Volume 31 · Issue 02 · 2015

In recent years, with the rapid development of science and technology, the research results of brain science began to subvert the traditional concepts and understandings in the past. Although we have a clearer understanding of brainstem structure and function, and more in-depth research on tumorigenesis, brainstem glioma is still one of the refractory diseases in neurosurgery due to its particularity of anatomical structure and physiological function. Throughout the history of neurosurgery, brainstem gliomas have changed from being once recognized as "surgical restricted areas" to surgically explorable; From surgical biopsy to determine the pathological nature of the tumor to the efficacy of surgical treatment is gradually recognized; From the neurological protection of brainstem tumors to the value embodiment of comprehensive treatment, it has experienced the arduous course of continuous exploration, summarization and innovation by several generations for nearly a century.

To retrospectively analyze the natural history and prognostic factors of untreated pediatric diffuse intrinsic pontine gliomas(DIPGs).

Twenty pediatric patients newly diagnosed with DIPGs in Beijing Tiantan Hospital from October 2010 to June 2012 were reviewed. The prognostic factors included gender, age, abducens palsy, enhancement, encasement of the basilar artery, presence of exophytic component, hydrocephalus, diagnostic latency and KPS at diagnosis.

The median survival was 23 weeks. One-year-survival rate was 10% and two-year-survival rate was 5%. Patients with enhancing lesions had a longer survival than those with nonenhancing lesions, but this difference was not statistically significant. Gender, diagnostic latency and KPS at diagnosis had prognostic value (P=0.01) in univariate analysis.But only diagnostic latency ≤1.5 months and KPS≤70 at diagnosis were associated with shorter survival time (P=0.05) during multivariate analysis.

The study revealed that only diagnostic latency and KPS at diagnosis carried prognostic value. Early presence of aducens palsy and encasement of basilar artery had no prognostic value. Age, enhancement and hydrocephalus might have prognostic value but need further investigation.

To investigate the methodology, technical essential and significance of three-dimension visualized image-guided stereotactic biopsy(SB) for lesions in pineal region and brain stem.

A total of 88 cases of lesions in pineal region and brain stem underwent image-guided SB in our department were retrospectively studied. Frame-based and CAS-2 type frameless SBs were performed in 57 and 31 cases respectively. Pre-biopsy three-dimension visualized image reconstruction was performed by SB planning software and the structure related to possible trajectory in each image slice was confirmed. The most suitable trajectory was selected accordingly. For lesions in pineal region, anterior-frontal trans-tentorium cerebella hiatus trajectory for avoiding tentorial margin was used. For lesions in mesencephalon, posterior-frontal trans-lateral ventrical- thalamus trajectory via the vertical axis of brain stem was used. For pontal lesions , supra-occipital trans- pedunculus cerebellaris medius trajectory was used.

Histological diagnosis was established in all 88 cases, which gave a high diagnostic yield (100%). Fifty-six lesions (64%) located in brain stem (middle brain and pons) and 32 (36%) in pineal region. In 56 brain stem lesions, there were 38 cases (68%) of glioma, 3(5%) lymphoma, 2(4%) neurodegenerative disease, 6(11%) multiple sclerosis and tumefactive demyelinating lesion, 2(4%) non-specific inflammation, 2(4%)brain infarct, 2(4%) brain metastases, and 1 (2%) radiation necrosis. For lesions in pineal region, there were 18 cases (56%) of germ cell tumor, 4(13%)glioma, 9 (28%) pineal cell tumor, and 1(3%) Wernicke encephalopathy. One case(1 %)died of biopsy-related hemorrhage. The neurological deficits became severe because of hemorrhage in 5 cases, the medical treatment was adopted in 3 cases(3%)and drainage in 2 (2%).

Stereotactic biopsy for lesions in pineal region and brain stem was a safe and effective procedure that could help for the selection of clinical management and provide important prognostic information. Three-dimension visualized image-guided technique could realize virtually individual visualized intuitionistic view of biopsy trajectory. It could remarkably improve the safety and decrease the operative complications.

To explore the role of Wnt/β-catenin signal pathway in the tumorigenesis and progression of brainstem gliomas by detecting the expression of Wnt/β-catenin signal pathway related components.

The samples were collected from patients with glioma and patients with primary epilepsy in Beijing Tiantan Hospital from May 2009 to May 2011.This study used Western blot and immunohistochemistrical methods to detect the expression of Wnt-1, Wnt-2, β-catenin and C-myc in six cases of normal brain tissues and 24 cases of brainstem gliomas, and analyzed the relationships between their expression and clinicopathological characteristics.

The expression of Wnt-1 was higher in brainstem gliomas than that in normal brain tissues (P<0.05). However, there was no significant difference between high- and low-grade brainstem gliomas(P>0.05). The expressions of Wnt-2, β-catenin and C-myc in high-grade brainstem gliomas were significantly higher than those in low-grade brainstem gliomas and normal brain tissues, and were positively correlated with the expression of Ki-67(P<0.05). The expression of Wnt-2 and C-myc was significantly associated with the prognosis of brainstem glioma patients(P<0.05). Additionally, there was a trend toward increased β-catenin expression with shorter survival, but there was no statistical difference(P>0.05).

