Incidence and Possible Predictors of Sodium Disturbance After Craniopharyngioma Resection Based on QST Classification.

OBJECTIVE: Serum sodium abnormalities are one of the most common manifestations after radical craniopharyngioma (CP) excision. The aim of this study was to report the incidence and possible predictors of serum sodium disturbance and explore features of sodium destabilization manifestation among QST classification results after CP resection. METHODS: A retrospective analysis was performed of clinical, biochemical, radiologic, and operative data for 134 successive patients who underwent primary CP removal between September 2016 and March 2018. Univariate and multivariate analyses were conducted to determine predictors. RESULTS: Sixty patients (44.8%) experienced hyponatremia and 67 patients (50%) hypernatremia; the median time of onset was 6 days and the first day after surgery, respectively. The incidence, onset, severity, and type of sodium disturbance among different types of CP differed significantly based on statistical tests (P < 0.05). Sodium disturbance was more common and severe in patients with type T tumors (P < 0.05). Age, tumor type, and preoperative diabetes insipidus were independent prognostic factors for obvious disorders of serum sodium. CONCLUSIONS: Hyponatremia/hypernatremia is common after primary CP resection. The site of tumor origin has a direct effect on the growth pattern of CP, which may serve as a useful index for anticipating sodium perturbation after surgery. The level of sodium in children and patients with type T tumors, preoperative diabetes insipidus should be monitored closely throughout hospitalization.

Core competencies in neurocritical care training in China: consensus developed by a national Delphi consensus survey combined with nominal group technique.

OBJECTIVES: To define the core competencies essential for specialist training in neurocritical care in China. DESIGN: Modified Delphi method and nominal group (NG) technique. SETTING: National. PARTICIPANTS: A total of 1094 respondents from 33 provinces in China participated in the online survey. A NG of 11 members was organised by the Neuro-Critical Care Committee affiliated with the Chinese Association of Critical Care Physicians and the National Center for Healthcare Quality Management in Neurological Diseases. RESULTS: 1094 respondents from 33 provinces in China participated in the online survey. A formal list containing 329 statements was generated for the rating by a NG. After five rounds of NG meetings and one round of comments and iterative review, 198 core competencies (54 on neurological diseases, 64 on general medical diseases, 42 on monitoring of practical procedures, 20 on professionalism and system management, five on ethical and legal aspects, three on the principles of research and certification and 10 on scoring systems) formed the final list. CONCLUSION: By using consensus techniques, we have developed a list of core competencies for neurocritical care training, which may serve as a reference for future specialist training programmes in China.

Traumatic brain injury in China.

China has more patients with traumatic brain injury (TBI) than most other countries in the world, making this condition a major public health concern. Population-based mortality of TBI in China is estimated to be approximately 13 cases per 100 000 people, which is similar to the rates reported in other countries. The implementation of various measures, such as safety legislation for road traffic, establishment of specialised neurosurgical intensive care units, and the development of evidence-based guidelines, have contributed to advancing prevention and care of patients with TBI in China. However, many challenges remain, which are augmented further by regional differences in TBI care. High-level care, such as intracranial pressure monitoring, is not universally available yet. In the past 30 years, the quality of TBI research in China has substantially improved, as evidenced by an increasing number of clinical trials done. The large number of patients with TBI and specialised trauma centres offer unique opportunities for TBI research in China. Furthermore, the formation and development of research collaborations between China and international groups are considered essential to advancing the quality of TBI care and research in China, and to improve quality of life in patients with this condition.

Endoplasmic reticulum stress induces apoptosis of arginine vasopressin neurons in central diabetes insipidus via PI3K/Akt pathway.

AIMS: Central diabetes insipidus (CDI), a typical complication caused by pituitary stalk injury, often occurs after surgery, trauma, or tumor compression around hypothalamic structures such as the pituitary stalk and optic chiasma. CDI is linked to decreased arginine vasopressin (AVP) neurons in the hypothalamic supraoptic nucleus and paraventricular nucleus, along with a deficit in circulating AVP and oxytocin. However, little has been elucidated about the changes in AVP neurons in CDI. Hence, our study was designed to understand the role of several pathophysiologic changes such as endoplasmic reticulum (ER) stress and apoptosis of AVP neurons in CDI. METHODS: In a novel pituitary stalk electric lesion (PEL) model to mimic CDI, immunofluorescence and immunoblotting were used to understand the underlying regulatory mechanisms. RESULTS: We reported that in CDI condition, generated by PEL, ER stress induced apoptosis of AVP neurons via activation of the PI3K/Akt and ERK pathways. Furthermore, application of N-acetylcysteine protected hypothalamic AVP neurons from ER stress-induced apoptosis through blocking the PI3K/Akt and ERK pathways. CONCLUSION: Our findings showed that AVP neurons underwent apoptosis induced by ER stress, and ER stress might play a vital role in CDI condition through the PI3K/Akt and ERK pathways.

