Accuracy of ADC derived from DWI for differentiating high-grade from low-grade gliomas: Systematic review and meta-analysis.

OBJECTIVE: Quantitative apparent diffusion coefficient (ADC) values of diffusion weighted imaging (DWI) could be applied to grade gliomas. This meta-analysis was conducted to assess the accuracy of ADC analysis in differentiating high-grade (HGGs) from low-grade gliomas (LGGs). METHODS: PubMed, Cochrane library, Science Direct, and Embase were searched to identify suitable studies up to September 1, 2018. The quality of studies was evaluated by the quality assessment of diagnostic accuracy studies (QUADAS 2). We estimated the pooled sensitivity, specificity, positive and negative likelihood ratios (LR), diagnostic accuracy ratio (DOR) with 95% confidence intervals (CI), and determined the accuracy of the data by using the summary receiver operating characteristic (SROC) and calculating the area under the curve (AUC) to identity the accuracy of ADC analysis in grading gliomas. RESULTS: Eighteen studies including 1172 patients were included and analyzed. The pooled sensitivity, specificity, PLR, NLR, DOR, and AUC with 95% CIs of DWI with b values of 1000 s/mm for separating HGGs from LGGs were 0.81 (95% CI 0.75-0.86), 0.87 (95% CI 0.81-0.91), 6.1 (95% CI 4.2-8.9), 0.22 (95% CI 0.17-0.29), 28 (95% CI 17-45), and 0.91 (95% CI 0.88-0.93), respectively. DWI with b values of 3000 s/mm showed slightly higher accuracy than that of 1000 (sensitivity 0.80, specificity 0.90 and AUC 0.92). Meta-regression analyses showed that field strengths and b values had significant impacts on diagnostic efficacy. Deeks testing confirmed no significant publication bias in all studies. CONCLUSIONS: This meta-analysis suggested that ADC analysis of DWI have high accuracy in differentiating HGGs from LGGs. Standardized methodology is warranted to guide the use of this technique for clinical decision-making.

LKB1 suppresses glioma cell invasion via NF-κB/Snail signaling repression.

BACKGROUND: Liver kinase B1 (LKB1) is involved in various human diseases. Aberrant expression of LKB1 expression is involved in glioma progression and associated with prognosis, however, the specific mechanism involving NF-κB/Snail signaling pathways remain unknown. MATERIALS AND METHODS: In the present study, quantitative real-time PCR analysis was used to investigate the expression of LKB1 tumor tissue samples and cell lines. In glioma cell lines, CCK-8 assay, transwell invasion and migration assays were used to investigate the effects of LKB1on proliferation and invasion. RESULTS: We observed that LKB1 knockdown promoted glioma cell proliferation, migration and invasion. This effect was induced through NF-κB/Snail signaling activation. Also, LKB1 overexpression suppressed proliferation, migration, and invasion, which could be rescued by Snail overexpression. CONCLUSION: Taken together, our results show that LKB1 knockdown promotes remarkably glioma cell proliferation, migration and invasion by regulating Snail protein expression through activating the NF-κB signaling. This may serve as a potential prognostic marker and therapeutic target for glioma.

Anatomic Variation and Hemodynamic Evolution of Vertebrobasilar Arterial System May Contribute to the Development of Vascular Compression in Hemifacial Spasm.

BACKGROUND: Hemifacial spasm (HFS) is caused by vascular compression of the facial nerve. The definitive mechanism of offending vessel formation remains unclear. The aim of this study was to explore whether the anatomic and hemodynamic characteristics of the vertebrobasilar artery play a role in problematic vessel formation in HFS. METHODS: Imaging data of 341 patients with HFS who underwent microvascular decompression were reviewed retrospectively and compared with 360 control subjects. Hemodynamics of typical anatomic variations of the vertebral artery (VA) were analyzed using computational fluid dynamics software. RESULTS: Asymmetry of the left and right VAs was prevalent, and the left VA was the most dominant VA. A dominant VA was more prevalent in the HFS group than in the control group (P = 0.026). Left HFS had a significantly higher proportion of a left dominant VA, and right HFS had a significantly higher proportion of a right dominant VA (P < 0.001). Computational fluid dynamics models showed that angulation and tortuosity of vessels caused remarkable pressure difference between vascular walls of opposite sides. Dynamic clinical observations showed the mode of vessel transposition coincided with biomechanical characteristics. CONCLUSIONS: Anatomic variations and hemodynamics of the vertebrobasilar arterial system are likely to contribute to vascular compression formation in HFS.

Burr hole drainage and burr hole drainage with irrigation to treat chronic subdural hematoma: A systematic review and meta-analysis.

