The long-term outcome predictors of pure microvascular decompression for primary trigeminal neuralgia.

OBJECTIVE: The aim of this study is to provide credible and comparable evidence on the efficacy and safety of pure microvascular decompression (MVD) for primary trigeminal neuralgia (TN), and also to find out the possible prognostic factors of excellent long-term outcome after the surgery. METHODS: A prospective cohort study was conducted, involving the patients who met the diagnostic criteria of primary TN (both typical and atypical). The cohort patients underwent pure MVD, and then were followed up by independent neurologists. The possible prognostic factors were analyzed by the logistic method. RESULTS: All 154 consecutive primary TN patients (98 typical, 56 atypical) underwent pure MVD from January 2001 to November 2005. The patients were followed up for median 5.6 years (10 lost in 5 years). Respective initial and 5-year's complete pain-free without medication (Barrow Neurological Institute pain score, I) rates were 84% and 72% for total primary TN, 87% and 80% for typical TN, and 79% and 54% for atypical TN. The Kaplan-Meier survival curves of 5 years demonstrated different long-term outcomes in different groups (typical TN vs. atypical TN). The typical symptoms (odds ratio [OR], 2.776), preoperative magnetic resonance indicating vessel compression (OR, 2.950), and obvious vessel compression found during operation (OR, 3.219) were proved to have a positive effect on long-term pain relief without medication. CONCLUSIONS: This is a perspective cohort study of pure MVD, which confirms the long-term effectiveness and safety of the surgery for primary TN. Patients with typical symptoms, positive magnetic resonance findings, or obvious vessel compressions might have better long-term prognosis.

Endovascular treatment of traumatic pseudoaneurysm presenting as intractable epistaxis.

OBJECTIVE: To investigate the clinical efficacy of individual endovascular management for the treatment of different traumatic pseudoaneurysms presenting as intractable epistaxis. MATERIALS AND METHODS: For 14 consecutive patients with traumatic pseudoaneurysm presenting as refractory epistaxes, 15 endovascular procedures were performed. Digital subtraction angiography revealed that the pseudoaneurysms originated from the internal maxillary artery in eight patients; and all were treated with occlusion of the feeding artery. In six cases, they originated from the internal carotid artery (ICA); out of which, two were managed with detachable balloons, two with covered stents, one by means of cavity embolization, and the remaining one with parent artery occlusion. All of these cases were followed up clinically from six to 18 months, with a mean follow up time of ten months; moreover, three cases were also followed with angiography. RESULTS: Complete cessation of bleeding was achieved in all the 15 instances (100%) immediately after the endovascular therapies. Of the six patients who suffered from ICA pseudoaneurysms, one presented with a permanent stroke and one had an episode of rebleeding requiring intervention. CONCLUSION: In patients presenting with a history of craniocerebral trauma, traumatic pseudoaneurysm must be considered as a differential diagnosis. Individual endovascular treatment is a relatively safe, plausible, and reliable means of managing traumatic pseudoaneurysms.

Cerebrospinal fluid absorption disorder of arachnoid villi in a canine model of hydrocephalus.

BACKGROUND: Hydrocephalus results from inadequate passage of cerebrospinal fluid (CSF) from its point of production within the cerebral ventricles to its point of absorption into systemic circulation. AIMS: The objective of this study was to investigate the disorders of CSF absorption by arachnoid villi during the different phases of hydrocephalus. MATERIALS AND METHODS: Silicone oil was injected into the fourth ventricle of 15 canines as an experimental group. Saline solution (0.9% NaCl) was injected in another nine canines as a control group. In order to block CSF transport through the cribriform plate, an external ethmoidectomy was performed in five dogs from experimental group and three dogs from control group at three days (acute stage), two weeks (sub-acute stage), and 12 weeks (chronic stage) respectively. Tritiated water was injected into the canines' cortical subarachnoid space and blood levels were measured at intervals of 1 h, 4 h, 8 h, 16 h and 48 h respectively. Time-concentration curve of tritiated water was drafted. The area under the curve (AUC) was calculated for variance analysis and t-testing. RESULTS: In the chronic group, the tritiated water concentration rose slowly to a peak at 16 h. It was significantly lower than other groups at 1h, 4h, 8h and 16 h, but was higher than other groups at 48 h. Analysis of the AUC showed significant differences among all the groups (P<0.01). There were no significant differences in the AUC between control groups, the acute group, and the sub-acute group (P>0.05); however, the AUC of the chronic group was significantly lower than other groups (P<0.05). CONCLUSIONS: The CSF absorption ability of arachnoid villi is significantly damaged in a long-term state of hydrocephalus.

