Study of vision-related resting-state activity in suprasellar tumor patients with postoperative visual damage.

INTRODUCTION: The objective of this study was to investigate changes in vision-related resting-state activity in patients with suprasellar tumors (ST) who experienced vision deterioration after surgery. METHODS: Twelve patients with ST and vision deterioration after surgery were included in the study. Resting-state functional connectivity (FC) was compared before and after surgery using a seed-based analysis with a priori specified regions of interest (ROIs) within the visual areas. The differences between the two groups were identified using a paired t-test. RESULTS: The data showed a decrease in FC within and between the dorsal and ventral pathways, as well as in the third pathway in ST patients. The middle temporal visual cortex (MT+) showed a decreased FC with more regions than other visual ROIs. The data also revealed an increase in FC between the visual ROIs and higher-order cortex. The superior frontal gyrus/BA8 showed an increased FC with more ROIs than other high-order regions, and the hOC4d was involved in an increased FC with more high-order regions than other ROIs. CONCLUSIONS: The study results indicate significant neural reorganization in the vision-related cortex of ST patients with postoperative vision damage. Most subareas within the visual cortex showed remarkable neural dysfunction, and some highe-order cortex may be primarily involved in top-down control of the subareas within the visual cortex. The hot zones may arise in the processing of "top-down" influence.

Efficacy and safety of drug-coated balloon for de novo lesions of large coronary arteries: Systematic review and meta-analysis of randomized controlled trials.

Background: Drug-coated balloon (DCB) is a novel approach to avoiding stent-related complications and has proven effective for the treatment of in-stent restenosis (ISR) and small vessels. However, its role in the treatment of de novo lesions in large vessels is less settled. Aims: To estimate the efficacy and safety of drug-coated balloon versus stent in the treatment of de novo lesions in large coronary arteries. Methods: We searched the literature until April 2023. We judged the safety of DCB based on major adverse cardiovascular events (MACEs), cardiac death, all-cause mortality, non-fatal myocardial infarction, target lesion revascularization (TLR), and bleeding event; and efficacy according to late lumen loss (LLL), minimum lumen diameter (MLD). We conducted subgroup analyses according to stent type and whether urgent PCI was required. Results: A total of 10 RCTs were included. Overall, LLL (mean difference (MD) = -0.19, 95 % confidence interval (CI): -0.32 to -0.06, P = 0.003) was lower in the DCB group than in the Stent arm. This effect was consistent in subgroup analysis regardless of stent type and disease type. In terms of safety indicators, there were no significant differences between DCB and stent. The subgroup analyses found that safety indicators showed no significant differences between DCB and drug-eluting stent (DES), but TLR was lower in the DCB than in the bare metal stent (BMS). Moreover, in ST-elevation myocardial infarction (STEMI), safety indicators and LLL showed no significant differences between DCB and DES, but MLD in the DCB was smaller. While in patients with excluded STEMI, MACE and TLR was lower in the DCB compared with the overall stent. Conclusions: DCB could be a promising alternative for treating de novo lesions in large coronary arteries with satisfactory efficacy and low risk, superior to BMS and not inferior to DES, with a trend toward lower late lumen loss.

Study of extravisual resting-state networks in pituitary adenoma patients with vision restoration.

