Assessment of a 3D printed simulator of a lateral ventricular puncture in interns' surgical training.

PURPOSE: In this study, a simulator for training lateral ventricular puncture (LVP) was developed using three-dimensional (3D) printing technology, and its function of improving the skills of LVP in young interns was evaluated. METHODS: A virtual 3D craniocerebral simulator of a 51-year-old female patient with hydrocephalus was reconstructed with 3D printing technology. The anatomical and practical validity were assessed by all interns on a 13-item Likert scale. The usefulness of this simulator was evaluated once a week by two neurosurgeons, based on the performance of the interns, using the objective structured assessment of technical skills (OSATS) scale. RESULTS: The Likert scale showed that all participants agreed with the overall appearance of the simulator. Also, the authenticity of the skull was the best, followed by the lateral ventricles, analog generation system of intraventricular pressure, cerebrum, and the scalp. This simulator could help the participants' learning about the anatomy of the lateral ventricle, effective training, and repeating the steps of LVP. During training, the interns' ratio of success in LVP elevated gradually. At each evaluation stage, all mean performance scores for each measure based on the OSATS scale were higher than the previous. CONCLUSIONS: The 3D printed simulator for LVP training provided both anatomical and practical validity, and enabled young doctors to master the LVP procedures and skills.

Clinical outcome of gliosarcoma compared with glioblastoma multiforme: a clinical study in Chinese patients.

Gliosarcoma (GSM) is a rare biphasic neoplasms of the central nervous system composed of a glioblastoma multiforme (GBM) admixed with a sarcomatous component. In clinical practice GSM is generally managed similarly to GBM. However, there are conflicting reports regarding their clinical aggressiveness, cell line of origin and possible prognosis compared with those of GBM. The objective of this study was to compare clinic-pathological features in GSM patients with the GBM patients during the same study period. 518 patients with GBM were treated at our hospital between 2008 and 2013, among them 51 were GSM. In this series the GSMs represented 9.8% of all GBMs and included 58.8% male with a median age of 44.7 years. The locations, all supratentorial, included temporal in 41.2%, frontal in 25.5%, parietal in 19.6%, and occipital in 13.7%. All patients underwent tumor resection followed by post-operative radiation and adjuvant chemotherapy. The O6-methylguanine-DNA methyltransferase promoter methylation studies were significantly more frequent in the GBMs than GSMs (80.1% vs. 44.7%, P < 0.001). The median progression free survival and overall survival for the patients with GSM were 8.0 and 13.0 months, respectively, as compared with 9.0 and 14.0 months in the GBM group (log rank test P = 0.001 and 0.004, respectively). The Cox proportional hazards regression model indicated that the extent of tumor resection (HR = 1.518, P = 0.009) and pathological types (HR = 0.608, P = 0.002) were the significant prognostic factors in our own series. With regard to clinical features and outcomes, GSM and GBM cannot be distinguished clinically. GSM in China may be managed similarly to GBM, with maximal safe surgical resection followed by chemo-radiotherapy. Our study adds further evidence to support GSM as a unique clinical entity with a likely worse prognosis than GBM.

Ultrastructural Changes of Brain Tissues Surrounding Hematomas after Intracerebral Hemorrhage.

Our knowledge about pathophysiology of intracerebral hemorrhage (ICH) mainly originates from preclinical models of ICH. In this study, cerebral ultrastructure surrounding hematoma and its correlation with clinical severity were investigated in ICH patients. Thirty patients with basal ganglia hemorrhage and 6 control subjects were enrolled. Surgical evacuation was performed for patients with a blood loss >30 ml. Stroke severity was assessed using the Glasgow Coma Scale (GCS) and the National Institute of Health Stroke Scale (NIHSS). Transmission electron microscopy (TEM) was used to evaluate the ultrastructural characteristics of tissue specimens. Neural cells surrounding the hematomas showed evidence of cell swelling and necrosis. Decreased numbers of organelles and mitochondrial cristae were accompanied by cytoplasmic vacuolization, nuclear membrane invagination and breakdown, and intranuclear chromatic agglutination. These changes resulted in disintegration together with malacia, disappearance of the nucleus and nucleolus, and karyopyknosis. More serious ultrastructural damage was seen in patients with greater NIHSS scores, lower GCS scores, and greater bleeding volumes (p < 0.001). These findings suggest that neural cells undergo unfavorable ultrastructural changes that are responsible for dysfunction after ICH.

