A Microanatomical Study of the Far Lateral Approach.

OBJECTIVE: The far-lateral approach (FLA) remains a challenge for neurosurgeons due to the complex anatomy of this region, especially in patients with anatomical variations. There is therefore an urgent need for better quantitative knowledge of the microsurgical anatomy of the FLA. METHODS: The study was performed using the dried skulls and atlas vertebrae of 50 Chinese adults, in which significant clinical parameters were measured. We further used 12 cadaveric heads to simulate the FLA to explore the step-by-step anatomy entailed by this procedure, enabling us to obtain key images and related information. RESULTS: Limited to hypoglossal canal, the occipital condyle posterior was abraded by roughly 10 mm, which provided good exposure to the ventral front of the foramen magnum. When occipital artery exits the occipital groove, the mean diameter was 2.20 mm. The average occipital artery suboccipital segment length was 65.26 mm. The posterior spinal artery (PSA) and posterior inferior cerebellar artery (PICA) generally originated from the fourth vertebral artery segment intradurally, and the mean distances from the PSA and PICA to the dural entry point of the vertebral artery were 2.62 mm and 8.71 mm, respectively. The incidence of PSA and PICA arising from the third vertebral artery segment was 16.67% and 4.17%, respectively. CONCLUSIONS: Understanding the important anatomic structures of the CVJ region and developing improved knowledge of the microsurgical anatomy of the FLA offer an opportunity to ensure safe exposure and treatment of lesions in the ventral and ventrolateral regions of the CVJ.

Ghrelin Ameliorates Traumatic Brain Injury by Down-Regulating bFGF and FGF-BP.

Traumatic brain injury (TBI) is a primary cause of disability and mortality. Ghrelin, a gastrointestinal hormone, has been found to have protective effects for the brain, but the molecular mechanism of these neuroprotective effects of ghrelin remains unclear. In this study, an electronic cortical contusion impactor was used to establish a rat TBI model and we investigated the effect of ghrelin on brain repair by neurological severity score and histological examination. An antibody array was employed to uncover the molecular mechanism of ghrelin's neuroprotective effects by determining the alterations of multiple proteins in the brain cortex. As a result, ghrelin attenuated brain injury and promoted brain functional recovery. After TBI, 13 proteins were up-regulated in the brain cortex, while basic fibroblast growth factor (bFGF) and fibroblast growth factor-binding protein (FGF-BP) were down-regulated after ghrelin treatment. It is known that bFGF can induce angiogenesis in the brain and accelerate wound healing, which can be further enhanced by FGF-BP. Based on the previous studies, it is hypothesized that the exogenous ghrelin curing TBI might cause the closure of bFGF and FGF-BP functions on wound healing, or ghrelin might exert the neuroprotective effects by competitively inhibiting bFGF/FGF-BP-induced neovascularization. Whether the combinational administration of ghrelin and bFGF/FGF-BP can enhance or weaken the therapeutic effect on TBI requires further research.

Predictors Associated With Post-Traumatic Hydrocephalus in Patients With Head Injury Undergoing Unilateral Decompressive Craniectomy.

OBJECTIVE: Post-traumatic hydrocephalus (PTH) makes recovery from head trauma after decompression more complicated and is associated with high risks of clinical deterioration and poor outcomes. The aim of this study was to verify the predictors associated with the development of PTH in patients with head injury undergoing unilateral decompressive craniectomy (DC). METHODS: Among traumatic brain injury (TBI) patients who underwent unilateral DC between January 2013 and December 2016, the clinical medical records, radiological information, and changes of patients' conditions in the 3-month after injury were reviewed retrospectively. RESULTS: 183 TBI patients after unilateral DC were analyzed, and 50 (27.32%) of them suffered PTH based on head CT scans. Univariate and multivariable analyses revealed that older age (p = 0.002), the Glasgow Coma Scale (GCS) score at admission (p < 0.001), intraventricular hemorrhage (IVH; p = 0.008), post-traumatic cerebral infarction (PCI; p = 0.007), and postoperative meningitis (p = 0.016) were independent predictors for the hydrocephalus after DC. Receiver operating characteristic curves were created and the area under the curve (AUC) were calculated to further assess the accuracy of the variables for predicting PTH. The AUC was 0.836 for the combined all five independent factors (95% confidence interval: 0.775-0.887). CONCLUSION: TBI patients who undergo unilateral DC with advanced age, lower GCS score at admission, coexisting IVH, PCI, and/or postoperative meningitis should be closely monitored at follow-up assessments for earlier prediction of PTH.

Risk Factors Predicting Posttraumatic Hydrocephalus After Decompressive Craniectomy in Traumatic Brain Injury.

OBJECTIVE: To identify risk factors for predicting posttraumatic hydrocephalus (PTH) development after traumatic brain injury in patients who underwent decompressive craniectomy (DC). METHODS: This retrospective study included 121 patients who underwent DC performed by 6 different neurosurgeons after traumatic brain injury between January 2013 and December 2016 at Yijishan Hospital and were still alive at 6-month follow-up. Patients were divided into PTH group and non-PTH group. Logistic regression analysis was used to identify PTH potential risk factors based on results obtained from univariate analysis. Power of the regression model to discriminate PTH from non-PTH was evaluated using receiver operating characteristic curve. RESULTS: With Glasgow Coma Scale (GCS) score cutoff value of 6, GCS scores <6 on admission, craniectomy site, and intraventricular hemorrhage (IVH) were significant predictors for development of PTH after DC. Receiver operating characteristic curve indicated that a final predictive model composed of these 3 factors (area under the curve [AUC] = 0.866, sensitivity = 0.78, and specificity = 0.83) was significantly better than each single model (AUC = 0.750 for GCS scores on admission, AUC = 0.650 for craniectomy site, AUC = 0.572 for IVH). A significantly positive association was found between patients' Glasgow Outcome Scale Extended scores and GCS scores on admission, whereas a significantly negative association was found between IVH, craniectomy site, and Glasgow Outcome Scale Extended. CONCLUSIONS: GCS scores <6 on admission, presence of IVH on first head computed tomography scan, and need for bilateral DC might be used to predict whether patients with traumatic brain injury after DC will develop PTH. The reliability of this specific combination might be useful for clinicians to make a correct prediction.