BACKGROUND: Pituitary adenoma (PA) may compress the optic apparatus, resulting in impaired vision. Some patients can experience improved vision rapidly after surgery. During the early period after surgery, however, the change in neurofunction in the extravisual cortex and higher cognitive cortex has yet to be explored. OBJECTIVE: Our study focused on the changes in the extravisual resting-state networks in patients with PA after vision restoration. METHODS: We recruited 14 patients with PA who experienced visual improvement after surgery. The functional connectivity (FC) of 6 seeds [auditory cortex (A1), Broca's area, posterior cingulate cortex (PCC) for the default mode network (DMN), right caudal anterior cingulate cortex for the salience network (SN) and left dorsolateral prefrontal cortex for the executive control network (ECN)] were evaluated. A paired t test was conducted to identify the differences between two groups of patients. RESULTS: Compared with their preoperative counterparts, patients with PA with improved vision exhibited decreased FC with the right A1 in the left insula lobule, right middle temporal gyrus and left postcentral gyrus and increased FC in the right paracentral lobule; decreased FC with the Broca in the left middle temporal gyrus and increased FC in the left insula lobule and right thalamus; decreased FC with the DMN in the right declive and right precuneus; increased FC in right Brodmann area 17, the left cuneus and the right posterior cingulate; decreased FC with the ECN in the right posterior cingulate, right angular and right precuneus; decreased FC with the SN in the right middle temporal gyrus, right hippocampus, and right precuneus; and increased FC in the right fusiform gyrus, the left lingual gyrus and right Brodmann area 19. CONCLUSIONS: Vision restoration may cause a response of cross-modal plasticity and multisensory systems related to A1 and the Broca. The DMN and SN may be involved in top-down control of the subareas within the visual cortex. The precuneus may be involved in the DMN, ECN and SN simultaneously.

Study of rapid reorganization of visual neurofunctions with the resting-state functional MRI in pituitary adenoma patients with vision improvement after transsphenoidal surgery.

INTRODUCTION: To investigate changes of vision-related resting-state activity in pituitary adenoma (PA) patients with visual improvement after transsphenoidal surgery. METHODS: 14 PA patients with visual improvement after surgery were enrolled. The resting-state functional MRI and neuro-ophthalmologic evaluation were performed before and after the operation. The functional connectivity (FC) of 8 seeds (the primary visual cortex (V1), the secondary visual cortex (V2), the middle temporal visual cortex (MT+), and fusiform gyrus(FG)) was evaluated. A paired t test was conducted to identify the differences between the two groups. RESULTS: Compared with the preoperation counterparts, the PA patients with improved vision exhibited decreased FC with the V1, V2, MT+, FG in the left paracentral lobule, bilateral lingual gyrus, precentral gyrus(BA 4), right superior temporal gyrus(BA 22), left fusiform gyrus, bilateral middle occipital gyrus (BA 19), left cuneus, right inferior occipital gyrus, left superior frontal gyrus, right cuneus, left superior parietal lobule(BA 7),the medulla, right postcentral gyrus, and increased FC in the right middle frontal gyrus, left inferior parietal lobule (BA 40), left declive, right lentiform nucleus, inferior frontal gyrus, right superior frontal gyrus(BA 11), cingulate gyrus(BA 32), right putamen, right thalamus, left medial frontal gyrus, left claustrum, left superior frontal Medial, right rectal gyrus(BA 25) and right parahippocampal gyrus. CONCLUSIONS: The results show most subareas within the visual cortex exhibit decreased functional connectivity. The functional changes in subareas within default mode network (DMN), action observation network (AON) and the multisensory system in PAs propose that vision improvement may lead to function remodeling in higher-order cortex.

Correlation between the Position of the Pituitary Stalk as Determined by Diffusion Tensor Imaging and Its Location as Determined at the Time of Surgical Resection of Pituitary Adenomas.

OBJECTIVE: An important factor during pituitary adenoma surgery is to preserve pituitary stalk (PS) as this plays a role in reduction of the risk of postoperative diabetes insipidus. The hypothalamic-hypophyseal tract (HHT) projects through the PS to the posterior pituitary gland. To reconstruct white matter fiber pathways, methods like diffusion tensor imaging (DTI) tractography have been widely used. In this report we attempted to predict the position of PS using DTI tractography and to assess its intraoperative correlation during surgery of pituitary adenomas. METHODS: DTI tractography was used to tract the HHT in nine patients before craniotomy for pituitary adenomas. The DTI location of the HHT was compared with the PS position identified at the time of surgery. DTI fiber tracking was carried out in nine patients prior to the planned craniotomy for pituitary adenomas. In one patient, the PS could not be identified during the surgery. In the other eight patients, a comparison was made between the location of the HHT identified by DTI and the position of the PS visualized at the time of surgery. RESULTS: The position of the HHT identified by DTI showed consistency with the intraoperative position of the PS in seven patients (88.9% concordance). CONCLUSION: This study shows that DTI can identify the position of the HHT and thus the position of the PS with a high degree of reliability.