OBJECTIVE: Numerous studies have investigated different operative procedures for treating chronic subdural hematoma (CSDH); however, the results are controversial. This meta-analysis was performed to evaluate the efficacy of burr hole drainage without irrigation (BHD) and burr hole drainage with irrigation (BHDI) for CSDH. METHODS: We searched the following electronic databases to identify all studies from their inception to September 2017: Cochrane Library, Science Direct, MEDLINE, EMBASE, Scopus, Google Scholar, the China Biomedical Database (CBM), and the Chinese National Knowledge Infrastructure (CNKI). Randomized clinical trials (RCTs), prospective cohort studies, retrospective observational cohort studies, and case-control studies investigating BHD and BHDI for the treatment of CSDH were included. The Cochrane Collaboration's RevMan 5.3 software was used for meta-analysis. RESULTS: In total, 7 retrospective cohort studies and 2 RCTs involving 993 participants were included. Comprehensive analysis results of 9 studies indicated that the recurrence of the BHDI was similar to that in BHD (odds ratio [OR] = 1.27, 95% confidence interval [CI] = .61-2.63, P = .53). Moreover, analysis for comparing recurrence in the 2 RCTs was not significantly different (OR = 1.14, 95% CI = .16-8.24, P = .95).In addition, meta-analysis of pneumocephalus (OR = 5.91, 95% CI = .61-56.86, P = .12) and mortality (OR = 0.94, 95% CI 0.14-6.16, P = .95) was not significantly different. CONCLUSIONS: The results of this meta-analysis demonstrated that procedures with or without irrigation in the treatment of CSDH might have similar effect regarding recurrence and complications; therefore, irrigation might not be necessary. However, well-conducted RCTs and high-quality observational studies are still required to corroborate this issue.

A comparative study of irrigation versus no irrigation during burr hole craniostomy to treat chronic subdural hematoma.

BACKGROUND: Burr hole craniostomy is a widely used method for the evacuation of CSDH. However it is not clear whether the irrigation during operation improves the prognosis or gives rise to additional complications instead. This retrospective cohort study was conducted to determine this issue. METHODS: Patients attending two medical centers in China who underwent burr hole drainage with irrigation (BHDI) or burr hole drainage without irrigation (BHD) for unilateral CSDH during January 2013 to December 2016 were included in this study. The patients' clinical information and follow-up data were retrospectively reviewed, and the radiologic findings were processed using the 3D Slicer software. The differences in outcomes were identified using t-test, chi-square test, or Fisher's exact test. RESULTS: A total of 151 patients comprising 63 patients in the BHD group and 88 patients in the BHDI group were included. Patients in the BHDI group had a higher volume of pneumocrania on the first postoperative day than that of patients in the BHD group (p < 0.05). No significant differences were observed between the two approaches in rates of rebleeding, recurrence and other complications (p > 0.05). CONCLUSIONS: Irrigation had no improvement in the long-term curative effect on CSDH, but it increased the risk of short-term complication in terms of pneumocrania. Therefore, this study suggests that irrigation is not an obligatory procedure during burr hole drainage.

Impact of operation details on hydrocephalus after decompressive craniectomy.

OBJECTIVE: To evaluate the correlation between the distance of craniectomy from the midline and hydrocephalus after DC. METHODS: The following electronic databases were searched from their inception to June 2015: Cochrane Library, MEDLINE, Science Direct, EMBASE, Scopus, Google Scholar, the Chinese Biomedical Database (CBM), and the Chinese National Knowledge Infrastructure (CNKI). All randomized clinical trials, prospective cohort, retrospective observational cohort, and case-control studies investigating the relationship between distance of craniectomy from the midline and hydrocephalus after DC were enrolled. The Cochrane Collaborations software RevMan 5.3 was used for meta-analysis. RESULTS: Six retrospective cohort studies involving 462 participants were included. Pooled analysis of 4 studies suggested that craniectomy close to the midline (<25 mm) was associated with a significantly increased risk of postoperative hydrocephalus (odds ratio [OR] = 3.61, 95% confidence interval [CI]: 1.3 - 9.97, p=0.01). However, meta analysis of 4 studies did not find statistical differences when comparing the distance of craniectomy from the midline in the hydrocephalus group and that in the non-hydrocephalus group (OR= - 0.14, 95% CI: -0.44 - 0.15, p=0.34). CONCLUSION: Available evidence was insufficient to support the theory that craniectomy close to the midline increases the risk of developing hydrocephalus after DC. Well conducted randomized clinical trials are required to verify this issue.

Prospective randomized evaluation of therapeutic decompressive craniectomy in severe traumatic brain injury with mass lesions (PRECIS): study protocol for a controlled trial.

