Volume 05 · Issue 01 · 2019

The surgical spinal degenerative pathology mainly concerns the herniated intervertebral disks. Surgery is indicated when the pain becomes chronic and intense, and when motor signs appear. The results are positive in about 90% of cases, leading to the solution of the problem. However, an estimated percentage of 4% to 20% reported residual pain and postural instability after the surgical treatment of discectomy.

We have examined a sample of patients, retrospectively registered, undergoing surgical treatment for degenerative lumbar disease. Some of them developed postural instability. They were subjected to cycles of postural gymnastics. Postural gymnastics has proved to be a tool capable of solving unstable post-surgical posture. It included an exercise of breathing, one or two of muscular distension, one of muscular reinforcement, and one of postural correction. We used an evaluation form we created in agreement with the physiatrist for postural exercises that was based on some basic parameters such as muscle and respiratory function. At each cycle, a score was attributed to the performance of muscular and respiratory exercise to evaluate the function and therefore the degree of instability (1-3 = mild, 4-7 = medium, 8-10 = severe).

Results were satisfactory, with return to normal posture. The improvement of postural instability has been demonstrated both by the score of the evaluation forms that have highlighted the transition from a state of severe intensity to one of normality and by a clinical aspect, concerning the static and dynamic posture.

The postural instability has a multifactorial genesis, and different mechanisms are involved: the vertebral bone structures and the pelvis, the paraspinal muscular structures, and the nerve structures. These structures are altered after surgery due to predisposing factors, and for the action of conditions acquired as obesity.

This study aimed to investigate the value of high field-strength intraoperative magnetic resonance imaging (iMRI)-guided stereotactic biopsy in the surgery of intracranial space-occupying lesions.

A total of 87 patients who underwent stereotactic biopsy of intracranial lesions in the Peking University International Hospital from March 2016 to August 2018 were retrospectively surveyed; among these, 50 patients underwent MRI-guided stereotactic biopsy using the Leksell frame (iMRI group) and 37 cases received traditional stereotactic biopsy using the Leksell frame (control group). The accuracy rates and complications of the two groups were compared.

A 100% positive diagnosis was observed in all cases (n = 50) in the iMRI group. In 4 cases, the biopsy site was clearly found to have deviated from the target point, and the biopsy was performed again. The control group had 33 cases (86.5%) with positive diagnosis. No severe complications like neural functional deficit were observed in the iMRI group, while two patients developed bleeding at the puncture site (1 case receiving surgery to remove the hematoma) in the control group. There were no deaths in either group.

iMRI-assisted stereotactic biopsy can confirm the target position and adjust the puncture path in real time. Compared to the traditional stereotactic biopsy technique, the iMRI method has a higher positive diagnostic rate, though surgical trauma and complications have no significant difference.

Preservation of anatomic integrity and function of the cranial nerves during the removal of skull base tumors is one of the most challenging procedures in endoscopic endonasal surgery. It is possible to use intraoperative mapping and identification of the cranial nerves in order to facilitate their preservation. The purpose of this study was to evaluate the effectiveness of intraoperative trigger electromyography in prevention of iatrogenic damage to the cranial nerves.

Twenty three patients with various skull base tumors (chordomas, neuromas, pituitary adenomas, meningiomas, cholesteatomas) underwent mapping and identification of cranial nerves during tumor removal using the endoscopic endonasal approach in Department of Neurooncology of Federal State Autonomous Institution "N.N. Burdenko National Medical Research Center of Neurosurgery" of the Ministry of Health of the Russian Federation from 2013 to 2018. During the surgical interventions, mapping and identification of the cranial nerves were carried out using electromyography in triggered mode. The effectiveness of the method was evaluated based on a comparison with a control group (41 patients).

In the main group of patients, 44 nerves were examined during surgery using triggered electromyography. During the study, the III, V, VI, VII, and XII cranial nerves were identified intraoperatively. Postoperative cranial nerve deficiency was observed in 5 patients in the study group and in 13 patients in the control group. The average length of hospitalization was 9 days.