Microsurgical treatment of craniopharyngioma: Experiences on 183 consecutive patients.

This study aimed to summarize the clinical experiences and postoperative effects of microsurgical approaches for craniopharyngioma.A total of 183 craniopharyngioma patients who underwent microsurgical treatment since March 2009 to March 2015 in our hospital were included in current research. Surgical approaches were selected based on preoperative evaluations, including tumor locations, sizes, and growth patterns. Active measurements to manage water-electrolyte disorder and insipidus were taken for postoperative treatments. During the follow-up, patients were monitored for residual or recurrent tumor by postoperative contrast MRI scans done 1 to 3 months after surgery.The used surgical approaches were as follows: frontopterional approach (76 cases), anterior interhemispheric approach (58 cases), transcallosal approach (10 cases), transsphenoidal approach (15 cases), unilateral subfrontal approach (15 cases), and combined approaches (9 cases). Around 124 cases (72.7%) received total tumor resection, 37 patients (20.2%) underwent subtotal resection, and 13 patients (7.1%) underwent partial removal. No significant difference was found on the postoperative complications among the different microsurgical approaches (all, P > .05). A total of 111 cases had an intact pituitary stalk preservation and 26 cases had partially preserved stalks during surgery. Visual improvement was achieved in 54 patients and visual deterioration occurred in 22 cases. Postoperative insipidus appeared in 114 cases and water-electrolyte disorder occurred in 99 cases. The postsurgical follow-up ranged from 3 to 69 months with a mean duration of 27.3 months and 23 patients suffered recurrence.Based on careful preoperative evaluation, microsurgical treatments may be safe and effective approach to improve postoperative outcomes of craniopharyngioma patients.

Anterior interhemispheric approach for removing large sellar region tumor.

The aim of the study was to explore anterior interhemispheric approach microsurgery for removing large sellar region tumors.A total of 118 patients with large sellar region tumors were treated with the anterior interhemispheric approach microsurgery. There were 58 craniopharyngioma, 37 pituitary adenoma, 5 hypothalamic glioma, 7 meningioma, and 11 other tumors cases. The maximal tumor diameter ranged from 3.0 to 8.2 cm, with a mean diameter of 4.3 cm. Diabetes insipidus and fluid and electrolyte imbalance were timely controlled after surgery. Postoperative examination of endocrine and of magnetic resonance imaging (MRI) enhancement scanning of the head were performed.Total, subtotal, and partial removal of tumors was, respectively, achieved in 80, 23, and 15 cases. A total of 109 patients had improved vision after surgery. During the hospital stay, 81 had diabetes insipidus, 68 had fluid and electrolyte imbalance, and 9 had hemorrhage and tumidness in the right frontal lobe (3 had frontal lobe contusion, and 6 had frontal lobe hematoma). The postoperative follow-up visit lasted for 3 to 105 months. During the follow-up period, 14 patients had recurrence of tumors, 38 cases had their single or multiple pituitary axis treated with hormonal replacement therapy for a long time after surgery, and 23 cases had to orally take drugs for the purpose of controlling diabetes insipidus.The anterior interhemispheric approach microsurgery is feasible for removing large sellar region tumors without significant sequels. Active postoperative managements of diabetes insipidus and fluid and electrolyte imbalance may help patients with earlier recovery.

Prediction of pituitary stalk position in pituitary adenomas by visualization of the hypothalamo-hypophyseal tract using diffusion tensor imaging tractography.