BACKGROUND: For cases of severe traumatic brain injury, during primary operation, neurosurgeons usually face a dilemma of whether or not to remove the bone flap after mass lesion evacuation. Decompressive craniectomy, which involves expansion of fixed cranial cavity, is used to treat intra-operative brain swelling and post-operative malignant intracranial hypertension. However, due to indefinite indication, the decision to perform this procedure heavily relies on personal experiences. In addition, decompressive craniectomy is associated with various complications, and the procedure lacks strong evidence of better outcomes. In the present study, we designed a prospective, randomized, controlled trial to clarify the effect of decompressive craniectomy in severe traumatic brain injury patients with mass lesions. METHODS: PRECIS is a prospective, randomized, assessor-blind, single center clinical trial. In this trial, 336 patients with traumatic mass lesions will be randomly allocated to a therapeutic decompressive craniectomy group or a prophylactic decompressive craniectomy group. In the therapeutic decompressive craniectomy group, the bone flap will be removed or replaced depending on the emergence of brain swelling. In the prophylactic decompressive craniectomy group, the bone flap will be removed after mass lesion evacuation. A stepwise management of intracranial pressure will be provided according to the Brain Trauma Foundation guidelines. Salvage decompressive craniectomy will be performed for craniotomy patients once there is evidence of imaging deterioration and post-operative malignant intracranial hypertension. Participants will be assessed at 1, 6 and 12 months after randomization. The primary endpoint is favorable outcome according to the Extended Glasgow Outcome Score (5-8) at 12 months. The secondary endpoints include quality of life measured by EQ-5D, mortality, complications, intracranial pressure and cerebral perfusion pressure control and incidence of salvage craniectomy in craniotomy patients at each investigation time point. DISCUSSION: This study will provide evidence to optimize primary decompressive craniectomy application and assess outcomes and risks for mass lesions in severe traumatic brain injury. TRIAL REGISTRATION: ISRCTN20139421.

Hydrocephalus after decompressive craniectomy for malignant hemispheric cerebral infarction.

PURPOSE: Several studies have investigated the incidence and risk factors of hydrocephalus after decompressive craniectomy (DC) for malignant hemispheric cerebral infarction. However, the results are controversial. Therefore, the following is a retrospective cohort study to determine the incidence and risk factors of hydrocephalus after DC for malignant hemispheric cerebral infarction. MATERIALS AND METHODS: From January 2004 to June 2014, patients at two medical centres in south-west China, who underwent DC for malignant hemispheric cerebral infarction, were included. The patients' clinical and radiologic findings were retrospectively reviewed. A chi-square test, Mann-Whitney U-test and logistic regression model were used to identify the risk factors. RESULTS: A total of 128 patients were included in the study. The incidence of ventriculomegaly and shunt-dependent hydrocephalus were 42.2% (54/128) and 14.8% (19/128), respectively. Lower preoperative Glasgow Coma Scale (GCS) score and presence of subarachnoid haemorrhage (SAH) were factors significantly associated with the development of post-operative hydrocephalus after DC. CONCLUSIONS: Cerebral infarction patients receiving DC have a moderate tendency to suffer from post-operative hydrocephalus. A poor GCS score and the presence of SAH were significantly associated with the development of hydrocephalus after DC.

The value of intraoperative intracranial pressure monitoring for predicting re-operation using salvage decompressive craniectomy after craniotomy in patients with traumatic mass lesions.

BACKGROUND: The risk factors of predicting the need for postoperative decompressive craniectomy due to intracranial hypertension after primary craniotomy remain unclear. This study aimed to investigate the value of intraoperative intracranial pressure (ICP) monitoring in predicting re-operation using salvage decompressive craniectomy (SDC). METHODS: From January 2008 to October 2014, we retrospectively reviewed 284 patients with severe traumatic brain injury (STBI) who underwent craniotomy for mass lesion evacuation without intraoperative brain swelling. Intraoperative ICP was documented at the time of initial craniotomy and then again after the dura was sutured. SDC was used when postoperative ICP was continually higher than 25 mmHg for 1 h without a downward trend. Univariate and multivariate analyses were applied to both initial demographic and radiographic features to identify risk factors of SDC requirement. RESULTS: Of 284, 41 (14.4%) patients who underwent SDC had a higher Initial ICP than those who didn't (38.1 ± 9.2 vs. 29.3 ± 8.1 mmHg, P < 0.001), but there was no difference in ICP after the dura was sutured. The factors which have significant effects on SDC are higher initial ICP [odds ratio (OR): 1.100, 95% confidence interval (CI): 1.052-1.151, P < 0.001], older age (OR: 1.039, 95% CI: 1.002-1.077, P = 0.039), combined lesions (OR: 3.329, 95% CI: 1.199-9.244, P = 0.021) and early hypotension (OR: 2.524, 95% CI: 1.107-5.756, P = 0.028). The area under the curve of multivariate regression model was 0.771. CONCLUSIONS: The incidence of re-operation using SDC after craniotomy was 14.4%. The independent risk factors of SDC requirement are initial ICP, age, early hypotension and combined lesions.

