2008年·第121卷第12期

The economy of China in the past three decades has boosted the development of neurosurgery in China.Currently,thousands of active neurosurgeons,all over the mainland of China,practise their clinical and basic research in all the fields of neurosurgery。

Abstract：Background Due to their location,large and giant intracavernous and paraclinoid aneurysms remain a challenge for vascular neurosurgeons.We identified characteristics.surgical indications and treatment strategies of large and giant intracavernous and paraclinoid aneurysms in 36 patients.Methods The pterional approach was routinely used.The cervical internal carotid artery was exposed for proximal control of parent vessel and retrograde suction decompression.Paraclinoid aneurysms were directly clipped,intracavernous pseudoaneurysm was repaired and the intracavernous aneurysms were trapped with extracranial-intracranial bypass of saphenous vein graft.Intraoperative electroencephaIogram (EEG) and somatosensory evoked potential (SSEP) monitoring were used to detect cerebral ischemia during the temporary occlusion of parent arteries.Microvascular Doppler ultrasonography was used to assess blood flow of the parent and branch vessels.Endoscopy was helpful particularly in dealing with internal carotid artery posterior wall aneurysms.Postoperative digital subtraction angiography (DSA) was performed in 33 of the 36 patients.Results Thirty-two paraclinoid aneurysms were directly clipped,1 intracavernous pseudoaneurysm was repaired and the other 3 intracavernous aneurysms were trapped with revascula rization.Except for two patients who died in the early postoperative stage,34 patients' follow-up was 6-65 months (mean 10 months)and a Glasgow Outcome Scale score of 4 to 5 at discharge.At the 6-month follow-up examination,Rankin Outcome Scale scores were 0 to 2 in 32 patients.EEG and SSEP monitoring changed in six patients.Twelve clips were readjusted when insufficient blood flow in parent and branch vessels was detected.Three posterior wall aneurysms were clipped.Conclusions Intracavernous aneurysms not amenable to endovascular treatment should be treated surgically and surgical treatment is the first option for paraclinoid aneurysms.The temporary parent vessel occlusion,retrograde suction decompression,endoaneurysmectomy, parent vessel reconstruction,vascular anastomosis,electrophysiological monitoring,Doppler ultrasonography and endoscopy are essential techniques in the treatment of the large and giant intracavernous and paraclinoid aneurysms。

Abstract：Background Oculomotor palsy is a common complication in patients with posterior communicating aneurysm.This study was conducted to investigate the postoperative recovery of patients with posterior communicating aneurysm complicated with oculomotor palsy and to analyze the factors influencing length of recovery.Methods From 2000 to 2006,148 patients with posterior communicating aneurysm were treated at our hospital,with 74 of them having concurrent unilateral oculomotor palsy.All of the patients underwent craniotomy after the diagnosis by means of whole-brain digital subtraction angiography (DSA).The patients were divided into two groups for observation of postoperative recovery during the follow-up period.Patients in group A were treated with simple pedicle clipping of the aneurysm while patients in group B were treated with pedicle clipping of the aneurysm and decompression of the oculomotor nerve.Results Of the 40 patients in group A.20 underwent surgery within 14 days and completely recovered from oculomotor palsy in 10-40 days.Fourteen patients underwent surgery within 14-30 days.of whom 12 completely recovered within 30-90 days and 2 cases recovered incompletely.The remaining six patients underwent surgery after more than 30 days:of these.four patients recovered completely and two recovered incompletely.Of the 34 cases in group B,15 underwent surgery within 14 days and completely recovered from oculomotor palsy in 10-40 days.Sixteen patients underwent surgery in 14-30 days.of whom 14 completely recovered in 30-90 days and 2 recovered incompletely.The remaining three patients underwent surgery after more than 30 days,of whom two patients recovered completely and one recovered incompletely.Conclusions Early diagnosis and surgical treatment of patients with unilateral oculomotor palsy induced by posterior communicating aneurysm are important to full postoperative recovery of the oculomotor nerve.No correlation was found,however,between decompression of the oculomotor nerve,such as excision or puncture of the aneurysm,and postoperative recovery time。