The preservation of pituitary stalk during surgery is very important for neurosurgeons. Sometimes, it is hard to identify the pituitary stalk in the operation. The hypothalamo-hypophyseal tract (HHT) projects through the pituitary stalk to the posterior pituitary gland. If the HHT can be identified, the position of pituitary stalk will be visualized. The diffusion tensor imaging (DTI) fiber tracking technique has been widely used for the quantitative assessment of the white matter integrity and thus may be suitable for the evaluation of the HHT.DTI was used to track the HHT in 11 patients with pituitary adenoma, and the location of the tract was compared with the pituitary stalk of postoperative image in those patients.The fiber tracking and 3D visualization of the HHT were successfully carried out in all 11 patients. Comparison between the tract and pituitary stalk of postoperative magnetic resonance imaging (MRI) was carried out in 9 patients. The results revealed that the position of tract was consistent with the pituitary stalk of postoperative MRI image in 8 patients (88.9%). The properties of tract showed that the median number of tract was 5.18 ±â€Š7.00, the median fractional anisotropy (FA) was 0.14 ±â€Š0.04, and the median length was 28.81 ±â€Š7.94 mm.HHT can be tracked and visualized with the DTI-FT technique. It will be helpful to identify the location of pituitary stalk preoperatively.

Predicting pituitary stalk position by in vivo visualization of the hypothalamo-hypophyseal tract in craniopharyngioma using diffusion tensor imaging tractography.

The pituitary stalk (PS) is crucial to endocrine function and water-electrolyte equilibrium. Preservation of the PS during craniopharyngioma (CP) surgery is critical; however, in a pathological state, it is difficult to identify. The hypothalamo-hypophyseal tract (HHT) connects the hypothalamus and the posterior pituitary gland and projects through the PS. Thus, visualization of the HHT can help locate the PS. Preoperative visualization of the neural fasciculus has been widely achieved using diffusion tensor imaging (DTI) tractography. Therefore, this study evaluated the use of DTI tractography to identify and characterize the human HHT. We used DTI tractography to track the HHT in 10 patients with CP and compared the location of the tract with the intraoperative view of the PS in these patients. We successfully tracked the HHT in nine patients, indicating that delineating and quantifying the tracked HHT using this method is feasible. In addition, we found that the tract was consistent with the intraoperative view of the PS in seven out of eight patients (87.50%). Finally, we found that the mean number of tracts was 7.11 ± 12.28, the mean fractional anisotropy (FA) was 0.11 ± 0.04, and the mean tract length was 24.22 ± 9.39 mm. Taken together, our results demonstrate that the HHT can be visualized and characterized with DTI even in a clinical application, which may aid in preoperative identification of the PS. Characterization of the tracked HHT with this technique could also be used to advance our understanding of the HHT.

Simulated effects of perianeurysmal bone on a cerebral aneurysm: A case study.

AIM: Perianeurysmal structures can affect the hemodynamics and geometric evolution of intracranial aneurysms. The purpose of this study was to use computational models to explore the influence of contact with perianeurysmal bone on an intracranial aneurysm. MATERIAL AND METHODS: A cerebral middle aneurysm in contact with an anterior clinoid process was selected. Two anatomic models were constructed from computed tomography angiography images: a non-contact model with elasticity of the entire aneurysm wall and a contact model with rigidity of the part of the aneurysm wall contacting bone. The blood flow pattern and wall stress and displacement were compared between the two models. RESULTS: The contact and non-contact models exhibited similar wall shear stress and pressure but different degrees of von Mises stress and wall displacement. Displacement close to the bone contact part of the aneurysm wall was less in the contact model than in the non-contact model, whereas displacement of the part opposite to the contact part was larger in the contact model than in the non-contact model. Also, von Mises stress close to the contact part was larger in the contact model than in the non-contact model. CONCLUSION: Contacting perianeurysmal bone affects the deformation and degree of von Mises stress but not the hemodynamics of intracranial aneurysms.

Application of Multimodal Navigation together with Fluorescein Angiography in Microsurgical Treatment of Cerebral Arteriovenous Malformations.