We did not receive statistically significant data supporting the fact that intraoperative identification of cranial nerves using trigger electromyography reduces the incidence of postoperative complications in the form of cranial nerve deficits (p = 0.56), but the odds ratio (0.6) suggests a less frequent occurrence of complications in the study group. Based on our experience, the trigger electromyography methodology appears quite promising and requires further research.

Facial nerve paralysis in patients occurs in varying degrees of self-image disorders, both physically and mentally, resulting in low self-esteem, anxiety, depression, and even suicide; however, there were few researches on psychological problems in facial palsy patients at home and abroad. This study’s objective was to investigate post-traumatic growth (PTG) in facial nerve palsy patients and analyze its influencing factors.

Using the convenience sampling method, a total of 47 patients with facial nerve paralysis were enrolled in the current study between June 1, 2016, and May 31, 2017. Post-traumatic growth rating scale was utilized to investigate the post-traumatic growth of these patients, and factors influencing patients’ post-traumatic growth were analyzed through collecting the general sociological information, disease-related information, simple coping style questionnaire, and social support rating scale.

The total score of post-traumatic growth in patients with facial nerve paralysis was mean (M) = 63.1, standard deviation (SD) = 19.14. The ranking of five dimensional scores from high to low was as follows: new possibilities, personal strength enhancement, appreciation of life, mental changes, and improvement of relationships with others. Multiple linear regression analysis showed that six variables, namely, the personality type, duration with facial nerve paralysis, and four coping styles, consisting of three types of positive coping styles and one negative coping style, could explain 71.6% of the total post-traumatic growth score.

Post-traumatic growth in facial nerve palsy patients is moderate. The personality type of patients, the disease duration, and the coping style are the primary influencing factors. Therefore, clinical staffs should perform personalized nursing protocol and psychological intervention for facial nerve palsy patients to reduce their negative mood, improve their compliance with treatment, and help them recover more rapidly.

Scalp arteriovenous fistula (sAVF) is a rare vascular disease; so far, the standard guidelines for the treatment of sAVF are still unclear. Since its complex vascular anatomical structure, surgical management of sAVF remains an enormous challenge.

Between March 2016 and October 2017, three patients with sAVF admitted to the First Affiliated Hospital of Chongqing Medical University were reviewed, and clinical characteristics, imaging features, and surgical outcomes were analyzed.

Three consecutive patients with sAVF were admitted to our hospital during the study period. Two patients received intravascular embolization and one patient received surgical resection. No procedure-related complications occurred after successfully treatment. During the long-term follow-up period, three patients recovered well and had no recurrence of lesion.

Either intravascular embolization or surgical resection is an effective therapy method for sAVF. Careful identification of angioarchitecture features contributes to successful treatment for the complex sAVF; therefore, it is recommended that neurosurgeons make the best treatment plan based on the location and number of the fistulas, feeding the artery, and draining the vein.

Brain metastases are significant causes of morbidity or mortality for patients with metastatic cancer. With the application of novel systematic therapy and improvement of overall survival, the prevalence of brain metastases is increasing. The paradigm of treatment for brain metastases evolved rapidly during the last 30 years due to the development of technology and emergence of novel therapy. Brain metastases used to be regarded as the terminal stage of cancer and left life expectancy to only 1 month. The application of whole brain radiotherapy for patients with brain metastases increased the life expectancy to 4–6 months in the 1980s. Following studies established surgical resection followed by the application of whole brain radiotherapy the standard treatment for patients with single metastasis and good systematic performance. With the development of stereotactic radiosurgery, stereotactic radiosurgery plus whole brain radiotherapy provides an alternative modality with superior neurocognitive protection at the cost of overall survival. In addition, stereotactic radiosurgery combined with whole brain radiotherapy may offer a promising modality for patients with numerous multiple brain metastases who are not eligible for surgical resection. With the advancing understanding of molecular pathway and biological behavior of oncogenesis and tumor metastasis, novel targeted therapy including tyrosine-kinase inhibitors and immunotherapy are applied to brain metastases. Clinical trials had revealed the efficacy of targeted therapy. Furthermore, the combination of targeted therapy and radiotherapy or chemotherapy is the highlight of current investigation. Advancement in this area may further change the treatment paradigm and offer better modality for patients who are not suitable for surgical resection or radiosurgery.