A Low-Cost Mobile-Based Augmented Reality Neuronavigation System for Retrosigmoid Craniotomy.

BACKGROUND AND OBJECTIVES: The correct positioning of the transverse-sigmoid sinus junction (TSSJ) during retrosigmoid craniotomy (RC) is crucial for enhancing surgical efficiency and preventing complications. An augmented reality technology may provide low-cost guidance for the TSSJ position. The authors aimed to investigate the clinical application of a self-developed mobile augmented reality navigation system (MARNS) for TSSJ positioning during RC and present their findings. METHODS: This observational research enrolled patients who underwent RC at Fujian Provincial Hospital from May 2023 to June 2023. All patients had their TSSJs located by MARNS. The surgical incision and skull "keyhole" for drilling were determined separately based on the projections of TSSJ on the 3-dimensional model displayed by MARNS. This method was assessed using matching error, positioning time, integrity of the bone flap, incidence of transversal sigmoid sinus injury, and other complications. RESULTS: Seven patients diagnosed with acoustic neuroma, trigeminal neuralgia, and hemifacial spasm were enrolled in this study. The MARNS system exhibited a matching error with an average magnitude of 2.88 ± 0.69 mm. The positioning procedure necessitated an average duration of 279.71 ± 27.29 seconds. In every instance, the inner edge of the TSSJ was precisely identified and exposed while the bone flap was successfully formed and maintained an average integrity of 86.7%. CONCLUSION: This study demonstrated the efficacy of MARNS in the precise placement of the TSSJ during RC procedures. It offers advantages for convenience, cost-effectiveness, and reliability for neurosurgical navigation.

Marker-less augmented reality based on monocular vision for falx meningioma localization.

BACKGROUND: The existing augmented reality (AR) based neuronavigation systems typically require markers and additional tracking devices for model registration, which causes excessive preparatory steps. METHODS: For fast and accurate intraoperative navigation, this work proposes a marker-less AR system that tracks the head features with the monocular camera. After the semi-automatic initialization process, the feature points between the captured image and the pre-loaded keyframes are matched for obtaining correspondences. The camera pose is estimated by solving the Perspective-n-Point problem. RESULTS: The localization error of AR visualization on scalp and falx meningioma is 0.417 ± 0.057 and 1.413 ± 0.282 mm, respectively. The maximum localization error is less than 2 mm. The AR system is robust to occlusions and changes in viewpoint and scale. CONCLUSIONS: We demonstrate that the developed system can successfully display the augmented falx meningioma with enough accuracy and provide guidance for neurosurgeons to locate the tumour in brain.

A virtual reality-based data analysis for optimizing freehand external ventricular drain insertion.

PURPOSE: This work exploits virtual reality technique to analyse and optimize the preoperative planning of freehand external ventricular drain (EVD) insertion. Based on the three-dimensional (3D) virtual brain models, neurosurgeons can directly observe the anatomical landmarks and complete the simulated EVD insertion. Simulation data is used to optimize preoperative planning parameters to ensure the surgical performance. METHODS: We used the computed tomography (CT) scans to construct the 3D virtual brain models. A group of EVD insertions were simulated by inserting virtual catheters at different entry points. The key parameters including the location of entry point, the catheter orientation, the catheter tip position on lateral ventricles, and the insertion depth were recorded. A data analysis method was then applied to optimize these parameters, resulting in the optimal parameters for the EVD insertion. RESULTS: When the lateral distance of entry point ranged from 2.5 to 3 cm, the success rate of 204 cases was 97.79%, which was higher than that of the classic method (59.52%). The optimal insertion angle towards the sagittal plane ranged from 10.46° to 12.73°. To prevent penetrating the lateral ventricles, the insertion depth was optimized to be 3.28 to 4.58 cm. CONCLUSIONS: The proposed data analysis method is helpful to optimize the key parameters of the preoperative planning, and provides useful references for neurosurgeons to perform the freehand EVD insertion. The EVD insertion experiments on 3D printing model had a success rate of 93.75%, which verified the effectiveness of the data analysis.