CSF fistula through the left lumbar region in adult following a ventriculoperitoneal shunt surgery: a rare case report.

A cranial spinal fluid fistula through left lumbar region following a ventriculoperitoneal (VP) shunt is an extremely rare complication. We report a 25-year-old man who presented with the leakage of clear fluid from the left lumbar region, 3 years after a VP shunt surgery. Computerized tomography scan of abdomen revealed that the distal end of the catheter penetrated into the inner layer of the wall of left lumbar region. He was managed successfully with abdominal part of shunt catheter removal from primary cervical and abdominal incision, a new abdominal part of VP shunt catheter replacement and prophylactic antibiotic.

Ruptured intracranial dermoid cyst with infarction in the basal ganglia--case report.

A 32-year-old, right-handed man presented with chronic headache persisting for the past 5 years. On admission, neurological examination revealed mild papilledema and bitemporal defects of the visual fields. Computed tomography showed a hypodense lesion in the suprasellar region. Magnetic resonance imaging revealed a 2.2 x 2.4 x 2.5-cm heterogeneously hyperintense lesion in the suprasellar region and an infarct region in the right basal ganglia on the T(1)- and T(2)-weighted images. The lesion was subtotally removed because part of the capsule was tightly adherent to important surrounding neurovascular structures. Histological analysis confirmed the diagnosis of dermoid cyst. Ruptured intracranial dermoid cyst may manifest as infarction in the basal ganglia caused by localized arterial inflammatory reaction combined with compression of the right internal carotid artery.

Giant cranionasal schwannoma.

Giant schwannomas concomitantly involving the intracranial and nasal cavities are rare. We report a 22-year-old male patient with a giant schwannoma involving the frontal skull base and extending into the nasal cavity. The patient had a 2-year history of nasal obstruction that was originally misdiagnosed as nasal polyps. A CT scan and an MRI revealed a large cranionasal tumor. Surgery was performed using a coronal incision with a bilateral frontal skull base extradural approach. The tumor originated from the anterior skull base and the dura and nasal mucosa were intact. Histopathology was consistent with a schwannoma. Schwannoma should be listed as part of the differential diagnosis of a cranionasal tumor and the surgical approach should be carefully selected to achieve total resection.

Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery.

Primitive trigeminal artery (PTA) and primitive otic artery (POA) is a very rare entity in adult life. We present a case of PTA and POA associated with a giant unruptured cavernous aneurysm in a 54-year-old woman. The PTA and the POA arose from the sac of the aneurysm directly, which greatly complicated endovascular therapy management.

A delayed frontorbital abscess caused by a penetrating nonmissile foreign body (a bamboo stick).

We report an interesting case of delayed frontal abscess caused by a penetrating nonmissile foreign body, a bamboo stick in a 1.5-year-old male child. A parietal craniotomy was performed, and the brain abscess was resected along with the foreign body without any damage to the surrounding brain tissue. He also received the appropriate antibiotics. The child made a good recovery.

An Echinococcosis multilocularis presenting as a giant anterior cranial basilar tumor.

Cerebral alveolar hydatid disease is a rare subtype of Echinococcus, and prevalent in northern China and Tibetan area. In this report, we presented a giant lesion of Echinococcus multilocularis which located in anterior cranial fossa, and discussed its clinicopathological and radiological features, and strategy of treatment.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms.

