR as an independent predictor for poor outcome after ICH. The predictive value of baseline LVR was confirmed by ROC analysis (area under the curve = 0.742; P < 0.001). The optimized baseline LVR cutoff point was 3.7, with a sensitivity of 64.9% and specificity of 80.2%. Using LVR >3.7 as an exposure factor yielded an odds ratio of 7.49 (P < 0.001), and a risk ratio of 2.98 (P < 0.001). CONCLUSIONS: LVV asymmetry was associated with clinical prognosis after ICH, and high LVR (>3.7) might independently predict poor outcome.

Management of Penetrating Skull Base Injury: A Single Institutional Experience and Review of the Literature.

BACKGROUND: Penetrating skull base injury (PSBI) is uncommon among head injuries, presenting unique diagnostic and therapeutic challenges. Although many cases of PSBIs have been reported, comprehensive understanding of its initial diagnosis, management, and outcome is still unavailable. MATERIALS AND METHODS: A retrospective review was performed for patients treated in neurosurgical department of Changzheng Hospital for PSBIs. Presurgical three-dimensional (3D) Slicer-assisted reconstructions were conducted for each patient. Then we reviewed previous literature about all the published cases of PSBIs worldwide and discussed their common features. RESULTS: A total of 5 patients suffering PSBIs were identified. Penetrating points as well as the surrounding neurovascular structures were clearly visualized, assisting in the presurgical planning of optimal surgical approach and avoiding unexpected vascular injury. Four patients underwent craniotomy with foreign bodies removed successfully and 1 patient received conservative treatment. All of them presented good outcomes after proper management. CONCLUSION: Careful physical examination and radiological evaluation are essential before operation, and angiography is recommended for those with suspected vascular injuries. 3D modeling with 3D Slicer is practicable and reliable, facilitating the diagnosis and presurgical planning. Treatment decision should be made upon the comprehensive evaluation of patient's clinicoradiological features and characteristics of foreign bodies.

Presurgical Planning for Supratentorial Lesions with Free Slicer Software and Sina App.

BACKGROUND: Neuronavigation systems are used widely in the localization of intracranial lesions with satisfactory accuracy. However, they are expensive and difficult to learn. Therefore, a simple and practical augmented reality (AR) system using mobile devices might be an alternative technique. OBJECTIVE: We introduce a mobile AR system for the localization of supratentorial lesions. Its practicability and accuracy were examined by clinical application in patients and comparison with a standard neuronavigation system. METHODS: A 3-dimensional (3D) model including lesions was created with 3D Slicer. A 2-dimensional image of this 3D model was obtained and overlapped on the patient's head with the Sina app. Registration was conducted with the assistance of anatomical landmarks and fiducial markers. The center of lesion projected on scalp was identified with our mobile AR system and standard neuronavigation system, respectively. The difference in distance between the centers identified by these 2 systems was measured. RESULTS: Our mobile AR system was simple and accurate in the localization of supratentorial lesions with a mean distance difference of 4.4 ± 1.1 mm. Registration added on an average of 141.7 ± 39 seconds to operation time. There was no statistically significant difference for the required time among 3 registrations (P = 0.646). CONCLUSIONS: The mobile AR system presents an alternative technology for image-guided neurosurgery and proves to be practical and reliable. The technique contributes to optimal presurgical planning for supratentorial lesions, especially in the absence of a neuronavigation system.

Vascular endothelial growth factor is neuroprotective against ischemic brain injury by inhibiting scavenger receptor A expression on microglia.

Vascular endothelial growth factor (VEGF) is a secreted mitogen associated with angiogenesis. VEGF has long been thought to be a potent neurotrophic factor for the survival of spinal cord neurons. However, the role of VEGF in the regulation of ischemic brain injury remains unclear. In this study, rats were subjected to MCAO (middle cerebral artery occlusion) followed by intraperitoneal injection of VEGF165 (10 mg/kg) immediately after surgery and once daily until the day 10. The expression of target genes was assayed using qPCR, western blot and immunofluorescence to investigate the role of VEGF165 in regulating ischemic brain injury. We found that VEGF165 significantly inhibited MCAO-induced up-regulation of Scavenger receptor class A (SR-A) on microglia in a VEGFR1-dependent manner. VEGF165 inhibited lipopolysaccharide (LPS)-induced expression of proinflammatory cytokines IL-1ß, tumor necrosis factor alpha (TNF-α) and iNOS in microglia. More importantly, the role of VEGF165 in inhibiting neuroinflammation is partially abolished by SR-A over-expression. SR-A further reduced the protective effect of VEGF165 in ischemic brain injury. These data suggest that VEGF165 suppresses neuroinflammation and ischemic brain injury by inhibiting SR-A expression, thus offering a new target for prevention of ischemic brain injury.

Presurgical visualization of the neurovascular relationship in trigeminal neuralgia with 3D modeling using free Slicer software.

