Bispectral Index Monitoring in the Nursing of Patients With Paroxysmal Sympathetic Hyperactivity.

AIM: To investigate the clinical nursing effect of bispectral index (BIS) monitoring for paroxysmal sympathetic hyperactivity (PSH) patients in the neurosurgical intensive care unit (NICU). METHODS: From January 2022 to June 2023, a total of 30 patients with PSH secondary to moderate to severe craniocerebral injury in the NICU were monitored for BIS. The patients' paroxysmal sympathetic hyperactivity-assessment measure (PSH-AM) scores were recorded. PSH patients generally appear in 3 states: calm state, seizure state, and postmedication state. Thirty PSH patients' BIS values were recorded during the calm period, during the seizure state, and postmedication state, and these 3 different stages' BIS values were divided into groups A, B, and C, using the Kruskal-Wallis H test to compare groups. RESULTS: The Kruskal-Wallis H test yielded a value of H=22.599, P <0.001. H0 was rejected against the test standard of α=0.05, and the BIS values of groups A, B, and C differed. The BIS values of group A and group B differed after a pairwise comparison, and the difference was statistically significant (adjusted P =0.001). Group B and group C had different BIS values, and the difference was statistically significant (adjusted P =0.001); group A and Group C had no difference in BIS values, and the difference was not statistically significant (adjusted P =1.00). CONCLUSIONS: Taking BIS value as the nursing observation index for PSH patients can make nursing work more objective, reasonable, and accurate, reduce the inducing factors of PSH attack, further reduce the attack of PSH, save nursing resources, and help guide the safety assessment of sedative use.

Aberrant brain functional hubs convergence in the acute severe traumatic brain injury patients with rapidly recovering.

PURPOSE: We aimed to identify the aberrant functional hubs in patients with acute severe traumatic brain injury (sTBI) and investigate whether they could help inform prognosis. METHODS: Twenty-eight sTBI patients and health controls underwent imaging scanning. The graph-theoretical measure of degree centrality (DC) was applied to identify the abnormal brain functional hubs and conjoined with regions of interest-based analysis to investigate their interaction and impact on whole-brain. We further split sTBI patients into two subgroups according to their recovery to explore whether the fractional amplitude of low-frequency fluctuation (fALFF) roles in functional connectivity (FC) differential areas to help inform the patients' long-term prognosis. RESULTS: We identified the part of prefrontal cortex (PFC), precentral and postcentral gyrus (Pre-/Post-CG), cingulate gyrus (CgG), posterior medial cortex (PMC), and brainstem that could be core hubs whose DC was significantly increased in patients with acute sTBI. The interaction strength of the paired hubs could be enhanced (CG-PFC, CgG-PFC, CG-brainstem, CgG-brainstem, PMC-brainstem, and PFC-brainstem) and weakened (CG-CgG, CG-PMC, CgG-PMC, and PMC-PFC), compared with healthy controls. We also found abnormal FC in 5 hubs to whole-brain. The spontaneous brain activities in the FC differential regions [e.g., the fALFF and mean fALFF value] were valid to predict outcome at 6-month in patients with sTBI. CONCLUSION: We demonstrated a compensatory mechanism that part of brain regions will converge into abnormal functional hubs in patients with acute sTBI, which provides a potential approach to objectively predicting patients' long-term outcome.

Prognostic value of the systemic inflammation response index in patients with aneurismal subarachnoid hemorrhage and a Nomogram model construction.

