Volume 07 · Issue 01 · 2021

An epidemic of COVID-19 broke out in Wuhan, China, since December 2019. The ordinary medical services were hindered. However, the emergency cases, including aneurysmal subarachnoid hemorrhage (aSAH), still required timely intervention. Thus, it provoked challenges to the routine management protocol. In this study, we summarized our experience in the emergency management of aSAH (Beijing Tiantan Protocol, BTP) in Beijing, China.

Demographic, clinical, and imaging data of consecutive emergency aSAH patients who underwent craniotomy clipping during the COVID-19 epidemic season were reviewed and compared with the retrospective period last year. Subgroup analysis was further performed to assess the outcomes of different screening results and several detailed protocols. Neurological outcomes were evaluated by the modified Rankin Scale (mRS).

A total of 127 aSAH were referred to our emergency department, and 42 (33.1%) underwent craniotomy clipping between January 20, 2020, and March 25, 2020. The incidence of preoperative hospitalized adverse events and the perioperative outcomes were similar (-0.1, 95% CI - 1.0 to 0.8, P = 0.779) to the retrospective period last year (January 2019-March 2019). After the propensity score matching (PSM), there were still no statistical differences in prognostic parameters between the two groups. Eight (19.0%) of the 42 individuals were initially screened as preliminary undetermined COVID-19 cases, in which 2 of them underwent craniotomy clipping in the negative pressure operating room (OR). The prognosis of patients with varied COVID-19 screening results was similar (F(2, 39) = 0.393, P = 0.678). Since February 28, 12 cases (28.6%) received COVID-19 nucleic acid testing (NAT) upon admission, and all showed negative. The false-negative rate was 0.0%. The preoperative hospitalized adverse events and postoperative prognosis were still similar between patients with and without COVID-19 NAT (-0.3, 95% CI - 1.4 to 0.9, P = 0.653).

Our emergency surgery management protocol (BTP) is reliable for scheduling emergency aneurysm craniotomy clipping in non-major epidemic areas.

Early microsurgical clipping is recommended for ruptured intracranial aneurysms to prevent rebleeding. However, dilemma frequently occurs when managing patients with current acetylsalicylic acid (aspirin) use. This study aimed to examine whether aspirin use was associated with worse outcomes after early surgery for aneurysmal subarachnoid hemorrhage (aSAH).

We retrieved a consecutive series of 215 patients undergoing early microsurgical clipping within 72 h after aneurysmal rupture from 2012 to 2018 in the neurosurgery department of Beijing Tiantan Hospital. The medical records of each case were reviewed. Twenty-one patients had a history of long-term aspirin use before the onset of aSAH, and 194 patients did not. To reduce confounding bias, propensity score matching (PSM) was performed to balance some characteristics of the two groups. The intraoperative blood loss, postoperative hemorrhagic events, postoperative hospital stay, and functional outcome at discharge were compared between aspirin and non-aspirin group.

We matched all the 21 patients in aspirin group with 42 patients in non-aspirin group (1:2). Potential confounding factors were corrected between the two groups by PSM. No hospital mortality occurred after surgery. No significant differences were found in intraoperative blood loss (P = 0.540), postoperative hemorrhagic events (P > 0.999), postoperative hospital stay (P = 0.715), as well as functional outcome at discharge (P = 0.332) between the two groups.

Our preliminary results showed that long-term low-dose aspirin use was not associated with worse outcomes. Early surgery can be safe for ruptured intracranial aneurysms in patients with long-term aspirin use.

Arteriovenous malformation(AVM) have long-term "blood stealing" characteristics, which result in complicated hemodynamic features. To analyze the application of intraoperative indocyanine green angiography with FLOW 800 software in AVM surgeries.

Data on 17 patients undergoing surgery with ICG fluorescence were collected in Beijing Tiantan Hospital. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM resection, we assessed the following hemodynamic parameters: maximum intensity, slope of rise, time to half-maximal fluorescence, and transit time from arteries to veins.

In the 17 superficial AVMs studied, the time-delay color mode of the FLOW 800 software was superior to the traditional playback mode for identifying feeding arteries, draining veins, and their relation to normal cortical vessels. The maximum fluorescence intensity and slope of the ICG fluorescence curve of feeder arteries and draining veins were higher than those of normal peripheral vessels (P < 0.05). The transit times in AVMs were significantly shorter than those in normal peripheral vessels (P < 0.05). After AVM resection, cerebral flow increased in the cortex, and local cycle time becomes longer, although the differences were not significant (P > 0.05).

Hemodynamic parameter analysis provided quality guidance for the resection of AVMs and could also be used in estimating changes in blood flow in the local cortex to identify abnormal hyperperfusion and residual nidus.

Although the single-stage posterior realignment craniovertebral junction (CVJ) surgery could treat most of the basilar invagination (BI) and atlantoaxial dislocation (AAD), there are still some cases with incomplete decompression of the spinal cord, which remains a technique challenging situation.

Eleven patients were included with remained myelopathic symptoms after posterior correction due to incomplete decompression of the spinal cord. Transoral odontoidectomy assisted by image-guided navigation and intraoperative CT was performed. Clinical assessment and image measurements were performed preoperatively and at the most recent follow-up.