Abstract：Background Vertebrobasilar artery stenosis is an important cause of ischemic posterior circulation strokes.This study aimed at evaluating the safety and efficacy of treatment including conservative therapy alone and conservative plus endovascular therapy for elderly patients with symptomatic vertebrobasilar artery stenosis.Methods Patients older than 60 years with symptomatic vertebrobasilar artery stenosis (≥50%) confirmed by cerebral angiography were enrolled.All of them were treated with medical therapy and some with additional stent-assisted angioplasty (the stenting subgroup).Their clinical,imaging,intervention and follow-up data were analyzed.Results One hundred and seventeen consecutive elderly patients (100 men,mean age (68.1±5.1) years) were enrolled and followed up for a mean time of 28.4 months:81.7% of fhem were symptomatically resolved or improved;a stroke rate of 5.1% and a stroke-related death rate of 1.7% were found among them during the hospitalization and follow-up.In the stenting subgroup,78 balloon expandable stents were employed in the 70 patients with a technical success rate of 98.7% and the mean degree of stenosis was significantly reduced from (81.7±14.3)% before stenting to(8.3±4.2)% after stenting (P＜0.001).Four (5.7%) periprocedural strokes occurred,of whom two Ied to death within 30 days after the procedure.During the follow-up(mean 27.7 months),sixty of the surviving 68 patients in the stenting subgroup were symptomatically resolved or improved.Only one(1.5%) posterior circulation stroke occurred,while duplex ultrasound scan of 34 patients demonstrated 10 (29.4%) in-stent restenosis.Conclusions Appropriate utilization of conservative therapy alone and conservative plus endovascular therapy may improve short-term clinical outcomes for elderly patients with symptomatic vertebrobasilar artery stenosis.Furthermore.stent-assisted angioplasty is technically feasible and relatively safe in elderly patients。

Abstract：Background Glioma is the most common type of malignant brain tumor and the prognosis of glioma is still poor.Moreover,the prognosis of patients diagnosed with grade Ⅲ gliomas varies significantly.In this study,we assessed the factors that contribute to the prognosis of patients with grade Ⅲ gliomas.Methods Data from 97 patients with grade Ⅲ glioma who received surgery from 2000 to 2005 were included in this study.Kaplan-Meier survival analysis and Cox regression analysis were used to analyze the prognostic effects of 16 different factors selected from clinical characteristics,results from neuroimaging and pathological examinations,as well as different treatment schemes.Results The results indicated that age,preoperative Karnofsky Performance Scale score,extent of tumor invasion,tumor resection degree,residual tumor shown by postoperative magnetic resonance imaging(MRI),and postoperative radiotherapy and chemotherapy all correlated with patient prognosis.Furthermore,Cox multivariate analysis also showed the age(P＜0.01),extent of tumor invasion(P＜0.01),residual tumor shown by postoperative MRI (P＜0.05),and postoperative radiotherapy (P＜0.05) significantly correlated with patients' prognosis.Conclusions Age,postoperative radiotherapy and residual tumor indicated by MRI after surgery correlated significantly with the prognosis of patients with grade Ⅲ glioma.The extent of tumor invasion may be an independent prognostic factor for patients with grade Ⅲ glioma。

Abstract：Background Stereotactic radiosurgery is an alternative to resection of intracraniaI cerebral arteriovenous malformations (AVMs),while it will failin some cases.This study aimed to evaluate the changes after stereotactic radiosurgery for AVMs.Methods Nineteen cases with cerebral AVMs had failure after stereotactic radiosurgery therapy.The symptoms and angiography were assessed.All patients underwent microsurgery.Pathologic examination was performed for all cases and electron microscopic examination was carried out in 6 patients.Reaults Seven cases had hemorrhage from 12 to 98 months after stereotactic radiosurgery,5 had headache.4 had refractory encephalon edema,2 had epilepsy as a new symptom and 1 had a pressure cyst 5 years after radiosurgery.Angiography in 18 cases,8-98 months after radiation therapy,demonstrated no significant changes in 5 cases.slight reduction in 9,near complete obliteration in 1 and complete obliteration in 3.An abnormal vessel was found on pathologic examination in 17 cases,even one case had obliterated in angiography.Electron microscopy examination showed vessel wall weakness,but the vessels remained open and blood circulated.One case died because of a moribund state before surgery.The other 18 cases had no new neurological deficiencies,seizure control and no hemorrhage occurred after microsurgery at an average follow-up of 3 years.Conclusion Stereotactic radiotherapy for AVMs should have a long period follow-up.If serious complications occur,microsurgery can be performed as salvage treatment。