OBJECTIVE: To investigate the prognostic value of inflammatory markers, including neutrophil/lymphocyte ratio (NLR), derived neutrophil/lymphocyte ratio (dNLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), prognostic nutritional index (PNI), and systemic inflammation response index (SIRI) in patients with aneurismal subarachnoid hemorrhage (aSAH), and then develop a Nomogram prognostic model. METHODS: We analysed 178 aSAH patients who underwent surgery at Subei People's Hospital of Jiangsu province from January 2015 to December 2017. Patients were divided into two groups according to Glasgow outcome scale (GOS) score at 3 months. Univariate and multivariate analysis were used to identify the association between inflammatory markers and prognosis. Subsequently, we identified the best cutoff of SIRI for unfavorable outcome using receiver operating characteristic (ROC) curve analysis and compared the clinical data between high and low SIRI levels. We further evaluated the additive value of SIRI by comparing prognostic nomogram models with and without it. RESULTS: A total of 47 (26.4%) patients had a poor outcome. Multivariate logistic regression analysis showed that SIRI was an independent risk factor of poor outcome. The SIRI of 4.105 × 109/L was identified as the optimal cutoff value, patients with high SIRI levels had worse clinical status and higher rates of unfavorable outcome. ROC analysis showed that a nomogram model combining the SIRI and other conventional factors showed more favorable predictive ability than the model without the SIRI. CONCLUSIONS: SIRI was independently correlated with unfavorable outcome in SAH patients, and the nomogram model combining the SIRI had more favorable discrimination ability.

Anatomical Study and Clinical Application of Neuroendoscopic Transfarlateral Supracerebellar Infratentorial Approach.

BACKGROUND: Tumors in the petroclival region have challenged neurosurgeons. However, neuroendoscopy has been increasingly applied internationally. This study simulated a pure neuroendoscopic transfarlateral supracerebellar infratentorial approach for petroclival tumor resection from the cadaveric head and discussed the advantages and safety of this approach. METHODS: The anatomical structure for petroclival tumor resection was visualized using a pure neuroendoscopic transfarlateral supracerebellar infratentorial approach in 5 cadaveric heads. Ten cases with petroclival tumors were retrospectively analyzed and summarized between January 2020 and June 2021. All the cases had undergone surgery using a pure neuroendoscopic supracerebellar infratentorial approach. RESULTS: The anatomical structure of the petroclival region was exposed using the pure neuroendoscopic supracerebellar infratentorial approach, and the partial anatomical structure of the middle skull base was further exposed by incision of the tentorium in the cadaveric head. Among the 10 cases, the tumors of 6 cases were totally removed, and those of 4 cases were subtotally removed; no cases of intracranial infection or death occurred after surgery. CONCLUSION: The neuroendoscopic transfarlateral supracerebellar infratentorial keyhole approach is a safe and effective surgical method to treat petroclival lesions and invasive middle cranial fossa lesions.

Anatomical Study and Clinical Application of Optic Canal Decompression Via Transethmoid-sphenoid Approach Under Endoscope.

This study aimed to evaluate the safety and accuracy of the endoscopic transethmoid-sphenoid approach for optic canal decompression. Twelve sides of 6 adult cadaveric heads fixed in formalin were selected to simulate optic canal decompression using the endoscopic transethmoid-sphenoid approach. Furthermore, this approach was used for optic canal decompression in 10 patients (11 eyes) with optic nerve canal injury. Related anatomical structures were observed using a 0-degree endoscope, and the anatomical characteristics as well as the surgical data were collected. The maximum effective widths of the cranial opening, orbital opening, and middle segment of the canal that could be drilled open endoscopically were 7.82±2.63, 8.05±2.77, and 6.92±2.01 mm, respectively. The angle between the line linking the center point of the tubercular recess with the midpoint of the cranial opening of the optic canal and the horizontal coordinate was 17.23±1.34 degrees. At the orbital opening of the optic canal, the ophthalmic artery was located directly inferior to the optic nerve in 2 cases (16.7%) and laterally inferior to the optic nerve in 10 cases (83.3%). Six of the operational eyes were effective while the remaining 5 were ineffective. No postoperative complications such as bleeding, infection, or cerebrospinal fluid leakage were observed during the follow-up period (6-12 mo). In conclusion, optic canal decompression positively impacts the prognosis of partial traumatic optic neuropathy. Furthermore, the endoscopic transethmoid-sphenoid approach for optic canal decompression is a minimally invasive procedure that provides direct access and adequate decompression. This technique is easy to master and suitable for clinical applications.