Flot2 targeted by miR-449 acts as a prognostic biomarker in glioma.

Flotillin-2 (FLOT2) was reported as oncogene and involves in the pathogenic process of several cancers, yet the precise mechanism of FLOT2 in glioma is still limited. In this study, we demonstrated that FLOT2 expression levels were greatly upregulated in glioma tissues and cell lines, and the FLOT2 expression in glioma tissue was markedly associated with tumour stage and size. Overexpression of FLOT2 was correlated with poor prognosis of glioma patients. The functional assay revealed that silenced FLOT2 repressed the viability, migration, and invasion of glioma cells. And then, we detected the relationship between miR-449 and FLOT2. Luciferase reporter assay and Western blot results showed that miR-449 directly binding the 3'UTR sequence of FLOT2 and regulated FLOT2 expression in glioma cells. Finally, we detected the expression levels of miR-449 in glioma tissue and cell lines and found that miR-449 was significantly downregulated in glioma tissues and cell lines. In conclusion, we demonstrated that overexpression FLOT2 was associated with poor prognosis of glioma patients and involved in the progression of glioma, identifying a novel prognostic biomarker and therapeutic target for glioma progression.

Increased perihematomal neuron autophagy and plasma thrombin-antithrombin levels in patients with intracerebral hemorrhage: An observational study.

Animal studies have demonstrated that autophagy was involved in neuronal damage after intracerebral hemorrhage (ICH). Several studies showed thrombin-antithrombin (TAT) plasma levels were elevated in patients with ICH. In this study, we aimed to evaluate if autophagy occurred in patients with ICH; and the relationship between the severity of brain injury and plasma TAT levels.A novel tissue harvesting device was used during hematoma removal surgery to collect loose fragments of tissue surrounding the affected brain area in 27 ICH patients with hematoma volumes of >30 mL in the basal ganglia. Control tissues were obtained from patients who underwent surgery for arteriovenous malformation (n = 25). Transmission electron microscopy (TEM) and immunohistochemistry for autophagy-related proteins were used to evaluate the ultrastructural and morphologic cellular characteristics; and the extent of autophagy in the recovered tissue specimens. Stroke severity was assessed by using the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS). An enzyme-linked immunosorbent assay (ELISA) was used to measure plasma TAT levels.Transmission electron microscopy showed autophagosomes and autolysosomes exist in neurons surrounding the hematoma, but not in the control tissues. The number of cells containing autophagic vacuoles correlated with the severity of brain injury. Immunohistochemistry showed strong LC3, beclin 1, and cathepsin D staining in ICH tissue specimens. Plasma TAT levels correlated positively with autophagic cells and ICH severity (P < .01).Autophagy was induced in perihematomal neurons after ICH. Autophagy and plasma TAT levels correlated positively with severity of brain injury. These results suggest that autophagy and increased plasma TAT levels may contribute to the secondary damage in ICH patients.

[Expression of matrix metalloproteinase MMP-9 in the plasma and hematoma fluid of intracerebral hemorrhage patients].

OBJECTIVE: To investigate the matrix metalloproteinase (MMP)-9 played in secondary brain injury following intracerebral hemorrhage (ICH). METHODS: Hematoma fluid and peripheral blood samples were collected from 60 ICH patients, 34 males and 26 females, aged 60 +/- 13 (37 - 81) n the days 1, 4, and 7 after evacuation of hematoma. Peripheral blood samples were collected form. 30 sex, and age-matched healthy adults as normal controls. Cerebrospinal fluid (SCF) samples were collected from 10 sex, and age-matched patients to undergo operation during lumbar anesthesia. ELISA was used to detect the content of MMP-9. Tada formula was used to calculate the perihematomal edema volume. The National Institutes of Health Stroke Scale (NIHHS) and Glasgow Coma Score (GCS) were used to assess the condition of patients. RESULTS: (1) The MMP-9 levels in the plasma and hematoma fluid of the ICH patients at all time points were all significantly higher than those of the normal controls (all P < 0.01). MMP-9 was not found in the normal CSF. (2) The plasma and hematoma fluid MMP-9 levels were increased already in the day 1, peaked in the day 4, and then kept at a high level until the day 7. (3) The MMP-9 levels in hematoma fluid t all time points were all significantly higher than those in the plasma (all P < 0.01). (4) The MMP-9 level was positively correlated with the hematoma volume and NIHSS score, and negatively correlated with the GCS score (both P < 0.01). CONCLUSIONS: MMP-9 may takes part in the secondary injury after ICH, and its change is correlated with the hydrocephalus of patients. The dynamical change of the plasma MMP-9 level is consistent with the hematoma fluid MMP-9 level after ICH. There is a positive correlation among the MMP-9 level, perihematomal edema volume, and severity of ICH.