This study aimed to explore the clinical applications of multimodal navigation combined with indocyanine green (ICG) fluorescein angiography in microsurgical treatment of cerebral arteriovenous malformations (AVMs). We retrospectively collected 52 patients with AVMs. Assisted by anatomic image, we reestablished three-dimensional structure using preoperative functional magnetic resonance imaging (fMRI) and Diffusion tensor imaging (DTI). The operation for lesion resection was finished under the assistance of neuro-navigation. ICG fluorescein angiography was performed for 16 of the study subjects, meanwhile, FLOW800 was used to rebuild blood vessel color visual image. Brain angiography was performed 1 week after the operation to check residual malformations. The patients' status was estimated by Modified Rankin Scale score. Of the AVMs, 92.3% (48/52) were totally removed, without severe side events. Among the patients, fluorescein angiography was carried out up to 58 times for 16 cases. All of these 16 cases were confirmed with malformations and 14 of them had draining vein. The total resection rate of these 16 cases reached 100%, and the occurrence rate of postoperative complications was not significantly increased. During the operation of lesion resection, the application of multimodal navigation could effectively protect functional cortex and conduction pathway.

A Preliminary Experience with Use of Intraoperative Magnetic Resonance Imaging in Thalamic Glioma Surgery: A Case Series of 38 Patients.

BACKGROUND: Thalamic gliomas are rare tumors that constitute 1%-5% of all central nervous system tumors. Despite advanced techniques and equipment, surgical resection remains challenging because of the vital structures adjacent to the tumor. Intraoperative magnetic resonance imaging (MRI) might play an active role during brain tumor surgery because it compensates for brain shift or operation-induced hemorrhage, which are challenging issues for neurosurgeons. METHODS: We reviewed 38 patients treated surgically under intraoperative MRI guidance between January 2008 and July 2015 at our center. Preoperative, intraoperative, and postoperative MRI scans were reviewed. Preoperative and postoperative motor power, morbidity and mortality, resection rate, surgical approach, pathologic results, and patient demographics were also reviewed. RESULTS: Mean patient age was 37 years ± 18; 12 patients were included in the low-grade group, and 26 patients were included in the high-grade group. Under intraoperative MRI guidance, the gross total resection rate was increased from 16 (42.1%) to 26 (68.4%), and the near-total or subtotal resection rate was increased from 5 (13.2%) to 9 (23.7%). Hematoma formation was discovered in 3 patients on intraoperative MRI scan; each patient underwent a hemostatic operation immediately. CONCLUSIONS: With improvements in neurosurgical techniques and equipment, surgical resection is considered feasible in patients with thalamic gliomas. Intraoperative MRI may be helpful in achieving the maximal resection rate with minimal surgical-related morbidity. However, because of severe disease progression, the overall prognosis is unfavorable.

[Anterior interhemispheric approach through the lamina terminalis for large intra- and extra-ventricular craniopharyngiomas].

OBJECTIVE: To investigate the techniques and effect of surgical resection of large intra- and extra-ventricular craniopharyngiomas via anterior interhemispheric trans-lamina terminalis approach. METHODS: Fifty-two patients who were surgically treated for large intra- and extra-ventricular craniopharyngiomas were retrospectively analyzed. All patients underwent surgery via anterior interhemispheric trans-lamina terminalis approach. Of the 52 patients, 28 were male and 24 were female, with age ranging from 3 to 67 years (mean age 33.5 years). The maximum tumor diameter varied from 4.0 to 7.8 cm, with mean diameter of 5.1 cm. Contrast-enhanced MRI was underwent to determine the extent of tumor resection on the 1 to 3 months after surgery. RESULTS: Total removal of the lesion was achieved in 47 cases (90.4%), 5 patients underwent subtotal resection (9.6%). Division of the anterior communicating artery was performed in 6 patients with no early or late complications related to division of the artery. Visual acuity was preserved or improved in 44 patients (84.6%). Preservation of the pituitary stalk were achieved in 33 patients (63.5%). No surgery-related deaths occurred. The postsurgical follow-up period varied from 3 months to 68 months (mean 25.4 months). Twenty-three cases had endocrinological deficit and received some form of hormonal replacement after surgery. Permanent diabetes insipidus occurred in 18 cases. Three patients died and 6 patients suffered recurrence during the followed-up period. CONCLUSIONS: The anterior interhemispheric approach, with opening of the lamina terminalis, is a valid choice for large intra- and extra-ventricular craniopharyngiomas. These tumors can be removed without significant sequelae related to the surgical approach because optic nerves, optic chiasm, internal carotid artery, hypothalamic structures and pituitary stalk can be seen and effectively protected.