Clinical study of puncture technique in single division of the trigeminal ganglion intumescentia.

OBJECTIVE: We explored the feasibility of single-division puncture in the ophthalmic division, maxillary division, and mandibular division of the trigeminal ganglion intumescentia (TGI) and the feasibility of radiofrequency treatment of trigeminal neuralgia. METHODS: According to the previous anatomical image studies, 3D Slicer software was used to analyze the CT images of the patients. The trigeminal ganglion fossa (TGF) was used as the imaging sign. TGI was identified in the sagittal plane along the fiber. The puncture path starts from the TGI center-foramen ovale line, extending outward to the epidermis as the needle insertion point, and extending inward to the division boundary. For lateral puncture, which is blocked by the mandible, the positions of closed mouth, open mouth, and over-open mouth were used. Multiple targets were generated using straight electrodes and curved electrodes to achieve full coverage of TGI. According to the preoperative design, general anesthesia surgery was performed. Xper CT was used for imaging, and the puncture was guided by Xper Guide. Radiofrequency treatment of TGI was conducted. RESULTS: In total, 45 patients with trigeminal neuralgia underwent 50 single-division TGI punctures. The procedure was smooth and the compliance with the design was good. Continuous radiofrequency (CRF) was performed, the VAS scores were 25 times at 70°C, 19 times at 65°C, two times at 60°C, and two times at 50°C (both in the ophthalmic division). Pulsed radiofrequency (PRF) was conducted two times. Within 24 h after the procedure, the VAS scores were all 0. From 1 to 7 days after the procedure, pain recurrence was found in three cases, of whom two cases received pulsed radiofrequency treatment. Patients were followed up for 1-24 months and there were no recurrence. After continuous radiofrequency at 65-70°C, the moderate tactile loss was observed, and nearly half of the patients had food residues on the surgical side after 6 months. After continuous radiofrequency at 60°C, there was mild tactile loss and no food residue. The tactile sensation was slightly decreased after continuous radiofrequency at 50°C, and the tactile sensation was normal the next day. CONCLUSION: Trigeminal ganglion intumescentia single-division radiofrequency is effective and feasible for the treatment of trigeminal neuralgia.

Does erythropoietin affect the outcome and complication rates of patient with traumatic brain injury? A pooled-analysis.

OBJECTIVE: The aim of this meta-analysis was to review the scientific literature published until April 18, 2021, to summarize existing knowledge on the efficacy and safety of erythropoietin (EPO) for traumatic brain injury (TBI). METHODS: This systematic review followed PRISMA guidelines. Randomized controlled trials (RCTs) reporting on the efficacy and safety of EPO in the treatment of TBI were systematically searched in relevant electronic databases according to a pre-designed search strategy. The primary outcomes are the mortality; and secondary outcomes are the good functional outcome (GFO) and adverse events (AEs). RESULTS: A total of 10 RCTs involving 2,402 participants fulfilled the inclusion criteria. The results showed that there is a significant difference in terms of the mortality (RR = 0.67, 95% CI = 0.54-0.84, P = 0.0003) and seizure rate (RR = 0.52, 95% CI = 0.29-0.96, P = 0.04) between the EPO groups compared to those in the control groups. However, compared with the control groups, the GFO in the EPO groups was not statistically significant (RR = 1.18, 95% CI = 0.93-1.48, P = 0.17). CONCLUSIONS: Findings of the present meta-analysis suggest that the use of EPO could reduce mortality rate in patients with TBI, without increasing the incidence of AEs. EPO has potential research and application value in the treatment of TBI.

Surgical treating lumbar intraspinal tumor through a para-split laminotomy.