OBJECT: Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. METHODS: Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. RESULTS: Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. CONCLUSIONS: Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

[Microsurgery for intracranial aneurysm:analysis of 438 cases].

OBJECTIVE: To summarize the experience of surgical therapy in a series of 438 patients with intracranial aneurysms. METHODS: A retrospective analysis was made on the clinical data of 438 patients, in terms of the perioperative management, timing of surgery, surgical skills, and The HUNT-HESS grade. RESULTS: 438 patients with 476 aneurysms underwent microsurgery, in which 450 aneurysms were clipped, 14 were wrapped, 8 were isolated,4 were cut. 32 aneurysms were ruptured (6.72%) during the operation. The relation between Hunt-Hess scale and mortality is significant postpone operation (> or =7 d) has got a better curative effect than the early. CONCLUSIONS: Microsurgical treatment is a confirmed effective method with intracranial aneurysms. The higher of HUNT-HESS grade will result to the worse clinical outcome.

The postoperative brain tumour stem cell (BTSC) niche and cancer recurrence.

Currently, surgical resection is one of only a few options for treating brain cancer. Unfortunately, postoperative tumour recurrence remains almost inevitable despite additional radiation or chemotherapy treatment following resection. Clinical observations and a growing body of experimental evidence have led to speculation that there is a population of persistent brain tumour stem cells (BTSCs)--or brain tumour initiating cells--that are difficult to completely remove surgically. Furthermore, residual BTSCs following surgery may actually be more resistant to subsequent radiation and/or chemotherapies. It remains to be determined if brain surgeries render the postoperative tissue microenvironment more favourable for the survival and growth of BTSCs, and therefore the recurrence of brain tumours.We hypothesise that BTSC-based tumour recurrence may develop within a specific niche of the aberrant tumour microenvironment. Even when the gross appearance of the primary tumour seems confined, BTSCs (albeit accounting only for a small population of tumour cells) may microscopically enter the stroma, hampering curative surgeries. This article discusses the theory that surgical resection of brain tumours generates niches recruiting BTSCs to the surgical wounds, stimulating the proliferation and invasiveness of BTSCs, and leading to tumour recurrence. Postoperative brains are marked with active wound repair in peritumoural margins, which is likely to be accompanied by increased inflammatory paracrine production, angiogenesis and reactive astrogliosis. The postoperative BTSC niche concept is consistent with the observation that brain tumour recurrence usually occurs in tissues that are proximal to the resection margin. In this article, we intend to reflect recent advances that may lead to novel strategies to eliminate postoperative brain tumour recurrence.

Intraventricular vascular malformations mimicking tumors: case reports and review of the literature.

Vascular malformations of the ventricular system are rare, and their clinical and radiologic characteristics vary depending on the location of the lesions. Many types are described, but a comprehensive summary is lacking. Herein, we add two cases to the literature and review known types of ventricular vascular malformations. One case involved a 37-year-old woman who presented with headache due to hydrocephalus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion of the foramen of Monro. The other case involved a 7-year-old boy who had dizziness and headache due to hydrocephalus. CT and MRI demonstrated a lesion of the third ventricle. In both cases, the images mimicked those of tumors with or without bleeding. As a result, the malformations were misdiagnosed, though surgical treatment was successful. In both cases, the lesions were proven to be arteriovenous malformations on pathologic evaluation. Correct diagnosis of ventricular vascular malformations is sometimes difficult but essential for good treatment planning. Their incidence is low. However, their bleeding and rebleeding rate is high, and they commonly cause hydrocephalus. Treatment should be timely and based on the type of lesion and its presentation.

[Efficacy of total removal or subtotal removal combined gamma knife radiation on giant pituitary adenoma: a report of 160 cases].