Effectiveness of acupuncture in treatment of facial spasm: a meta-analysis.

CONTEXT: Facial spasm is one of the common facial diseases, especially in the aged. It is mostly characterized by initially progressive, involuntary, irregular, recurrent, clonic, or tonic movements of muscles innervated by the facial nerve on one side. Acupuncture is a low-risk treatment with purported claims of effectiveness for facial spasm. OBJECTIVE: To assess the efficacy of acupuncture in facial spasm comprehensively. DESIGN: The research team conducted a systematic review and meta-analysis of all randomized clinical trials (RCTs) that examined the effectiveness of acupuncture for facial spasm. OUTCOME MEASURE(S): The research team categorized results from each of the reviewed studies in two ways: (1) the number of participants who showed a positive response to therapy (total effectiveness rate) and (2) the number of participants who made a full recovery (clinical cure rate). RESULTS: The research team reviewed a total of 13 studies involving 1262 participants with facial spasm. Researchers in China had conducted all studies, and most studies were poor in methodological quality. All studies reported that acupuncture was superior to other treatments, including carbamazepine, mecobalamin, and massage, and the meta-analysis on these low-quality studies yielded similar results. CONCLUSION: Present trials evaluating the efficacy of acupuncture in treatment of facial spasm are mostly poor in methodological quality. These studies showed that acupuncture was superior to other treatments for facial spasm; however, in its meta-analysis, the research team could not draw an affirmative conclusion as to the benefits of acupuncture due to the poor methodological quality and localized population of the included trials. The field needs large international, well-conducted RCTs.

Topiramate versus carbamazepine for the treatment of classical trigeminal neuralgia: a meta-analysis.

BACKGROUND: Carbamazepine is currently the drug of first choice in the treatment of trigeminal neuralgia. However, it is reported as efficacious in only 70-80% of patients, and can be associated with adverse effects such as drowsiness, confusion, nausea, ataxia, nystagmus and hypersensitivity, which may necessitate discontinuation of medication. Therefore, alternative drugs such as oxcarbazepine, baclofen and topiramate are also used to treat the disease. OBJECTIVES: The aim of this study was to compare the effectiveness and safety of topiramate with carbamazepine in the treatment of classical trigeminal neuralgia. METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) [Issue 3 of 12, March 2011], MEDLINE, EMBASE, the Chinese Biomedical Database (CBM), the Chinese National Knowledge Infrastructure (CNKI) and the Chinese Science and Technique Journals Database (VIP) for the period January 1998 to March 2011, and we also manually searched all relevant journals. We included all confirmed randomized controlled trials treating trigeminal neuralgia with topiramate and carbamazepine. We evaluated the risk of bias of the included trials according to the Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1. The Cochrane Collaboration's software RevMan 5.1 was used for the meta-analysis. RESULTS: A total of six randomized controlled trials with poor methodological quality were included. All trials were conducted in China. Altogether, they included 354 patients with trigeminal neuralgia. The results of the meta-analysis showed that topiramate was more effective than carbamazepine after a treatment duration of 2 months (relative risk [RR] = 1.20, 95% CI 1.04, 1.39, p = 0.01). However, no difference was found in the effectiveness rate after a treatment duration of 1 month (RR = 1.00, 95% CI 0.87, 1.14, p = 0.94), in the remission rate after a treatment duration of 1 month (RR = 1.06, 95% CI 0.83, 1.36, p = 0.63), in the remission rate after a treatment duration of 2 months (RR = 1.31, 95% CI 0.96, 1.80, p = 0.09) or in adverse events when comparing topiramate with carbamazepine. CONCLUSIONS: Present trials comparing topiramate with carbamazepine are all poor in methodological quality. A meta-analysis of these studies showed that the overall effectiveness and tolerability of topiramate did not seem to differ from carbamazepine in the treatment of classical trigeminal neuralgia. However, the meta-analysis yielded a favourable effect of topiramate compared with carbamazepine after a treatment duration of 2 months. RESULTS were limited due to the poor methodological quality and the geographic localization of the randomized controlled trials identified. Therefore, large, international, well conducted, randomized controlled trials are needed to further assess the relative efficacy and tolerability of topiramate and carbamazepine in this indication.