BACKGROUND: to explore the feasibility and effectiveness of para-split laminotomy in the treatment of lumbar intraspinal tumors. METHODS: We retrospectively review the clinical data of 15 patients suffering lumbar intraspinal tumors, who underwent tumor resection using the para-split laminotomy, from October 2016 to May 2018. Observation indicators were as follows: (1) surgical and postoperative recovery situations; (2) the neurological function of the spinal cord and the follow-up situations. RESULTS: Mean blood loss was 95.3 ± 58.2 ml, and the mean duration of the surgical procedure was 176.7 ± 35.2 min. All lumbar intraspinal tumors were resected completely. There were no operative complications. The postoperative CT scans showed no pedicle or vertebral fractures. During the follow-up period of 6-18 months (average 10.8 ± 3.9 months), no tumor recurrence or spinal deformation was found according to the imaging examination. CT 3D reconstructions showed that the split laminae tended to heal. The average preoperative JOA score was 15.5 ± 4.9 and the average postoperative JOA score improved to 24.0 ± 3.5 (average improvement rate 65.9 ± 19.6%). CONCLUSION: The para-split laminotomy could reduce the damage to the posterior spinal tension band and help to protect the stability of the spine. It is feasible and effective to apply the para-split laminotomy to the operation of a lumbar intraspinal tumor, and this technique may be a promising option when considering surgical methods for some multilevel well-circumscribed intraspinal tumors.

Clinical Study of Cranioplasty Combined With Ipsilateral Ventriculoperitoneal Shunt in the Treatment of Skull Defects With Hydrocephalus.

OBJECTIVE: To explore the clinical effect and safety of cranioplasty combined with ipsilateral ventriculoperitoneal shunts in the treatment of skull defects with hydrocephalus. METHODS: The clinical data of 78 patients with skull defects with hydrocephalus were analyzed retrospectively. All patients were treated with cranioplasty and ventriculoperitoneal shunts in 1 stage, including 35 cases of cranioplasty combined with ipsilateral ventriculoperitoneal shunts (ipsilateral operation group) and 43 cases of contralateral operations (contralateral operation group). RESULTS: The incision length (28.97 ±â€Š4.55 cm), operation time (139.00 ±â€Š42.27 minutes), and intraoperative hemorrhage (174.57 ±â€Š79.35 mL) in the ipsilateral operation group were significantly better than those in the contralateral operation group (respectively they were 37.15 ±â€Š5.83 cm, 214.07 ±â€Š34.35 minutes, and 257.21 ±â€Š72.02 mL), and the difference was statistically significant (t = 6.786, 8.656, and 4.815, all P < 0.05). The degree of postoperative hydrocephalus was significantly improved in both groups, but there was no statistically significant difference in the degree of hydrocephalus between the 2 groups (P > 0.05). Among the postoperative complications, there was no statistically significant difference in infection, epilepsy, subdural effusion, titanium plate effusion, or excessive cerebrospinal fluid drainage between the 2 groups (P > 0.05), but the incidence of intracranial hemorrhage in the ipsilateral operation group (2.86%) was significantly lower than that in the contralateral operation group (20.93%, χ2 = 4.138, P = 0.042). The postoperative Glasgow Coma Scale scores of the 2 groups were improved compared with those before the operation (P < 0.05), and there was no statistically significant difference in the postoperative Glasgow Coma Scale scores (P > 0.05). At 6 months after surgery, there was no statistically significant difference in Glasgow Outcome Scale effectiveness between the 2 groups (χ2 = 0.005, P = 0.944). CONCLUSIONS: Cranioplasty combined with ipsilateral ventriculoperitoneal shunt has the same therapeutic effect as a contralateral operation, but it has the advantage of a short operation time, less intraoperative trauma, less bleeding, and less risk of intracranial hemorrhage, which is suitable for clinical applications.