Abstract：Background Acute subdural haematoma (ASDH) is a common traumatic brain injury with a relatively high mortality rate.However,few studies have examined the factors predicting the outcome of isolated traumatic ASDH.This clinical study examined the hospital mortality and analyzed the risk factors for mortality in patients treated surgically for isolated traumatic ASDH.Methods We collected 308 consecutive patients who underwent neurosurgery for isolated traumatic ASDH between January 1999 and December 2007 and used multivariate Logistic regression analysis to evaluate the influence of 11 clinical variables on hospital mortality.Results The overall hospital mortality was 21.75% (67/308).Age (OR=1.807),preoperative Glasgow Coma Score (OR=0.316),brain herniation (OR=2.181) and the time from trauma to decompression (OR=1.815) were independent predictors of death,while no independent association was observed between hospital mortality and haematoma volume,midline shift,acute brain swelling or brain herniation duration,although these variables were correlated with hospital mortality in univariate analyses.Conclusions This study identified the risk factors for hospital mortality in patients who underwent surgical treatment for isolated traumatic ASDH.An increased risk of dealh occurs in patients who are over 50 years of age and have lower preoperative Glasgow Coma Scores,the presence of brain herniation and a long interval between trauma and decompression.The findings should help clinicians determine management criteria and improve survival。

Abstract：Background Compared with smaller aneurysms,giant intracranial aneurysms (GICAs) have a poorer prognosis and require more meticulous surgical planning and techniques to exclude them from the circulation.GICAs continue to challenge the limits of neurosurgical techniques.A series of 170 patients with GICAs were reviewed for understanding the clinical characteristics.surgical treatment and outcomes of patients with GICAs.Methods Collected data of 170 consecutive patients with GICAs from January 1995 to July 2007 were analyzed.The clinicaI Characteristics in this study included age,sex,intracranial aneurysms size,the first presentations,locations and Hunt & Hess grade.Surgical methods included direct clipping of the aneurysm neck,parent artery reconstruction,proximal artery ligation,trapping and wrapping.Surgical results were evaluated postOperatively by the Glasgow Outcome Scale (GOS).Results GICAs were more commonly diagnosed at age 30 to 50 years with a mean age of 39.3 years and without obvious gender preponderance in our study (88 male and 82 female patients).The size of the GlCAs ranged from 2.5 cm to 8.0 cm(mean,2.9 cm).Hemorrhage (41%),mass effect (34%) and headache (12%) were the first 3 most common presentations.Regarding the Hunt & Hess classification,at admission there were 1 00 cases in grade 0,24 in grade 1,21 in grade 2,16 in grade 3,8 in grade 4 and 1 in grade 5.There were 84 cases of GICAs treated by direct neck-clipping,47 by parent artery reconstruction,19 by proximal artery occlusion(with 4 combined with reVascuIarization),18 by trapping and 2 by wrapping.The follow-up study (ranging from 6 to 115 months,mean 32 months)showed good results in 108 cases.moderate disability in 26 and severe disability in 15 according to GOS.Six cases died.Conclusions Surgical treatment is an effective treatment for GICAs.SurgicaI strategies should be made carefully and individually.Doppler ultrasonography,neuroendoscope and intraoperative angiography are useful to perfect surgical results。