BACKGROUND & OBJECTIVE: Pituitary adenoma, a kind of familiar benign intracranial tumor, is mainly treated with surgical operation, medication, and radiation. However, the outcome, especially for giant pituitary adenoma, is not very satisfactory. This study was to explore the efficacy of total tumor removal or subtotal tumor removal combined gamma knife radiation on giant pituitary adenoma. METHODS: Clinical data of 160 giant pituitary adenoma patients were analyzed. Of the 160 patients, 90 received total tumor removal, 70 received subtotal tumor removal combined gamma knife radiation. The symptom improvement, tumor size change, serum hormone concentration, complications after treatment, and so on, of the 2 groups were compared. RESULTS: At 12 months after treatment, the efficiency rate, recurrence rate, and mortality were 74.4%, 31.1%, and 3.3%, respectively, in total tumor removal group; however, the efficiency rate reached 91.4%, the recurrence rate decreased to 11.4%, and no patients died in combined therapy group. The follow-up results at 24 months after treatment and at present (over 5 years) showed that though the efficiency rate had descended and recurrence rate or mortality had ascended in both groups, the efficacy of combined therapy was obviously better than that of total tumor removal. The decrease of serum hormone concentration was more obvious in combined therapy group than in total tumor removal group at 12 months after treatment. Moreover, total tumor removal group had more serious complications than combined therapy group after treatment. CONCLUSION: Subtotal tumor removal combined gamma knife radiation is better than total tumor removal for giant pituitary adenoma.

[Expressions of CD31 and vWF in arachnoid villus endothelium cell from experimental animal with Hydrocephalus].

OBJECTIVE: The aim of this study was to investigate the CD-31 and vonWillebrand factor (vWF) expressions and the cell morphological alterations ofarachnoid villus endothelium in different stages of animal hydrocephalus. METHODS: Silicon oil was injected into the fourth ventricle of experimental canine for buildinghydrocephalus model. The post-injection ethology of the canine was observed, and thescoring of Tarlov n was performed. The magnetic resonance (MR) images of canineskulls were achieved for verification of hydrocephalus at 3 day, 2 weeks, and 12 Cweeks post-injection. The expressions of CD-31 and von Willebrand factor (vWF) inthe arachnoid villus endothelium cells at different stages of hydrocephalus werestudied by immunofluorescence histochemistry. RESULTS: Experimental hydrocephalusanimal model was built up satisfactorily by injection of silicon oil. Experimentalcanines appeared the hydrocephalus symptoms and Tarlov scoring decrease. MRimages revealed progressive ventricular enlargement in different stages ofhydrocephalus. The immunofluorescence histochemistry staining showed that CD31 expressed positively in all the endothelium cells, including the endothelium cell of thevillus. The immunofluorescence histochemistry staining showed that the vWFexpression in the endothelium of the villus was diminished when compared to that innormal sinus wall. And in sub-acute and chronic hydrocephalus, the expression of vonWillebrand factor increased. CONCLUSIONS: The fourth ventricular injection of siliconoil may induce the hydrocephalus animal model. The expression of von Willebrandfactor in the endothelium cell of arachnoid villus increases during progressedhydrocephalus.

A comparative study on therapeutic method of traumatic epidural hematoma.

OBJECTIVE: To explore the therapeutic methods, surgical indications and clinical practice of minimally invasive surgery on traumatic epidural hematoma (EDH). METHODS: Retrospective study was made on 135 patients with traumatic EDH admitted into our hospital from June 2002 to August 2005. Sixty-five patients were treated with mini-invasive negative pressure drainage (treatment group), 70 patients with comparable condition used traditional craniotomy (control group). The mean time of operation, average days in hospital, expenditure and prognosis of two groups were recorded and analyzed. RESULTS: There was no significant difference in therapeutic efficacy between two groups. Patients in treatment group had a shorter hospital stay and less expenditure than those in control group. CONCLUSION: Mini-invasive negative pressure drainage is simple, effective, economical and applicable to some traumatic EDH patients.

[Cathepsin B expression and malignances and angiogenesis in gliomas].