Activated Microglia Exosomes Mediated miR-383-3p Promotes Neuronal Necroptosis Through Inhibiting ATF4 Expression in Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) is the second largest type of stroke, with high mortality and morbidity, and most patients have severe sequelae. Brain injury induced by ICH includes primary damage and secondary damage, and the secondary brain injury is the main reason of neurological impairment. The hallmark of secondary brain injury is cell death. Necroptosis is a type of the cell death and plays vital roles in various neurological diseases, but the roles of necroptosis in ICH are still not fully known. Microglia cell is the type of immune cell, plays protective roles in nerve damage and modulates the activity of neurons through secreting exosomes. Exosome-contained miRNAs are also involved in the regulating neuronal activity. However, the roles and the mechanisms of microglia-secreted exosomes miRNAs in ICH neurons necroptosis need to further explore. In this study, ICH model was construct in rats and cells. Injury of cells in brain was detected by PI staining. Necroptosis in rats and cells was detected by western blot and flow cytometry. The expression of miR-383-3p was detected by RT-qPCR. The roles of activated microglia-secreted exosomes and exosome-contained miR-383-3p were detected through co-culturing medium or exosomes with neurons. The target gene of miR-383-3p was determined by luciferase assay and the expression of target gene was detected by western blot. Rescue experiments were used to confirm the mechanism of miR-383-3p in neurons necroptosis. The miR-383-3p role was verified in vivo through injecting miR-383-3p mimic into ICH rats. Here, we found that the necroptosis of neurons was increased in ICH rats through detecting the expression of RIP1 and RIP3 and PI staining. Microglia that activated by ICH promote neurons necroptosis through secreting exosomes and transferring miR-383-3p into neurons. In mechanism, miR-383-3p negatively regulated the expression of ATF4 and then promoted the necroptosis of neurons. Overall, our results provide a novel molecular basis to neurons necroptosis in ICH and may provide a new strategy to retard the secondary brain injury of ICH.

The diagnosis and prognostic value of plasma copeptin in traumatic brain injury: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this meta-analysis was to assess the diagnosis and prognostic value of plasma copeptin levels after traumatic brain injury (TBI). METHODS: The databases PubMed, Cochrane Library, OvidSP, Google Scholar, VIP, CNKI, and WFSD were systematically searched from the inception dates to May 9, 2020. The pooled analysis of relevant data was conducted by the RevMan 5.3 software. Subgroups analysis was performed to explore the impact of age, country, male ratio, follow-up time, and Glasgow coma score (GCS) on the pooled area under curve (AUC) values of assessment mortality. RESULTS: A total of 17 studies involving 2654 participants were included in the current meta-analysis. The pooled results demonstrated that increased plasma copeptin levels were significantly associated with TBI [SMD, 2.44; 95%CI, 1.59 ~ 3.29; P < 0.00001] and also were significantly associated with mortality [SMD, 1.37; 95%CI, 1.16 ~ 1.58; P < 0.00001], and poor functional outcomes (PFO) [SMD, 1.44; 95%CI, 1.20 ~ 1.68; P < 0.00001] in patients with TBI. Furthermore, the copeptin had a significant value in diagnosing brain concussion [AUC, 0.90; 95%CI, 0.84 ~ 0.95; P < 0.00001] and predicting progressive hemorrhagic injury [AUC, 0.83; 95%CI, 0.80 ~ 0.87; P < 0.00001], acute traumatic coagulopathy [AUC, 0.84; 95%CI, 0.79 ~ 0.89; P < 0.00001], mortality [AUC, 0.89; 95%CI, 0.87 ~ 0.92; P < 0.00001], and PFO [AUC, 0.88; 95%CI, 0.84 ~ 0.92; P < 0.00001] in patients with TBI. The subgroup analysis findings suggested that the age, country, male ratio, follow-up time, and GCS were not obvious factors influencing the pooled AUC values of assessment mortality. CONCLUSIONS: The authors indicate that the plasma copeptin is a potentially promising biomarker for TBI diagnosis and prognosis prediction.