Diagnostic value of preoperative inflammatory markers in patients with glioma: a multicenter cohort study.

OBJECTIVE Glioma is the most common form of brain tumor and has high lethality. The authors of this study aimed to elucidate the efficiency of preoperative inflammatory markers, including neutrophil/lymphocyte ratio (NLR), derived NLR (dNLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), and prognostic nutritional index (PNI), and their paired combinations as tools for the preoperative diagnosis of glioma, with particular interest in its most aggressive form, glioblastoma (GBM). METHODS The medical records of patients newly diagnosed with glioma, acoustic neuroma, meningioma, or nonlesional epilepsy at 3 hospitals between January 2011 and February 2016 were collected and retrospectively analyzed. The values of NLR, dNLR, PLR, LMR, and PNI were compared among patients suffering from glioma, acoustic neuroma, meningioma, and nonlesional epilepsy and healthy controls by using nonparametric tests. Correlations between NLR, dNLR, PLR, LMR, PNI, and tumor grade were analyzed. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic significance of NLR, dNLR, PLR, LMR, PNI, and their paired combinations for glioma, particularly GBM. RESULTS A total of 750 patients with glioma (Grade I, 81 patients; Grade II, 208 patients; Grade III, 169 patients; Grade IV [GBM], 292 patients), 44 with acoustic neuroma, 271 with meningioma, 102 with nonlesional epilepsy, and 682 healthy controls were included in this study. Compared with healthy controls and patients with acoustic neuroma, meningioma, or nonlesional epilepsy, the patients with glioma had higher values of preoperative NLR and dNLR as well as lower values of LMR and PNI, whereas PLR was higher in glioma patients than in healthy controls and patients with nonlesional epilepsy. Subgroup analysis revealed a positive correlation between NLR, dNLR, PLR, and tumor grade but a negative correlation between LMR, PNI, and tumor grade in glioma. For glioma diagnosis, the area under the curve (AUC) obtained from the ROC curve was 0.722 (0.697-0.747) for NLR, 0.696 (0.670-0.722) for dNLR, 0.576 (0.549-0.604) for PLR, 0.760 (0.738-0.783) for LMR, and 0.672 (0.646-0.698) for PNI. The best diagnostic performance was obtained with the combination of NLR+LMR and dNLR+LMR, with AUCs of 0.777 and 0.778, respectively. Additionally, NLR (AUC 0.860, 95% CI 0.832-0.887), dNLR (0.840, 0.810-0.869), PLR (0.678, 0.641-0.715), LMR (0.837, 0.811-0.863), and PNI (0.740, 0.706-0.773) had significant predictive value for GBM compared with healthy controls and other disease groups. As compared with the Grade I-III glioma patients, the GBM patients had an AUC of 0.811 (95% CI 0.778-0.844) for NLR, 0.797 (0.763-0.832) for dNLR, 0.662 (0.622-0.702) for PLR, 0.743 (0.707-0.779) for LMR, and 0.661(0.622-0.701) for PNI. For the paired combinations, NLR+LMR demonstrated the highest accuracy. CONCLUSIONS The NLR+LMR combination was revealed as a noninvasive biomarker with relatively high sensitivity and specificity for glioma diagnosis, the differential diagnosis of glioma from acoustic neuroma and meningioma, GBM diagnosis, and the differential diagnosis of GBM from low-grade glioma.