OBJECTIVE: To test the expression of Cathepsin B (CB) protease in gliomas and to investigate its correlation with the malignance and angiogenesis of gliomas. METHODS: Immunochemistry technique of strept actividin-biotin complex (SABC) was used to identify the CB expression and to measure the microvessel density (MVD) in 47 gliomas samples and 5 normal human brain tissues from patients with spontaneous cerebral hemorrhage. RESULTS: No CB expression was detected in the normal brain tissues. The expression levels of CB in astrocytoma, anaplastoma, and glioblastoma were 30% (6/20 weak positive), 86.7% (3/15 weak and, 10/15 moderate positive), and 100.0% (2/12 moderate and 10/12 strong positive), respectively. The malignances of gliomas increased with CB expression (r=0. 77, P<0.05). The MVD also increased with CB expression (r= 0.56, P<0. 05), with an average of 15.57 +/- 8.52, 22.50 +/- 14.42, 39.85 +/- 8.75 and 49.90 +/- 11.30 for the negative, weak, moderate, and strong CB expression gliomas respectively. CONCLUSION: CB expression is positively correlated with the malignances and angiogenesis of gliomas. CB expression could be one of the indicators for the degree of malignances and invasion of gliomas.

[An experimental research of hyperthermic preconditioning on the spinal cord injury].

OBJECTIVE: To assess the effects of hyperthermic preconditioning on spinal cord injury(SCI) in rats. METHODS: A total of 96 SD rats were divided into control(A), trauma(B) and hyperthermic preconditioning (C) group. SCI models were made by static compression. The animals were decapitated at 6 h, 12 h, 1 d, 2 d, 3 d, 1 w, 2 w and 3 w after injury. With in situ hybridization and immunohistochemistry, the expression of HSP70 after spinal cord injury was studied at the transcript level and translation level respectively. Neurological outcome was evaluated by the combined behavioral score (CBS). RESULTS: Neurological outcome in Group C was significantly higher than that in Group B (P < 0.05). In-situ hybridization and Immunohistochemistry analysis showed that expression of HSP70 in spinal cord elevated after hyperthermic preconditioning; furthermore, the level of HSP70 in Group C was significantly higher than that in Group B (P < 0.05). CONCLUSION: Hyperthermic preconditioning might improve neurological outcome after spinal cord injury in rats, and the protective mechanism in this connection might involve the induction of HSP70 synthesis in spinal cord.

[Neuroprotective effect of exogenous vascular endothelial growth factor on anoxic rat spinal cord astrocyte and the underlying mechanism].

OBJECTIVE: To observe the effect of hypoxia on primary cultured rat spinal cord astrocyte and investigate the neuroprotective effect of exogenous vascular endothelial growth factor (VEGF) on anoxic astrocyte in vitro. METHODS: The rat embryonic spinal cord astrocytes were cultured and identified by cellular morphology and glial fibrillary acidic protein (GFAP). The astrocytes were treated with VEGF at different concentrations (10 ng/ml-100 ng/ml) as well as with VEGF receptor (Flk-1) inhibitor SU1498. Then the astrocytes were exposed to hypoxia for different time. The light microscope, MTT assay, TUNEL labeling and SABC immuno-histochemistry were used to measure and observe the changes of the astrocytes in cell morphology, growth, proliferation, GFAP identified that 98% of the purified 1-week cultured cells apoptosis, VEGF and Flk-1 expression. RESULTS: were astrocytes. 8-12 hours hypoxia obviously induced the activity of astrocyte. The cytobody became bigger, the cytoskeleton grew thicker. The activity of proliferation decreased but apoptosis index increased. The GFAP, VEGF and Flk-1 expression increased. The treatment with 50 ng/ml VEGF 20-24 hours before hypoxia apparently enhanced the activity, decreased the apoptosis index of the astrocytes, and hence improved the hypoxia-injuried astrocytes. Howerver, 700 ng/ml SU1498 obviously inhibited the neuroprotective effect of VEGF on anoxic astrocytes. CONCLUSION: Hypoxia induces reactive activity of astrocyte. The exogenous VEGF exerts neuroprotective effect on astrocytes via VEGF receptor-Flk-1.