[An improved method for stereotactic location of the supraoptic nucleus with oblique stereotactic puncture in rats].

OBJECTIVE: To establish an improved method for stereotactic location of the supraoptic nucleus in rats. METHODS: Twenty-four SD rats were randomly divided into experimental group (12 rats) and control group (12 rats) for oblique (20° to the left) stereotactic puncture (OSP group) and vertical stereotactic puncture (VSP group), respectively, both targeting the supraoptic nucleus (SON). The surgical data and postoperative (within 24) mortality of the rats were compared between the two groups. RESULTS: The nucleus locating time was longer in OSP group than in VSP group (59.55∓3.64s vs 27.44∓2.18 s, P=0.000), and the postoperative mortality rate of the rats did not differ significantly between the groups (0 vs 44.4%, P=0.082). In OSP group, compared with VSP group, the procedure was associated with a lowered rupture rate of the superior sagittal sinus (11.1% vs 88.9%, P=0.003), a shortened hemostatic time after craniotomy (52.89∓24.05 s vs 157.445 ime a s, P=0.000) and after puncture (24.33 reas 45 s vs 133.89∓28.81 s, P=0.000), and also a shortened operation time (178.89 on tims vs 362.44 timees, P=0.000). CONCLUSION: The improved method for locating supraoptic nucleus in rats is convenient, stable and reproducible, and helps to avoid important blood vessels and specific nuclei according to the needs of different experiments and allows the operators to choose different surgical paths.

Bifocal germinomas in the pineal region and hypothalamo-neurohypophyseal axis: Primary or metastasis?

Whether bifocal germinomas (BFGs) synchronously presenting within the pineal region and the hypothalamo-neurohypophyseal axis (HNA) are primary germinomas of dual-origin remains to be elucidated. We analyzed MRI images and clinical features of 95 neurohypophyseal germinomas and 21 BFG patients and developed a tentative definition of the BFGs. We found dual-primary BFGs (true BFGs) do exist. The fundamental difference between primary and metastatic HNA germinomas was the direction of tumor growth. For a true BFG, the primary HNA tumor grew from the neurohypophysis toward the hypothalamus and almost invaded the whole pituitary stalk. For a false BFG (primary pineal germinoma with HNA metastasis), the metastatic HNA tumor first appeared at the third ventricular floor (TVF), grew toward the neurohypophysis, but commonly did not invade the inferior pituitary stalk. Compared to false BFGs, true BFGs commonly had diabetes insipidus as the first symptom, dysfunction of the anterior pituitary, no high-intensity MRI signal at the posterior pituitary, a larger extension of the HNA tumor, and fewer numbers of remote lesions from cerebrospinal fluid seeding. Accordingly, 12.8% (12/96) of our germinoma patients had true BFGs, and of these, 58.3% (7/12) were free of remote metastases and warranted treatment with limited radiotherapy. True BFGs with remote metastases and all false BFGs should be treated with craniospinal irradiation. We provided evidence for the diagnosis of true BFGs that is useful for radiotherapy strategy, suggesting that the existence of metastasis to other locations is not a diagnostic criterion for a true BFG.

[Operative strategies for bilateral brain contusion and laceration].