Endoscopic Resection of a T-Shaped Benign Fibrous Histiocytoma at the Skull Base in a Pediatric Patient.

BACKGROUND: Benign fibrous histiocytoma (BFH) is a benign tumor composed of cells with characteristics of histiocytes and with fibroblastic components. BFHs are rare lesions, especially in the skull base. CLINICAL PRESENTATION: Here, the authors report the case of a 9-year-old girl presented with reduced binocular vision for 2 months. The computerized tomography (CT) of the tumor appearance was high-density annular sclerosis. The tumor was removed via nasal endoscopic approach. Final pathologic diagnosis was benign fibrous histiocytoma. The post-operative period was uneventful after 8 months, and the visual acuity was improved to some extent. DISCUSSION AND CONCLUSION: This is the first case of BFH in a pediatric patient that was removed by endoscope. For similar case, endoscopic resection might be the first choice, including pediatric patient. Moreover, the CT feature and literature review may provide further insight into the diagnosis and management.

Chronic subdural haematoma in antithrombotic cohorts: characteristics, surgical outcomes, and recurrence.

Objective: With the continuing increase of the aged population, neurosurgeons face increasing numbers of chronic subdural haematoma (CSDH) patients using antithrombotic (AT) drugs, i.e., anticoagulants (ACs) and antiplatelets (APs). However, there are few case reports that address this cohort and their outcomes. Here, a retrospective analysis of CSDH patients on AT therapies was performed to investigate their clinical characteristics, surgical outcomes, and postoperative recurrence.Methods: We analysed 546 CSDH patients who underwent surgery at the Subei People's Hospital of Jiangsu province from January 2014 to December 2017. The patients were divided into groups based on their history of preceding AT treatments as well as recurrence. The clinical data, surgical outcomes, and recurrence were collected for further analysis.Results: A total of 124 patients (22.7%) were receiving AT therapy, including 43 patients (7.9%) taking ACs and 81 patients (14.8%) taking APs. AT cohorts exhibited significantly higher non-traumatic CSDH, more serious pre-illness status, and larger haematoma volume, compared with the control patients. The haematoma clearance rate, duration of YL-1 needle, complications, and functional outcomes did not differ after novel YL-1 needle drainage, whereas a higher recurrence, mortality, and prolonged length of stay were observed in the AT group. Multivariate regression of postoperative recurrence within 3 months revealed that preoperative consciousness disorders, AC therapy, haematoma volume, and operative complications were significant predictive factors of CSDH recurrence. However, AP therapy was not associated with recurrence.Conclusions: The use of ATs causes large haematoma volumes that aggravate the severity in CSDH patients and is more prevalent among non-traumatic patients. AC therapy was a risk factor for CSDH recurrence, whereas AP therapy was not.

A Footprint-Like Intracranial Solitary Fibrous Tumor/Hemangiopericytoma With Extracranial Extension and Acute Intratumoral Hemorrhage.

BACKGROUND: Intracranial solitary fibrous tumors/hemangiopericytomas (ISFTs/HPCs) are extremely rare spindle-cell tumors that are mostly benign and derived from mesenchymal tissue. Extracranial metastasis and intratumoral hemorrhage are considered to be special manifestations of malignant tumors, of which extracranial metastases of ISFTs/HPCs have been reported, while tumor hemorrhage has rarely been described. Here, the authors present an interesting case of ISFTs/HPCs with acute intratumoral hemorrhage. CLINICAL PRESENTATION: A 72-year-old woman underwent brain magnetic resonance imaging (MRI) for recurrent headaches and nausea. The MRI scan showed a footprint-like space-occupying lesion in the bilateral parietooccipital lobe. This lesion had multiple cystic components and invaded the superior sagittal sinus, destroying adjacent cranial bones. While waiting for routine surgery, the patient suddenly developed acute tumor bleeding and then underwent emergency surgery. Postoperatively, the diagnosis of ISFT/HPC was confirmed by pathological and immunohistochemical analysis. DISCUSSIONS AND CONCLUSIONS: The diagnosis of ISFT/HPC mainly depends on pathological and immunohistochemical results. Malignant cases with cystic necrosis may be prone to acute hemorrhage. Early total surgical excision can provide a good clinical prognosis. Adjuvant radiotherapy is an effective supplement to surgical treatment. Metastasis and recurrence require long-term follow-up monitoring.