Wnt/β-catenin signaling pathway might be abnormally activated and play an important role in the occurrence and development of brainstem gliomas.Wnt-2, β-catenin and C-myc could be used as markers for the prognosis of brainstem gliomas, which also were potential targets for brainstem glioma treatment.

To compare the MRI characteristics with histopathological findings of brainstem glioma and identify the characteristics associated with the diagnosis of pathologies.

From January 2002 to January 2012, 150 patients was diagnosed as brainstem gliomas by MRI and received operations in Beijing Tiantan Hospital. All the MRI and histopathological findings of these patients were respectively reviewed.

One hundred and eight patients were low-grade glioma (72.0%), and 35 high-grade (23.3%). The accuracy of the MRI diagnosis for brainstem glioma was 95.3%. The data analysis of the MRI findings revealed that in not only the intrinsic (P=0.005) but also the exophytic (P=0.001) brainstem glioma patients, having a focal lesion was a significant factor associated with a more favorable histopathological diagnosis. In the intrinsic diffuse type, tumors without enhancement had the better pathologies (P=0.009). There was no significant difference of the histopathological diagnosis between the adults and children in not only the intrinsic (P=0.624) but also the exophytic (P=0.771) brainstem glioma.

The results of this study could help us to estimate the pathology with data obtained from MRI and help to obviate the need for invasive biopsy. The pathology of tumors with a focal appearance was better than their diffuse counterparts. For the intrinsic diffuse type, tumors with nonenhancement might have a better pathology. The different growth pattern and invasiveness of brainstem glioma between children and adult could be due to the different host cellular environments between the two age groups.

To study the surgical techniques and effectiveness of the extended pterional transtemporal transtentorial approach for the resection of large and giant petroclival meningiomas.

Some modifications were made to the pterional approach by liberation and retraction of temporal pole, incision of tentorium and petrous apicectomy to provide effective corridor to the sphenopetroclival region. Thirty-three patients with large(14 cases) and giant meningiomas(19 cases) were analyzed retrospectively who received the extended pterional transtemporal transtentorial approach from January 2000 to March 2012. The neurological dysfunction, resection rate and quality of life were analyzed.

Gross total resection was achieved in 15 patients (45%), subtotal in 17(52%) and partial in 1(3%). One patient died of hyperthermia and electrolyte disorder postoperatively. Twenty-eight patients were followed-up for mean 37.8 months (range 4-135 months). Three patients had tumor recurrence. Karnofsky Performance Scale showed the outcome of prognosis was improved in 11 patients (39%), unchanged in 12 (43%) and deteriorated in 5(18%). There was no statistically significance according to Karnofsky Performance Scale compared with that of preoperation.

The extended pterional transtemporal transtentorial approach was an effective approach for the resection of large and giant petroclival meningiomas, especially for giant meningiomas that predominantly occupied the middle fossa and extended to the supratentorial region.

To evaluate the microsurgical treatment strategy of petroclival meningioma, the risk factors of tumor resection and the prognosis of the patients in order to improve the surgical therapeutic effects.

The clinical and follow-up data were retrospectively analyzed in a consecutive series of 71 cases with petroclival meningiomas who received microsurgical resection between July 1991 and April 2010.

The study consisted of 71 patients with a female-to-male ratio 2.9 and mean age (47.0±11.2) years. The mean duration of symptom was (32.5±3.0) months and the mean diameter of tumor was 44.4 mm. The retrosigmoid (transtentorial) approach was mainly chosen (65 cases, 91.5%) in the study. Three cases were treated visa transpetrosal presigmoid approach and 3 cases with other kinds of approaches. The gross total removal (GTR) reached in 48 cases (67.6%). The subtotal removal was achieved in 10 cases and partial removal in 13 cases.Forty-seven cases (72.3%) reached GTR via retrosigmoid (transtentorial) approach. One case (1.4%) died postoperatively. The mean of postoperative KPS was (73.2±15.6). Sixty-four cases were followed-up with a mean period of (60.7±47.5) months. The mean KPS at the last visit was (83.2±13.4). Recurrence and progression were identified in 6 and 8 cases respectively and 7 cases died during the follow-up period. In the follow-up patients, the overall survival rate was 100% at 6 months, 91.3% at 1 year, 89.2% at 3 years, 88.5% at 5 years and 85.7% at 10 years. The tumor texture (P=0.092), subtype (P=0.088), depth of invasion into cavernous sinus (P=0.001) and whether to warp neurovascular structures (P=0.033) had significant correlations with the extent of tumor removal.