OBJECTIVE: To explore the operative strategies for bilateral brain contusion and laceration and evaluate their clinical significance. METHODS: Based on the clinical manifestations, computed tomography (CT) and intracranial pressure (ICP), different operative strategies were applied to 25 cases of bilateral brain contusion and laceration. The strategies were classified into 6 types according to the principles of decompression and brain protection.All cases received routine treatments at neurosurgical intensive care unit (ICU) ward. And the occurrences of operative complications and 6-month Glasgow outcome scale (GOS) were statistically analyzed. RESULTS: Type 1:4 cases of unilateral decompressive craniectomy without resection of contusion focus; Type 2:8 cases of unilateral decompressive craniectomy with resection of bilateral contusion focus; Type 3:5 cases of bilateral decompressive craniectomy with resection of unilateral brain contusion; Type 4:5 cases of bilateral decompressive craniectomy; Type 5:1 case of bilateral brain contusion resection; Type 6:2 cases of bilateral decompressive craniectomy and brain contusion resection.Postoperative complications such as epilepsy, expanding contusion foci, brain infarction, encephalocele, incisional CSF leakage, intracranial infection, subdural hydroma and hydrocephalus were rare. The 6-month GOS revealed 6 cases of good outcome (n = 6), moderate disability (n = 8), severe disability (n = 3) and vegetative status (n = 5) and death (n = 3). CONCLUSION: Different operative strategies may be applied for severe brain contusion and laceration according to their clinical manifestations, CT findings and ICP values. And the efficacies are improved by operative strategies based on the principles of ICP control, prevention of secondary injury and brain function preservation.

[Pathological features and origin of primary pineal mixed germ cell tumors].

OBJECTIVE: To investigate the origin of mixed germ cell tumors in the pineal region based on the image data, surgical findings and pathological examination of the tumor. METHODS: The preoperative CT and magnetic resonance imaging (MRI) findings and tumor specimens were retrospectively analyzed in 15 cases of pineal mixed germ cell tumors confirmed by postoperative histological examination between January 2000 and September 2010. RESULTS: Radiographic examination of the tumor revealed calcification in 12 cases, cystic changes in 10 cases, and the presence of lipid in 5 cases. On the anteroposterior images, the tumors appeared round or elliptic with smooth edge in 6 cases, and showed irregular shape with multiple processes on the edge in 9 cases. Surgical exploration found all the tumors located in the the suprapineal recess enclosed by the arachnoidal envelope of the Galen vein. Pathologically, 13 specimens contained germinoma component, 9 contained teratoma component, 4 had embryonic carcinoma component, 3 had choriocarcinoma component, 7 showed yolk sac tumor component, and 3 showed rhabdomyoma component. Germinoma components were found on the tumor margin in 7 specimens, and intermingled germinoma and other components were found in 10 specimens. CONCLUSION: Pineal mixed germ cell tumor originates from the residue germ cells around the pineal gland, and most likely evolves from single primordial germ cells.

Anatomical study of the arachnoid envelope over the pineal region.

BACKGROUND: The distribution of the arachnoid membrane and its relationship with the neurovascular structures in the pineal region are still not fully understood. OBJECTIVE: Because the arachnoid membrane has an intimate relationship with the neurovascular structures in the pineal region and it will always be encountered surgically, we attempted to clarify the formation and distribution of the arachnoid envelope over the pineal region (AEPG). METHODS: The formation and distribution of the AEPG and its relationship with the neurovascular structures in the pineal region were examined by anatomic dissection in 20 adult cadaveric formalin-fixed heads. RESULTS: The supratentorial and infratentorial outer arachnoid membranes converged at the tentorial apex and then embraced and ran forward along the vein of Galen to form the AEPG. The AEPG could be divided into 2 parts. Typically, the posterior part of the AEPG enveloped the vein of Galen and the terminal segments of its tributaries, and the anterior part of the AEPG enveloped the suprapineal recess, the pineal gland, and the distal segment of the internal cerebral veins. The compartment demarcated by the AEPG did not communicate with the adjacent subarachnoid cisterns or space. CONCLUSION: Previous knowledge about the AEPG, as well as the superior boundary and the contents of the quadrigeminal cistern, needs to be revised. The arrangement and individual variation of AEPG are important for a better understanding of the various growth patterns of the pineal tumors and the relationship between the tumor and the neurovascular structures in the pineal region.

[Clinical study of pineal region tumors: experience with 132 patients].