[Treatment for giant pituitary adenomas through transcranial approach in a series of 112 consecutive patients].

OBJECTIVE: To investigate the clinical features, surgical transcranial approaches and outcomes of giant pituitary adenomas. METHODS: A series of 112 consecutive cases of giant pituitary adenomas underwent microsurgery through transcranial approaches at People' s Liberation Army General Hospital were retrospectively analyzed. Of the 112 patients, 58 were male and 54 were female, with age ranging from 3 to 72 years(mean age 44. 3 years). There were 91 non-functioning adenomas and 21 hormone-secreting adenomas. The maximum tumor diameter varied from 4. 0 to 7. 2 cm, with mean diameter of 4. 8 cm. Unilateral subfrontal approach was chosen in 16 cases, pterional approach in 41 cases, anterior interhemispheric approach in 34 cases, transcallosal-interforniceal approach in 6 cases, transcortical- transventricular approach in 5 cases, combined approach in 6 cases and other approaches in 4 cases. Postoperative MRI and endocrine function were re-examined routinely to evaluate the therapeutic efficacy. Staged operation through transsphenoidal approach or adjuvant treatments including medical and radiation therapies were administered in patients with hormone-secreting adenomas when hormonal excess persisted after surgery and in patients with non-functioning adenomas who had postoperative MRI evidence of residual tumor. RESULTS: Total removal of the lesion was achieved in 57 cases (50. 9%) , 26 patients (23. 2%) underwent subtotal resection, and 29 patients (25. 9%) underwent partial removal. Postoperative mortality occurred in 3 patients (2. 7%). Major surgical morbidity occurred in 38 patients (33. 9%). Vision was preserved or improved in 98 patients (87. 5%). The postsurgical follow-up period varied from 3 to 64 months (mean 19. 5 months) . Nineteen of the 21 patients with hormone-secreting adenomas were considered to be in hormonal remission, and 87. 2% of the cases were capable of normal work and life and 8 patients suffered recurrence during the followed-up period. CONCLUSIONS: Selection of appropriate transcranial approaches is the key to successful microsurgery for giant pituitary adenomas according to the morphological characteristics presented in image examinations and clinical symptoms. Staged transsphenoidal operation and/or adjuvant therapies including medical and radiation therapies offer the best chances to control the residual tumors after the maximal surgical removal of giant adenomas through transcranial approaches.

[Microsurgical treatment of craniopharyngiomas: approaches in a series of 169 consecutive patients].

OBJECTIVE: To explore the clinical features, surgical approaches and postoperative outcomes of craniopharyngiomas. METHODS: A series of 169 consecutive cases of craniopharyngiomas undergoing microsurgical resection via various approaches at our hospital were retrospectively analyzed. There were 102 males and 67 females with a mean age of 34.1 (3-74) years. The operations were performed via unilateral subfrontal (n = 11), frontopterional (n = 69), anterior interhemispheric (n = 57), transcallosal (n = 9), transsphenoidal (n = 14), transcortical (n = 2), transventricular-foramen with neuroendoscope (n = 5) and combined (n = 2). Postoperative measures included the managements of blood sodium disorder and diabetes insipidus. During follow-ups, they were monitored for residual or recurrent tumor by postoperative contrast magnetic resonance imaging (MRI) every 1-3 months. RESULTS: The removals of lesions were total (n = 124, 73.4%), subtotal (n = 32, 18.9%) and partial (n = 13, 7.7%). And 104 cases had an intact preservation of pituitary stalk and stalk was partially preserved in 21 patients. Visual improvement (n = 49) and deterioration (n = 21) were achieved. The major postoperative complications included diabetes insipidus (n = 101) and electrolyte disorder (n = 89). And 26 patients had recurrence during a follow-up period of 26.1 (3-66) months. CONCLUSION: Selection of appropriate approaches according to morphological characteristics is essential for successful microsurgery of craniopharyngiomas.

Minimally invasive image-guided keyhole aspiration of cerebral abscesses.