[Neural apoptosis and apoptosis-related genes in intracerebral hemorrhage patients].

OBJECTIVE: To observe the neural apoptosis and expression of apoptosis-related genes in brain in order to elucidate the regulation mechanism in the perihematomal region of intracerebral hemorrhage (ICH) patients. METHODS: Specimens of perihematomal region in human brain were obtained from 29 patients undergoing surgical evacuation of an intracerebral hematoma. Specimens of brain tissue were collected from the corpses of 6 persons within 3 hours after the accidental death. Neural apoptosis was evaluated by terminal deoxynucleotidyl transferase-mediated deoxyuridine 5' triphosphate nick end labeling (TUNEL) method and immunohistochemistry was used to detect the expression of Bcl-2, Bax, P53, and caspase-3 genes. RESULTS: The apoptosis rates of the ICH group was 4.10 +/- 0.28, significantly higher than that of the control group (0.57 +/- 0.43, P < 0.01). The expression rate of Bcl-2 the ICH group was 2.68 +/- 0.52, significantly higher than that of the control group (1.54 +/- 0.56, P < 0.01). The expression rate of Bax of the ICH group was 3.49 +/- 0.18, significantly higher than that of the control group (0.96 +/- 0.27, P < 0.01). The expression of P53 was 4.12 +/- 0.63, significantly higher than that of the control group (0.96 +/- 0.71, P < 0.01). The expression of caspase-3 of the ICH group was 3.50 +/- 0.25, significantly higher than that of the control group (0.74 +/- 0.73, P < 0.01). The expression levels of Bcl-2 and P53 were negatively correlated with the apoptosis rate (both P < 0.01), while the expression levels of Bax and caspase-3, and the Bax/Bcl-2 ratio were positively correlated with the apoptosis rate in perihematomal region of ICH patients (all P < 0.01). CONCLUSION: Apoptosis is involved in the delayed brain injury after ICH in human and is the main factor of delayed neural death. Some of the genes take part in the regulation of neural apoptosis: Bax and caspase-3 hasten the apoptosis while Bcl-2 and P53 restrain it.

Similar MR imaging characteristics but different pathological changes: a misdiagnosis for Lhermitte-Duclos disease and review of the literature.

Although previous reports purpored that the unique magnetic resonance imaging (MRI) features of Lhermitte-Duclos disease (LDD) obviates the need for biopsy, we have made a misdiagnosis of LDD which has an indistinguishable imaging appearance. We present a patient who suffered from a normal cerebellum with arachnoid vascular malformation that had imaging characteristics which were indistinguishable from LDD before operation. This atypical imaging appearance, which could potentially be confused with LDD, may lead to misdiagnosis and inappropriate treatment in the absence of tissue sampling. Thus, this finding suggests that in those patients where images are highly suggestive of LDD but lack other manifestations of Cowden syndrome, biopsy is required and advanced imaging with magnetic resonance spectroscopy (MRS) should be strongly considered.

Secondary headache due to aspergillus sellar abscess simulating a pituitary neoplasm: case report and review of literature.

Fungal sellar abscess is rare. A 42-year-old man was admitted with 2-month headache characterized by right peri-orbital pain. An intrasellar mass was found to be simulated a pituitary neoplasm after magnetic resonance imaging examination, and operated on via an endoscopic trans-sphenoidal approach. Milk-like pus and a mass of ash black mixed and necrotic material were found and removed. Histopathology revealed numerous aspergillus hyphae. Itraconazole was given on a dosage of 200 mg twice a day orally for 6 weeks. No recurrence was observed during follow-up. Complete surgical resection through endoscopic trans-sphenoidal approach combined with systemic anti-fungal therapy, should be considered as the optimal treatment.

Continuous versus intermittent infusion of cefepime in neurosurgical patients with post-operative intracranial infections.