OBJECTIVE: To review the clinical manifestations, imaging, tumor markers, treatment methods, pathology results and clinical curative effects of pineal region tumors and to evaluate the characteristics and intervention strategies for those tumors. METHODS: The clinicopathological data of 132 patients with pineal region tumor treated in our department between January 2000 and May 2008 were retrospectively studied. RESULTS: A moderate predominance in males was presented. The clinical manifestations of the disease included increased intracranial pressure and ocular movement impairment. There were some features but no regularity and specific appearance on imaging including CT and MRI. 88.6% of patients associated with hydrocephalus. A high serum level of alpha-fetoprotein (AFP) was presented in 14 cases and high HCG in 9 cases. Eighteen cases received direct radiation therapy and 7 had radiotherapy post biopsy. 107 cases were treated surgically and 63 cases received postoperative adjuvant treatment. 114 cases had pathology results including 56 germ cell tumors. The patients were followed up for 12 approximately 132 months. Recurrence developed in 23 cases and 12 cases died. The 5-year survival rate was 89.3%. CONCLUSION: Pineal region tumors are often associated with hydrocephalus and this makes preoperative diagnosis difficult. Imaging examination may help diagnosis but less specific. Germ cell tumors may diagnosed by some tumor markers. Radiation therapy is the choice of treatment for pure germinomas. Other types of pineal region tumors should receive surgical treatment. Postoperative adjuvant treatment based on pathology can provide a good prognosis in pineal region tumor.

[Dynamic changes of serum interleukin-6 and interleukin-8 in patients with acute traumatic brain injury and the clinical significance].

OBJECTIVE: To explore the dynamic changes of serum interleukin-6 (IL-6) and IL-8 in acute traumatic brain injury (TBI) and their correlations to the severity of brain injury and the condition of the patients. METHODS: Thirty-four patients with acute TBI were divided into two groups according to the Glasgow Coma Scale (GCS) score, clinical manifestations and the imaging data, namely patients with GCS score < or = 8 and those with GCS score between 9 and 12. Radioimmunoassay was employed to determine the serum levels of IL-6 and IL-8 at 6 different time points within 15 days after the injury in the two groups. RESULTS: The serum IL-6 reached the peak level on the second day after the injury in patients with GCS score < or = 8 and on the 7th day in patients with GCS score of 9-12, showing significant differences in IL-6 variations between the two groups (P=0.046). The peak serum level of IL-8 occurred on the 7th day in patients with GCS score < or = 8 and on the 3rd day in patients with GCS score of 9-12, also showing significant differences (P=0.045). The peak level of IL-6 on the second day after the injury was significantly higher than the peak level of IL-8 that occurred on the 7th day, demonstrating significant differences in the variations of IL-6 and IL-8 after the injury (P=0.000). CONCLUSION: The changes of serum IL-6 and IL-8 levels show positive correlations to the severity of the condition of the patients sustaining TBI. IL-6 variation is more obvious than that of IL-8 without intimate correlations between them. Clinically, serum IL-6 level can be more informative than serum IL-8 level in evaluating the changes of the condition of the TBI patients in early stage following the injury.

[Predisposing factors for postoperative epilepsy in patients with gliomas].

OBJECTIVE: To explore the predisposing factors for postoperative epilepsy in patients with gliomas. METHODS: A total of 258 glioma patients with complete clinical data receiving cranial surgeries were analyzed retrospectively. With gender, age, predominant symptoms, positive signs, history of preoperative epilepsy, time of epilepsy onset, tumor location, surgical approaches, cortical injury, arterial and venous injury, scope of tumor resection, postoperative edema, tumor pathology, tumor recurrence, number of operation, radiation therapy as the independent variables, the occurrence of postoperative epilepsy was analyzed as the dependent variable using logistic regression to identify the risk factors for postoperative epilepsy. RESULTS: History of preoperative epilepsy, surgical approaches, postoperative edema, tumor pathology and tumor recurrence were identified as the risk factors for postoperative epilepsy in glioma patients. CONCLUSIONS: Postoperative epilepsy severely affected the quality of life of glioma patients, and rigorous treatment targeting the risk factors may decrease the occurrence of postoperative epilepsy.

[Combined modality therapy for primary choriocarcinoma in the pineal region: report of two cases].

OBJECTIVE: We report two rare cases of primary choriocarcinoma in the pineal region verified histologically. In both cases, the pre-operative serum level of human chorionic gonadotropin (HCG) was significantly elevated to 128-/+935.7 and 9 -/+088.9 mIU/ml, respectively, and serum alpha-fetoprotein (AFP) was negative. The tumors were microsurgically removed, and postoperative hydrocephalus were treated by endoscopic third ventriculostomy. Both patients underwent chemotherapy and radiotherapy. After adjunctive treatment, the serum HCG decreased within normal range. During the two-year-long follow-up, no radiological (MRI) evidence was found to suggest recurrence in MR imaging, and the serum HCG was normal in one patient, but mildly elevated in the other. HCG measurement can be crucial to the diagnosis and post-treatment monitoring of choriocarcinoma, and radical surgical tumor removal and combined modality therapy including chemotherapy and radiotherapy may ensure good results.