Eleven patients were followed up for an average of 47 months. Symptoms were alleviated in 10 of 11 patients (90.9%). One patient died of an unknown reason 1 week after the transoral approach. The clinical and radiological parameters pre- and postoperatively were reported.

Transoral odontoidectomy as a salvage surgery is safe and effective for properly selected BI and AAD patients after inadequate indirect decompression from posterior distraction and fixation. Image-guided navigation and intraoperative CT can provide precise information and accurate localization during operation, thus enabling complete resection of the odontoid process and decompression of the spinal cord.

The Tubridge™ flow diverter (TFD) was recently developed in China; however, its safety and efficacy in treating large cavernous carotid artery aneurysms (LCCAs) are unclear. Our objective was to evaluate the safety and efficacy of the TFD in patients receiving TFDs to treat LCCAs (10-25 mm).

Between June 2013 and May 2014, seven patients with LCCAs were enrolled in our study, and all seven patients underwent TFD implantation combined with coils.

Angiographic follow-up images were available for all seven patients at a median of 57.5 ± 16.7 (range, 6-69) months. Seven patients obtained favorable angiographic results defined as O'Kelly-Marotta Scale C and D. Clinical follow-up data were available for all seven patients at a median of 73.32 ± 3.6 (range, 66-78) months. No patients developed new neurological deficits. Six patients achieved a modified Rankin scale score of 0, and diplopia improved in the remaining patient.

The results were excellent for the aneurysms treated with TFDs in our patients with LCCAs. TFDs are feasible for the treatment of LCCAs, but a multicenter, controlled clinical trial is needed to evaluate the long-term safety and efficacy of the TFD to treat LCCAs.

Three-dimensional (3D) fusion imaging has been proved to be a promising neurosurgical tool for presurgical evaluation of tumor removal. We aim to develop a scoring system based on this new tool to predict the resection grade of medial sphenoid wing meningiomas (mSWM) intuitively.

We included 46 patients treated for mSWM from 2014 to 2019 to evaluate their tumors' location, volume, cavernous sinus involvement, vascular encasement, and bone invasion by 3D multimodality fusion imaging. A scoring system based on the significant parameters detected by statistical analysis was created and evaluated.

The tumor volumes ranged from 0.8 cm³ to 171.9 cm³. A total of 39 (84.8%) patients had arterial involvement. Cavernous sinus (CS) involvement was observed in 23 patients (50.0%) and bone invasion was noted in 10 patients (21.7%). Simpson I resection was achieved in 10 patients (21.7%) and Simpson II resection was achieved in 17 patients (37.0%). Fifteen patients (32.6%) underwent Simpson III resection and 4 patients (8.7%) underwent Simpson IV resections. A scoring system was created. The score ranged from 1 to 10 and the mean score of our patients was 5.3 ± 2.8. Strong positive monotonic correlation existed between the score and resection grade (R_s = 0.772, P < 0.001). The scoring system had good predictive capacity with an accuracy of 69.60%.

We described a scoring system that enabled neurosurgeons to predict extent of resection and outcomes for mSWM preoperatively with 3D multimodality fusion imaging.

Retrospectively registered

IgG4-related hypertrophic pachymeningitis is a relative newly recognized and rare manifestation of IgG4-related disease, an immune-mediated fibroinflammatory tumefactive disorder. Fewer than 80 patients have been reported in the literature, and it can mimic common neurosurgical conditions. We describe the clinical presentation of two patients that were initially considered to have a subdural collection, tuberculous meningitis, and a cervical spinal meningioma, but were eventually diagnosed with this disease.

Two ethnic Chinese men, 86 and 62 years old, experienced a 4-week history of headache. Both patients had a history of autoimmune disease, namely glomerulonephritis and Grave's disease, respectively. Magnetic resonance brain imaging revealed diffuse dural thickening with the latter patient exhibiting homogeneous and intense gadolinium-contrast enhancement. Since the 86-year-old patient also had progressive bilateral visual loss, giant cell arteritis was suspected and a 2-week course of glucocorticoid therapy was prescribed, but his symptoms failed to improve. The 62-year-old patient also had accompanying low-grade fever and was treated empirically as having tuberculous meningitis although there were no confirmatory microbiological findings. This patient further developed right hemiparesis, and additional imaging revealed a C4/5 intradural-extramedullary contrast-enhancing lesion resembling a meningioma causing cord compression. Both patients underwent neurosurgical intervention with the former undergoing a dural biopsy and the latter having the cervical lesion resected. The final diagnosis was IgG4-related hypertrophic pachymeningitis with the hallmark histological features of lymphoplasmacytic infiltration of IgG4+ plasma cells, storiform fibrosis, and obliterative phlebitis. In addition, their serum IgG4 levels were elevated (i.e., > 135 mg/dL). Both patients received at least 6 months of glucocorticoid therapy while the latter also had azathioprine. Their symptoms improved significantly and recurrent lesions were not detected on follow-up imaging.

A high index of suspicion for this condition is suggested when a male patient with a history of autoimmune disease and compatible radiological findings, experiences subacute headache that is disproportionate to the degree of dural involvement. Neurosurgeons should consider early meningeal biopsy to establish a definitive histological diagnosis in order for early effective immunosuppressive treatment to be initiated and to avoid unnecessary morbidity.