Despite the low incidence of brain abscesses in Western nations (1-2%), the incidence in developing countries is as high as 8%. We evaluate a minimally invasive image-guided keyhole aspiration of cerebral abscesses and compare it with a series of cases treated with surgical excision. 23 patients (20 male and 3 female, aged 7-67 years) underwent image-guided burr hole aspiration of single or multiple cerebral abscesses. Patient characteristics, perioperative, and postoperative data were analyzed and compared with a second group of 22 patients (14 male and 8 female, aged 12-72) treated for cerebral abscesses with open surgical excision. In all cases, the surgical procedure was performed successfully without complication. 8 of the 23 aspiration cases were performed with the aid of iMRI. A comparison of patient demographics, duration of hospital stay, duration of antibiotic therapy, postoperative neurological recovery time, intraoperative blood loss, operative duration, length of incision, postoperative fever, repeat surgery, and mortality was performed between the aspiration and excision groups. Intraoperative blood loss, operative duration, length of incision, and postoperative fever were all significantly reduced in the aspiration group. Though, duration of hospital stay and antibiotic therapy and postoperative neurological recovery time were all increased in the aspiration group, and statistical significance was observed in all except the duration of hospital stay. This technique is a feasible and comparable minimally invasive alternative to open surgical excision and may provide reduced intraoperative blood loss, shortened operative duration, improved cosmetic outcomes, and a lessened incidence of postoperative fever.

[The surgery of giant symptomatic cavernous sinus aneurysms].

OBJECTIVE: To evaluate the management and outcomes in patients with giant symptomatic cavernous sinus aneurysms who underwent aneurysms trapping with bypass, proximal carotid occlusion and aneurysms trapping. METHODS: Twenty-three patients with giant symptomatic cavernous sinus aneurysms underwent surgery between February 2007 and March 2013, 3 cases were male and 20 cases were female patients, the age of the patients ranged between 24 and 68 years, mean age was 54.7 years. The pre-operative digital subtraction angiography (DSA) and ballon occlusion test (BOT) were performed to confirm the diagnosis and identify hemodynamic reserve with carotid occlusion, and the aneurysms trapping with bypass, aneurysms trapping and proximal occlusion of the internal carotid artery were performed according to BOT results. During the surgery, the neurophysiological monitoring and the intraoperative CT perfusion were used. The follow-up by DSA or CT angiography were made. RESULTS: Seventeen patients underwent aneurysms trapping with bypass, 1 underwent aneurysms trapping and 5 underwent proximal occlusion of the internal carotid artery. After surgery, symptom improved in 4 cases, did not change in 10 cases, and new neural function deficit developed in 9 cases. The follow-up period were 3 months to 75 months. Two patients were lost. The Glasgow Outcome Scale of last follow-up were 5 in 19 patients, 3 in 1 patient and 1 in 1 patient. CONCLUSIONS: The aneurysms trapping with bypass and proximal occlusion of the internal carotid artery are effective and reliable procedure for treatment of giant symptomatic cavernous sinus aneurysms in selected patients after evaluation of the pre-operative BOT, intra-operative neurophysiological monitoring and the intraoperative CT perfusion.

[Anterior interhemispheric approach for giant sellar region tumors in a series of 110 consecutive patients].