Cefepime is administered as an intermittent infusion (II); however, continuous infusion (CI) may be advantageous because ß-lactam antibiotics exhibit time-dependent antibacterial activity. This retrospective, non-randomised, comparative study included 68 neurosurgical patients with post-operative intracranial infections treated with 4g/day cefepime over 24h as a CI (n=34) or 2g every 12h as II (n=34). CI controlled the intracranial infection more rapidly and effectively than II (6.6±1.9 days vs. 7.8±2.6 days; P=0.036). By considering the minimum inhibitory concentrations (MICs) to be 4µg/mL and 8µg/mL, the percentage of time when the cefepime plasma or CSF concentrations were higher than the MIC (%T>MIC) was calculated for each patient. For plasma cefepime concentrations, the %T(>MIC) in the CI group was higher than in the II group (for MICs of 8µg/mL, 100% vs. 75%, respectively). The mean calculated area under the curve (AUC) in the CI group was similar to the II group (1197.99±72.15µgh/mL vs. 890.84±140.78µgh/mL; P=0.655). For CSF cefepime concentrations, the %T(>MIC) in the CI group was higher than in the II group (for MICs of 4µg/mL and 8µg/mL, 83.3% and 75% vs. 25% and 0%, respectively). The mean calculated AUC for the CI group was higher than the II group (220.56±13.59µgh/mL vs. 86.34±5.69µgh/mL; P=0.003). Therefore, CI of cefepime significantly enhanced the antibacterial effect and reduced the treatment duration in neurosurgical patients with post-operative intracranial infections.

A meta-analysis of bevacizumab alone and in combination with irinotecan in the treatment of patients with recurrent glioblastoma multiforme.

Combining bevacizumab with irinotecan is a new chemotherapy regimen for patients with recurrent glioblastoma multiforme (GBM). Recent phase II trials suggest that this combined chemotherapy is beneficial to patients, but the subsequent adverse events may lead to treatment discontinuation. No comparison has yet demonstrated conclusively that the combined chemotherapy is more beneficial than single-agent chemotherapy. Thus, a meta-analysis was conducted to assess the efficacy and safety of bevacizumab compared to bevacizumab combined with irinotecan for the treatment of recurrent GBM. A total of 480 patients were included in the study, with 183 patients (38.1%) in the bevacizumab group and 297 patients (61.9%) in the bevacizumab plus irinotecan group. The median overall survival was 8.63 months (95% confidence interval [CI], 8.54-8.72 months) and 8.91 months (95% CI, 8.69-9.13 months), respectively. The mean objective response rate (complete response plus partial response rate) was 33.9% (95% CI, 18.1-52.1%) and 45.8% (95% CI, 28.2-66.7%), respectively. The 6-month progression-free survival rates (PFS-6) were 38.8% (95% CI, 18.8-57.0%) and 48.3% (95% CI, 25.4-54.3%), respectively. The rate of discontinuation was 5.5% and 20.0%, respectively. Compared with patients treated with bevacizumab only, those in the bevacizumab plus irinotecan group had higher PFS-6 (p=0.046), objective response (p=0.013) and rate of discontinuation (p=0.000) but there was no statistically significant difference in overall survival between the groups (p=0.487). Thus, although the combination of bevacizumab and irinotecan may increase the rate of discontinuation, it provided no obvious improvement in overall survival in patients with recurrent GBM. Therefore, the benefits of drug combination are outweighed by the treatment discontinuity and quality of life effects of drug toxicity and should be considered on an individual patient basis only.

Application value of 3D printing technology in the surgery of sphenoid ridge meningioma / 中国肿瘤临床

Objective:To investigate the value of 3D printing technology in sphenoid ridge meningioma dissection. Methods:By using craniocerebral spiral enhanced CT scan DICOM images, the skull, vessels, and tumor were extracted, reconstructed, and assembled and integrated in the same coordinate system. Then, we constructed a 3D virtual model and a 3D-printed entity model, which was ap-plied for preoperation and postoperation. Results:Virtual models of the brains of five patients were reconstructed successfully and 3D entity models were produced. The models expressed the relationship among tumors, adjacent blood vessels, and the important posi-tion of the nerve tissue. Then, the models were applied to the reference before surgery planning and after surgery. Five cases were successfully performed. Conclusion:The use of the entity model of sphenoid ridge meningioma is important in optimizing operation plans, improving tumor resection, and reducing intraoperative bleeding.