[Radiation-induced rat cerebral neuron apoptosis].

OBJECTIVE: To explore the correlation between X-ray-induced rat cerebral neuron apoptosis and radiation doses. METHODS: In a controlled experiment, the rats in the experimental group received X-ray radiation at different doses (2, 4, 6 and 8 Gy), and the apoptotic cerebral neurons were counted after in situ end-labeling and immunohistochemical staining. RESULTS: X-ray radiation induced apoptosis of rat cerebral neurons, and the apoptotic rate varied with the radiation doses. Significant difference in the apoptotic rate was noted before and after radiation (P<0.0001), and between different radiation dose groups (P<0.005). The apoptotic rate differed significantly at different time points after the radiation. CONCLUSION: Low or medium doses of X-ray is able to induce rat cerebral neuron apoptosis depending on the radiation doses and following a definable time course.

[Clinical features and surgical treatment of posttraumatic epilepsy].

OBJECTIVE: To study the clinical features of posttraumatic epilepsy and evaluate the surgical procedures for anti-epileptic treatment and their therapeutic effects. METHODS: Neurological and scalp EEGs were performed in 35 patients with posttraumatic epilepsy, who also underwent CT, MRI examination, single photon emission computerized tomography (SPECT) and positron emission tomography (PET) prior to intracranial surgery, with intraoperative monitoring of the cortical EEG. RESULTS: With the cortical EEG monitoring, 16 patients underwent surgical resection of the epileptogenic foci identified by intraoperative EEG, 7 had multiple subpial transection and 12 received stereotactic radiosurgery for the epileptogenic foci localized by PET. In most of the cases, the epileptogenic foci were located around the lesions of encephalomalacia. During the follow-up of 32 patients varying from 1 to 4 years, 18 patients became seizure free, 10 had obvious reduction in the frequency of seizure while 4 failed to respond favorably to the treatment. CONCLUSIONS: Seizures of posttraumatic epilepsy may aggravate the brain dysfunction due to primary trauma, and surgical treatment often yields good effect and lessens the toxic and adverse effect of antiepileptic drugs. Stereotactic radiosurgery guided by PET is safe and effective in the treatment of patients with posttraumatic epilepsy.

[Treatment of recurrent malignant brain gliomas by surgical excision combined with biodegradable polymers of interstitial chemotherapy].

OBJECTIVE: To investigate the effectiveness of treatment of recurrent malignant brain gliomas by surgical excision combined with biodegradable polymers of interstitial chemotherapy. METHODS: In 30 patients with recurrent malignant brain gliomas, the tumor was surgically removed and Vp-16 biodegradable polymers were implanted during operation in the tumor bed at a dose of 100 - 150 mg. The patients were followed up for 3 - 24 months, and the results were compared with 46 cases with the recurrent malignant brain gliomas who received operation only. RESULTS: At 3, 6, 12, 24 months after treatment, the recurrent rate was 16.7%, 30%, 50% and 83.3%, respectively; the mortality rate was 6.67%, 20%, 40% and 70%, respectively. All the patients had no apparent side-effects of chemotherapy. CONCLUSION: Surgical treatment combined with interstitial chemotherapy with biodegradable Vp-16 polymers improves the treatment result of recurrent malignant brain gliomas compared to surgery alone.

Application of electromagnetic navigation in surgical treatment of intracranial tumors: analysis of 12 cases.

OBJECTIVE: To explore the application and characteristics of electromagnetic navigation in neurosurgical operation. METHODS: Neurosurgical operations with the assistance of electromagnetic navigation were performed in 12 patients with intracranial tumors. RESULTS: Total removal of the tumor was achieved in 8 cases, subtotal removal in 3 and removal of the majority of the tumor in 1 case. The error in the navigation averaged 1.9+/-0.9 mm and the time consumed by preoperative preparation was 19+/-2 min with the exception in 1 case. CONCLUSION: In comparison with optic navigation, electromagnetic navigation offers better convenience and absence of signal blockage, and with a head frame, automatic registration can be achieved.