Endoscopic Anatomic Study Via Grinding Partial Petrous Ridge to the Middle Fossa in Retromastoid Keyhole Approach.

OBJECTIVE: This study aimed to observe the range of exposure, indications, and feasibility of the retromastoid keyhole approach via grinding partial petrous ridge to the middle fossa. METHODS: Simulated endoscopic surgeries via grinding suprameatal tubercle and petrous ridge to expose the middle fossa in retromastoid keyhole approach were performed on 8 adult cadaver heads (16 sides) fixed by formalin. The maximum exposure range in endoscope was observed. The boundaries of Parkinson triangle and the anatomic structures contained by Meckel cave and cavernous sinus (CS) lateral wall were revealed. The distances from midpoint of sigmoid sinus posterior border to every important anatomic structures in the middle fossa and the length of all sides of Parkinson triangle were measured. RESULTS: By using endoscope, the exposure of the cerebellopontine angle, ventrolateral brainstem, incisure of tentorium, petroclival region, and CS lateral wall were satisfactory. Many important anatomic structures in middle fossa were exposed well. The distances from midpoint of posterior border of sigmoid sinus to suprameatal tubercle, trigeminal semilunar ganglion, posterior curve segment of internal carotid artery were 34.42 ± 2.14, 54.52 ±â€Š2.87, and 65.15 ±â€Š3.13 mm. The lengths of all sides of Parkinson triangle were 18.97 ±â€Š2.93, 16.23 ±â€Š2.02, and 8.04 ±â€Š2.34 mm. CONCLUSION: The retromastoid keyhole approach via grinding partial petrous ridge to the middle fossa by using endoscope can increase the exposure of middle fossa effectively, which is proper for most lesions in posterior cranial fossa while some parts extend to middle fossa.

Midline Suboccipital Endoscopic Transcerebellomedullary Fissure Keyhole Approach.

OBJECTIVE: To study the endoscopic anatomy of the 4th ventricle and lateral brainstem regions via the midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach assisted by a neuronavigation system and discuss the feasibility and indications of this approach. MATERIALS AND METHODS: Craniotomy procedures performed via the midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach were simulated on 8 adult cadaveric heads fixed by formalin, and the related anatomic structures in the 4th ventricles or around the brainstem were observed through the 0° endoscope or alternatively 30° one. A neuronavigation system was used to measure the exposed area of the floor of 4th ventricle, the maximum exposure range, the length of the floor of 4th ventricle, the shortest distance from the midpoint of posterior arch of atlas to the opening of the aqueduct in the 4th ventricle and to the jugular foramen on both sides, respectively. RESULTS: All the anatomic structures within the 4th ventricle and partial anatomic landmarks around brainstem were identified by means of the midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach. The exposed area of the floor of 4th ventricle is 459.68 ±â€Š73.71 mm. However, the total exposed area is 1601.70 ±â€Š200.76 mm. The length of the floor of 4th ventricle is 36.08 ±â€Š2.63 mm. The shortest distance from the midpoint of posterior arch of atlas to the opening of the aqueduct in the 4th ventricle is 63.87 ±â€Š2.97 mm, to the jugular foramen on both sides, respectively, is 40.11 ±â€Š2.47 mm/40.30 ±â€Š2.31 mm. CONCLUSIONS: Midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach can basically meet the medial and lateral route of the transcerebellomedullary fissure approach. A tumor within the 4th ventricle or near the jugular tubercle extending into the 4th ventricle through the cerebellomedullary fissure can be removed by this approach.