Abstract：Background Deafferentation pain is a kind of chronic pain syndrome and hard to manipulate.To evaluate the effectiveness and safety of junctional dorsal root entry zone (DREZ) coagulation,23 consecutive patients with intractable deafferentation pain syndrome were studied.Methods Twenty-three patients underwent junctional DREZ coagulation (C5-T1 for upper extremities and L2-S1 for lower extremities) under general anesthesia.The pain severity was evaluated by the short McGill pain questionnaire (MPQ) and the visual analog scale (VAS),and the depression and anxiety of patients were assessed by Hamilton rating scale for depression (HRSD),Hamilton anxiety scale (HAMA),self-rating anxiety scale(SAS)and self-rating depression scale (SDS).Results All the patients experienced significant pain reduction immediately after surgery.The scales of short MPQ and VAS at pre-operation,6-month and 12-month follow-up were 31.5±3.4 and 8.8±1.5,6.5±1.9 and 2.5±2.2,7.1±2.1 and 2.9±1.9,respectively.The postoperative scores comparing to pre-operative scores showed a statistically significant difference (P＜0.01).The depression and anxiety state was also significantly relieved.At 12-month follow-up 6 patients had complete pain relief,11 had excellent results with more than 75% pain relief,17 had good results with more than 50% pain relief (73.9%).The main postoperative complications were transient slight hemiplegia(8),hypesthesia and paresthesia (15),a bearing down feeling of affected extremity (6),and deep sensory disability in the lower Iimbs(4)on the operated side.Because of the long time and prone position of the operation.13 cases had a transient hyperalgesia in the upper chest.Conclusion DREZ coagulation is a safe and effective procedure in the treatment of deafferentation pain syndromes。

Abstract：Background The anatomic value of the aortic root is important for aortic valve repair.This study was to determine the normaI diameters of the aortic valve annulus (AVA) and sinus-tube ioint (STJ) in the healthy adults of Chinese Han ethnic group,and to provide a morphological foundation for potential clinical application.Methods Echocardiography was performed in 326 normal subjects,who were divided into 5 groups according to their age.The diameters of the AVA and STJ were measured in the parasternal long-axis view.and normalized to body surface area (BSA).They were averaged for each age group and for each gender.Differences were then determined between the normalized diameters for each age group and for both genders.Pearson's product-moment correlation coefficient was used to determine the differences between AVA and STJ diameters.It was also used to determine any positive or neqative correlations between the above two variables and age,BSA,weight,and height.Results The diameters of the AVA and STJ of Han nationality patients increased with an increase in age,BSA,weight,and height.The correlation coefficient between AVA diameter and BSA was 0.4944 (P＜0.0001),between AVA diameter and age,0.1138 (P＜0.05),between AVA diameter and weight,0.4521 (P＜0.001),and between AVAdiameter and height,0.471 3 (P＜0.001).The correlation coefficient between STJ diameter and BSA was 0.3910 (P＜0.0001),between STJ diameter and age,0.3667 (P＜0.0001),between STJ diameter and weight,0.4586 (P＜0.0001),and between STJ diameter and height,0.3736 (P＜0.0001).The difference between the above two diameters was statistically significant at 2.42±2.45 mm (paired t-test:t=-17.25;P＜0.0001).AVA and STJ diameters were similar in both genders of each group when indexed to BSAConclusions The diameters of the AVA and STJ of adults of Chinese Han ethnic group increase with age,BSA,weight,and height.The diameters of the AVA and the STJ are similar in both genders.when indexed to BSA.The diameter of the AVA js shorter(about 10%) than that of the STJ,and the difference between the two diameters was 2.42±2.45 mm。

Abstract：Background Previous brain imaging studies suggested that the brain activity underlying the perception of chronic pain maV differ from that underlying acute pain.To investigate the brain regions involved in chronic spontaneous pain due to brachial plexus avulsion(BPA),fluorine-18fluorodeoxygIucose (19F-FDG) positron emission tomography (PET) scanning was applied to determine the glucose metabolic changes in patients with pain due to BPA.Methods Six right-handed patients with chronic spontaneous pain due to left-BPA and twelve right-handed age-and sex-matched healthy control subjects participated in the 18F-FDG PET study.The patients were rated by visual analog scale (VAS) during scanning and Hamilton depression scale and Hamilton anxiety scale after scanning.Statistical parametric mapping 2 (SPM2) was applied for data analysis.Results Compared with healthy subjects,the patients had significant glucose metabolism decreases in the right thalamus and S I(P＜0.001,uncorrected),and significant glucose metabolism increases in the right orbitofrontaI cortex (OFC) (BA11),left rostral insula cortex and left dorsolateral prefrontal codex (DLPFC) (BA10/46) (P＜0.001,uncorrected).Conclusion These findings suggest that the brain areas involved in emotion.aRention and internal modulation of pain may be related to the chronic spontaneous pain due to BPA。