OBJECTIVE: To explore whether segmentation and 3D modeling are more accurate in the preoperative detection of the neurovascular relationship (NVR) in patients with trigeminal neuralgia (TN) compared to MRI fast imaging employing steady-state acquisition (FIESTA). METHOD: Segmentation and 3D modeling using 3D Slicer were conducted for 40 patients undergoing MRI FIESTA and microsurgical vascular decompression (MVD). The NVR, as well as the offending vessel determined by MRI FIESTA and 3D Slicer, was reviewed and compared with intraoperative manifestations using SPSS. RESULTS: The k agreement between the MRI FIESTA and operation in determining the NVR was 0.232 and that between the 3D modeling and operation was 0.6333. There was no significant difference between these two procedures (χ2 = 8.09, P = 0.088). The k agreement between the MRI FIESTA and operation in determining the offending vessel was 0.373, and that between the 3D modeling and operation was 0.922. There were significant differences between two of them (χ2 = 82.01, P = 0.000). The sensitivity and specificity for MRI FIESTA in determining the NVR were 87.2 % and 100 %, respectively, and for 3D modeling were both 100 %. CONCLUSION: The segmentation and 3D modeling were more accurate than MRI FIESTA in preoperative verification of the NVR and offending vessel. This was consistent with surgical manifestations and was more helpful for the preoperative decision and surgical plan.

Analysis of the embolization spinal dural arteriovenous fistula and surgical treatments on 52 cases of the patients.

BACKGROUND: Spinal dural arteriovenous fistula (SDAVF) highly threatens people's life and health. Effective methods for the diagnosis and treatment of the disease are badly needed in clinical application. OBJECTIVE: The objective of the present study was to sum up the diagnosis and treatment method of SDAVF to improve the diagnosis and treatment effect of the disease. METHODS: The epidemiological data, imaging data, therapeutic methods and postoperative follow-up data of 52 cases of patients with SDAVF received in our hospital in recent 6 years were collected and retrospectively analyzed. RESULTS: There were 43 male patients and 9 female patients with ages of 39-77 years and average age of 59.6 years. The course of disease was 1 to 48 months with an average disease course of 14.4 months. All the patients had syndromes of lower limb numbness, pain, weakness and other sensory and movement disorders mostly accompanied with defecation dysfunction. Magnetic resonance imaging (MRI) results demonstrated that spinal cord abnormalities were found in spinal cord, which could be diagnosed by digital subtraction angiography (DSA) examination. There were 40 cases received surgical treatment and there was no recurrence in the follow-up. There were 12 patients received embolotherapy, of whom 3 patients were operated the second time and 2 patients had embolization again. After 0.5-6 years of follow-up, postoperative symptoms of the 40 patients were improved in different degrees. The modified Aminoff-Logue function scoring was significantly decreased after treatment. CONCLUSION: SDAVF is the easily diagnosed and delayed spinal cord vascular lesions in clinical applications. The diagnosis relies mainly on MRI and DSA examinations. The surgical treatment effect is good and is not easily relapsed. The trauma of the interventional embolization treatment is small, but the recurrence rate is high.

Treatment of Hawkins type II fractures of talar neck by a vascularized cuboid pedicle bone graft and combined internal and external fixation: a preliminary report on nine cases.

BACKGROUND: Fractures of the talar neck are relatively uncommon. The reported rates of avascular necrosis in Hawkins type II fractures vary from 34% to 50%. Various strategies have been adapted to prevent the occurrence of avascular necrosis. METHODS: We retrospectively reviewed the records of nine patients with Hawkins type II fractures. Open reduction and internal fixation with percutaneous cannulated screws were performed, and external fixation was used to unload the talus. A vascularized cuboid pedicle bone graft based on the lateral tarsal artery is adapted to improve the blood supply to the talar body. Postoperative radiographs were used to evaluate the adequacy of the reduction and the process of fracture healing. Osteonecrosis was defined on plain radiographs as any area of increased density of the talar dome relative to the adjacent structures. The postoperative global foot function was assessed using the Maryland Foot Rating Score. RESULTS: The average length of follow-up was 39 months (range, 16-58 months). The mean time to fixation was 54.4 hours. In all of the cases, the wound was closed primarily, and there were no postoperative infections or skin necrosis. Fractures healed uneventfully in all the patients with an average time to union as 15.6 weeks (range, 13-18 weeks). The avascular necrosis rate of talus was 0%. Hawkins sign was seen in one patient at 8 weeks after surgery in the anteroposterior view. According to the Maryland Foot Rating Score, excellent result (90-100) in seven cases and good result (75-89) in two cases were seen. CONCLUSION: The use of a vascularized cuboid pedicle bone graft and combined internal and external fixation can effectively prevent avascular necrosis of the talus in preliminary study. Further randomized control research is necessary to clarify the effectiveness of this technique.