Endoscopic Intradural Subtemporal Keyhole Kawase Approach to the Petroclival and Ventrolateral Brainstem Regions.

OBJECTIVE: To study the endoscope anatomy of the petroclival and ventrolateral brainstem regions via the intradural subtemporal keyhole Kawase approach and discuss the feasibility and indications of this approach to the regions. MATERIALS AND METHODS: Craniotomy procedures performed via the intradural subtemporal keyhole Kawase approach were simulated on 16 sides of 8 adult cadaveric heads fixed by formalin, and the related anatomical structures were observed through the 0-degree endoscope or alternatively 30-degree one. Measurements of the shortest distances from the highest point of arcuate eminence to the 4 anatomic marks and the lengths of the Kawase rhombus were recorded, and the 2 kinds of milled ranges of petrous apex were compared. RESULT: Most of the related anatomical structures could be clearly observed under the endoscope. The shortest distances from the highest point of arcuate eminence to the foramen spinosum, the greater superficial petrosal nerve hiatus, the intersection of the greater superficial petrosal nerve and mandibular nerve, and the outside edge of the trigeminal impression are 22.90 ±â€Š2.34, 14.05 ±â€Š2.09, 24.94 ±â€Š1.98, 23.49 ±â€Š2.38 mm. The area of routine milled Kawase rhombus is 3.04 ±â€Š0.47 cm, which would increase 0.66 cm on average after the maximum drilling of the petrous apex. CONCLUSIONS: The intradural subtemporal keyhole Kawase approach can provide an ideal exposure to the petroclival and ventrolateral brainstem regions via the endoscope with less damaging of the normal structures. It can be used to treat the lesions located in those areas through the natural gap combined with the drilling of petrous apex bone.

Spontaneous acute hemorrhage of intraspinal canal cellular schwannoma with paraplegia: A case report.

Cellular schwannoma, an unusual histological subtype of schwannoma, is a benign hypercellular variant of a peripheral nerve sheath tumor. We report a 48-year-old woman with sudden onset of paraplegia. The complete surgical resection was achieved. This is the first report about intraspinal canal cellular schwannoma following spontaneous acute hemorrhage and paraplegia.

Analysis of the relationship between different bleeding positions on intraoperative rupture anterior circulation aneurysm and surgical treatment outcome.

BACKGROUND: It is well recognized that intraoperative aneurysm rupture (IAR) is a serious event that is difficult to manage and has a relatively serious influence on a patient's prognosis. The aim of this study was to evaluate the prognostic value of different bleeding positions of IAR in patients, and to describe the technique that the authors have used to clip the ruptured aneurysms. METHODS: From May 2009 to March 2012, a total of 148 aneurysms in 135 consecutive patients in our institution underwent clipping surgeries, and 31 IARs occurred in 30 patients. The clinical data of all patients were retrospectively analyzed. Statistics analysis was performed to analyze possible factors of different bleeding positions of IARs, to assist observation. RESULTS: Outcome was estimated by Glasgow outcome scale via following up or calling back within 1, 3, and 6 months after surgery: 94 patients were 5', 23 patients were 4', nine patients were 3', two patients were 2' and eight patients were 1'. There was no significant difference between the outcome of IAR and that of no intraoperative aneurysm rupture (NIAR) in Hunt-Hess groups 0-III (P = 0.802) and Hunt-Hess groups IV-V (P = 0.229), and the different bleeding positions were shown to be an important factor that significantly influences the patients' prognosis (P = 0.001). CONCLUSIONS: Different bleeding positions of IAR have a significant impact on surgical outcome; IAR of the neck is the most devastating complication. If surgeons take appropriate measures according to different bleeding positions, the efficiency, accuracy and security of the operation will be improved.