The extremely complex anatomic relationships among bone,tumor,blood vessels and cranial nerves remains a big challenge for cranial base tumor surgery.Therefore.a good understanding of the patient specific anatomy and a preoperative planning are helpful and crocial for the neurosurgeons.Three dimensional (3-D) visualization of various imaging techniques have been widely explored to enhance the comprehension of volumetric data for surgical planning.1 We used the Destroscope Virtual Reality (VR) System (Singapore,Volume Interaction Pte Ltd,software:RadioDexterTM 1.0) to optimize preoperative plan in the complex cranial base tumors.This system uses patient-specific,coregistered,fused radiology data sets that may be viewed stereoscopically and can be manipulated in a virtual reality environment.This article describes our experience with the Destroscope VR system in preoperative surgical planning and simulation for 5 patients with complex cranial base tumors and evaluates the clinical usefulness of this system。

Dumbbell tumors have both intraspinal and anterior paraspinal components connected through an intervertebral foramen. Most of these tumors are neurogenic and include schwannomas,neurofibromas,ganglioneuromas and neuroblastomas.1 Fortunately,more than 90% of these tumors are benign.2 Dumbbell tumors of the thoracic spine are particularly difficult to expose and remove by virtue of their location and relationship with vital structures of the thoracic cavity.The traditional surgical approach for removing these tumors has been using either combined anterior thoracotomy and posterior neurosurgical procedures or the lateral extracavitary approach.3-5 We present our experience with resection of three dumbbell tumors with a combined microneurosurgical and thoracoscopic procedures in a single stage。

Meningiomas are the second most common intractranial benign tumors and represent about 15%-24% of primary brain tumors.1 Most meningiomas grow slowly at a rate of only 2.4 miTt annually.2 Due to their slow growth,few clinical symptoms occur until the tumor reaches a large size.If the meningioma grows at the front or rear of the cranial cavity,it can grow to be very large before that area's vital functions are affected.Therefore,giant meningiomas are not infrequent,and actually account for 11.9% of meningiomas in our hospital。

Hepatitis B virus (HBV) is an admitted oncogenic virus. Many epidemiological and molecular biological studies have demonstrated that chronic infection with HBV is a major risk factor associated with the development of hepatocellular carcinoma (HCC) and intrahepatic bile duct cancer.1-4 Compared with hepatocytes and intrahepatic bile duct epithelial cells,extrahepatic bile duct epithelial cells have autoploid in embryogenesis,continuity in anatomy and a similar internal environment.The question arises whether extrahepatic bile duct epithelial cells can receive HBV infection or not? The role of hepatitis viral infection in the pathogenesis of bile duct carcinoma has not yet been clarified.although a causative relationship between HBV or HCV infection and extrahepatic bile duct carcinoma has been reported in the literature.5,6 In this study,we focused on the evidence of hepatitis viral infection in tissue of bile duct carcinoma。

As a non-atherosclerotic chronic cerebral vasculopathy,moyamoya disease is characterized by progressive steno-occlusion of the arteries of the circle of Willis with a developed collateral vascular network mainly at the cerebral base.1 And it is named moyamoya disease because of a characteristic "puff-of-smoke" angiographic appearance。

There are very few reports concerning the failure of devices used in carotid artery stenting.Here we report a fracture of the dishal part of the guiding wire of a cerebral protection device during carotid artery stenting for management of a restenotic lesion after carotid endarterectomy。

Chordoma as a rare malignant tumor arising from remnants of the fetal notochord accounts for 1%-4% of primary bone tumors.It is usually predominant in males.Local recurrences are common (44%-78%)1-3 and distant metastases may occur years after the initial presentation.The reposed rates of metastases range from 10% to 48%,4-6 which are usually accompanied by a sacrococcygeal chordoma.Cases of surgical seeding and intradural spinal seeding also have been reported clinically.7-9 To our knowledge,the present case is the first one concerning cerebrospinal fluid metastases and fatal progression of a sacrococcygeal chordoma。