OBJECTIVE: To explore the techniques and efficacies of surgical resection of giant sellar region tumors via anterior interhemispheric approach. METHODS: A series of 110 consecutive cases of giant sellar region tumors undergoing microsurgery through an anterior interhemispheric approach at our hospital were retrospectively analyzed. Their mean age was 35.6 (3-72) years. There were craniopharyngioma (n = 57), pituitary adenoma (n = 33), hypothalamic glioma (n = 5), meningioma (n = 4) and other lesions (n = 11). The maximal tumor diameter varied from 4.0 to 8.2 cm with a mean diameter of 4.8 cm. Active measurements were taken for managing blood sodium disorder and diabetes insipidus. During the follow-ups, the patients were monitored for residual or recurrent tumor by hormonal assessment (in cases of functioning adenomas) and postoperative contrast magnetic resonance imaging (MRI) performed 1-3 months after surgery. RESULTS: Total lesion removal was achieved in 76 cases (69.1%). Twenty patients (18.2%) underwent subtotal resection and 14 (12.7%) had partial removal. No surgery-related mortality occurred. Visual acuity was preserved or improved in 97 patients (88.2%) within 1 week after surgery. The major postoperative complications included diabetes insipidus (n = 76, 69.1%), permanent diabetes insipidus (n = 23, 20.9%), electrolyte disorder (n = 62, 56.4%), seizures (n = 7, 6.4%), brain damage (3 cerebral contusions and 5 hematomas) (n = 8, 7.3%) and infarction(n = 2, 1.8%). During a median post-surgical follow-up period of 26 (3-96) months, 11 patients had recurrence. And 35 cases (31.8%) of endocrinological deficit received hormonal replacement after surgery. CONCLUSION: The interhemispheric approach is feasible for removing giant sellar region tumors without significant sequels. Active postoperative managements of diabetes insipidus and electrolyte disorder may accelerate early patient recovery.

[Functional neuro-navigation and intraoperative magnetic resonance imaging for the resection of gliomas involving eloquent language structures].

OBJECTIVES: To explore the clinical value of functional neuro-navigation and high-field-strength intraoperative magnetic resonance imaging (iMRI) for the resection of intracerebral gliomas involving eloquent language structures. METHODS: From April 2009 to April 2010, 48 patients with intracerebral gliomas involving eloquent language structures, were operated with functional neuro-navigation and iMRI. Blood oxygen level dependent functional MRI (BOLD-fMRI) was used to depict both Broca and Wernicke cortex, while diffusion tensor imaging (DTI) based fiber tracking was used to delineate arcuate fasciculus. The reconstructed language structures were integrated into a navigation system, so that intra-operative microscopic-based functional neuro-navigation could be achieved. iMRI was used to update the images for both language structures and residual tumors. All patients were evaluated for language function pre-operatively and post-operatively upon short-term and long-term follow-up. RESULTS: In all patients, functional neuro-navigation and iMRI were successfully achieved. In 38 cases (79.2%), gross total resection was accomplished, while in the rest 10 cases (20.8%), subtotal resection was achieved. Only 1 case (2.1%) developed long-term (more than 3 months) new language function deficits at post-operative follow-up. No peri-operative mortality was recorded. CONCLUSIONS: With functional neuro-navigation and iMRI, the eloquent structures for language can be precisely located, while the resection size can be accurately evaluated intra-operatively. This technique is safe and helpful for preservation of language function.

Revascularization for complex cerebral aneurysms.

BACKGROUND AND PURPOSE: Complex cerebral aneurysms may require indirect treatment with revascularization. This manuscript describes various surgical revascularization techniques together with clinical outcomes. METHODS: Thirty-two consecutive patients with complex cerebral aneurysm were managed from November 2005 to October 2008. Techniques used for revascularization were high-flow bypass, low-flow bypass, branch artery reimplantion, and primary reanastomosis. Physiologic and anatomic monitoring technologies, including electroencephalography, somatosensory evoked potential monitoring, microvascular doppler ultrasonography, and/or indocyanine green videoangiography were used intraoperatively to assess both brain physiology and vascular anatomy. Patient outcome was determined using the Glasgow Outcome Scale at discharge and at a mean of 12 months post operation (range 6-25 months). RESULTS: Two cervical carotid aneurysms (6%) were resected followed by primary reanastomosis, 21 aneurysms (66%) were trapped following saphenous vein high-flow bypasses, five (16%) were clipped after superficial temporal or occipital artery low-flow bypasses, and four (12%) middle cerebral branch arteries were reimplanted. Of the 32 patients at discharge, 29 (91%) had a Glasgow Outcome Scale of four or five, two (6%) had severe disability, and one (3%) died. CONCLUSION: Cerebral revascularization remains an effective and reliable procedure for treatment of complex cerebral aneurysms. Low morbidity and mortality rates reflect the maturity of patient selection and surgical technique in the management of these lesions.