Hyperdynamic therapy, also called triple-H therapy, is the standard treatment and prophylaxis for aneurysmal-associated vasospasm. In patients who are able to tolerate cardiopulmonary stressors induced by this therapy, it is of benefit as a modality for prevention and treatment of delayed ischemic neurologic deficit. However, it can be a cause of significant cardiopulmonary or neurologic sequelae. In rare cases, it can be associated with posterior reversible encephalopathy syndrome (PRES), secondary to prolonged vasopressor and hypertensive therapies.

We present the case of a patient with right-sided aneurysmal-associated vasospasm who, after 10 days of triple-H therapy, experienced a seizure and was found to have left-sided PRES. Right-sided vasospasm served as a protective mechanism from triple-H therapy-associated PRES. It presented a treatment conundrum due to contradictory perfusion requirements. Hypertensive therapy was curtailed and in efforts to preserve local cerebral perfusion and vasodilation, local therapy with intrathecal nicardipine was initiated. We present our case, a review of the literature, and management considerations.

Therapies that have conventionally functioned as second line treatments for aneurysmal subarachnoid hemorrhage (intra-arterial vasodilators and intrathecal vasodilators) may be beneficial as earlier treatments in the setting of vasospasm given the systemic difficulties and complications associated with HHH therapy in patients with PRES.

Recurrent, previously stented basilar trunk aneurysms pose significant challenges to either microsurgical clipping or traditional endovascular treatment. We here presented an intriguing case that was successfully treated by the pipeline embolization device (PED; ev3/Covidien Neurovascular, Irvine, California, USA).

A 62-year-old male found a recurrent aneurysm, which had been treated with coiling and stent-assisted coiling before. The patient came to our center seeking for a third treatment. In our center, a single PED and additional coils were used to treat this refractory aneurysm. The whole length of the PED was delicately implanted in the previous Enterprise stent (Cordis Corporation, Miami FL, USA), which resembled the double-layer flow diverter FRED (Microvention, Tustin, California, USA). The inflow zone of the aneurysmal sac was further coiled considering that this aneurysm had ruptured. No procedure-related complications occurred. Follow-up angiogram at 6 months indicated that the intractable aneurysm was completely occluded and the patient was free from any neurologic deficit.

This is a case that adds knowledge to improve the poor performance of flow diverters in previously stented aneurysms. However, future studies with larger group of patients are needed to further test the safety and efficacy of this technique.

Ewing’s sarcoma family of tumors consists of small round cell neoplasms, inclusive of primitive neuroectodermal tumor (PNET), Askin’s tumor, and PNET of the bone. Extraosseous Ewing’s sarcoma occurs commonly at bones of lower extremities and paravertebral region of the spine. It rarely presents as a primary intracranial lesion. When intracranial, it can be misdiagnosed as central PNET (e.g., medulloblastoma, pinealoblastoma, or supratentorial PNET), other intracranial lesions, or even as an epidural hematoma.

We report the case of a 20-year-old patient who presented to the emergency department with complaints of drowsiness, headache, and fever for 1 day. On initial computed tomography (CT) scan of the brain, a right temporal biconvex epidural lesion involving squamous-temporal bone with periosteal reaction was noted. The patient underwent urgent craniotomy, and a tumor was found and excised. Biopsy report confirmed Ewing’s sarcoma.

Ewing’s sarcoma is a rare intracranial malignancy with only a few cases reported in literature. In a young patient with a biconvex epidural lesion, in the absence of trauma or ongoing infection, the possibility of Ewing’s sarcoma should be considered as well.