With regard of improving therapeutic effect and patient prognosis, adjustable approach should be chosen individually based on the different factors affecting tumor removal. Retrosigmoid (transtentorial) approach was one of the most crucial and effective approaches for the removal of petroclival meningioma.

To present our experience with the surgical management of giant pituitary adenomas through endoscopic endonasal transsphenoidal approach.

A retrospective data analysis of all patients who underwent endoscopic endonasal transsphenoidal surgery in Nanfang Hospital between January 2007 and June 2013 was performed. Patients who presented with pituitary adenomas larger than 4 cm were included in the study. Analysis of factors related to the choice of the operative approach, extent of resection, follow-up outcome, and complications were evaluated.

Sixty-nine patients (18%) with giant adenomas matched our inclusion criteria. This included 51 (74%) patients with nonfunctional tumors, 11 (16%) prolactinomas, and 7 (10%) growth hormone-secreting adenomas. Gross total removal of the tumor was achieved in 26 cases (38%), subtotal removal in 23 (33%), and 20 (29%) had partial resection. Postoperative diabetes insipidus occurred in 9 cases (13%), new anterior pituitary insufficiency in 10 (15%), CSF leaks in 2 (3%), and meningitis in 2(3%). There was no dead case. The patients with Knosp score 3-4 adenomas had a higher total resection rate than those with Knosp score 0-2 (P< 0.001). Preoperative headache, visual dysfunction, oculomotor disorders and hypopituitarism were recovered in 20(83%), 59(86%), 9(60%), and 12(36%) cases, respectively. Nine patients with nonfunctional tumors underwent a second transsphenoidal surgery, 10 underwent radiotherapy, and 14 had a follow-up care. Drug therapy was performed in 11 patients with functional tumors, and radiotherapy in 3.

Endoscopic endonasal surgery might provide safe and effective treatment for patients with giant adenomas. The selection of surgical approach should be established according to the tumor extension and personal experience. In cases in which total resection might be associated with high risk, we advocated the use of partial resection followed by adjuvant drug therapy or radiotherapy. In cases of progressive enlargement of residual lesions, a second endoscopic procedure or radiotherapy might be considered.

To observe the clinical effects of microsurgical treatment for tumors in the medullocervical junction.

The clinical data of 25 patients with tumors in the medullocervical junction were analyzed retrospectively. CTA was examined in 17 cases. The feeding arteries were embolized by Onyx glue in 4 patients and the microsurgical procedures were performed after 1 week. The suboccipital midline approach was chosen in 14 cases and the far lateral approach in 11.

Complete tumor resection was achieved in 21 patients (84%), subtotal tumor resection was done in 4 patients (16%) and no case was dead. There were pulmonary infection in 3 cases (12%), leakage of incision in 2 (8%), neck collar fixed for 3 months in 2 cases because of getting ride of 1/3-1/2 occipital condyle during operation, diameter of about 3 cm occipital scalp necrosis in one after operation.The preoperative occipital artery embolism patient became better in occipital scalp necrosis after active treatment. 23 patients were followed-up for 6 to 48 months, and 2 patients were not followed-up. There was no recurrence in 19 cases after complete tumor resection. 2 tumors recurrence were found in 4 cases after subtotal tumor resection. There was no dead case during follow-up. The Karnofsky performance scale was above 80 in 19 patients. 5 patients experienced different degrees of cranial nerve dysfunction symptoms, 2 patients lived independently. 4 tumors with preoperative occipital artery embolism were completely removed and the Karnofsky performance scales were above 80 during the follow-up period.

Doing preoperative examinations of CTA, embolizing feeding arteries through DSA, choosing proper operation approach and operating along subarachnoid flat were important for successful resection of tumors in the medullocervical junction.

Olfactory groove meningioma originates from the sieve plate and frontosphenoidal suture. It is a common skull base tumor, accounting for about 10% of intracranial meningiomas^[1]。 Because there are no obvious symptoms in the early stage of tumor growth, the volume of tumors found in clinical practice is often large. Tumors larger than 5 cm in diameter are called giant olfactory groove meningiomas, which are closely related to the optic path, hypothalamus, anterior cerebral artery and its branches, and are difficult to surgically resect^[2]。 From January 2006 to June 2014, 31 patients undergoing olfactory groove brain tumor were treated in the Department of Neurosurgery of Xinjiang Autonomous Region People's Hospital. The analysis report is as follows.

Most patients with cerebellopontine angle tumors can be resected by retrosigmoid approach. In the past, there were complications such as poor exposure, overexposure of sinuses or injury of venous sinuses, subcutaneous effusion or poor wound healing after surgery. How to avoid venous sinus injury, achieve good intraoperative exposure, and reduce the occurrence of postoperative complications often trouble us. From January 2010 to July 2012, our department used CT thin-section scan and three-dimensional reconstruction of body surface markers to locate transverse sinus and sigmoid sinus sulcus to guide suboccipital posterior sigmoid sinus approach craniotomy in 49 cases, with satisfactory results. The report is as follows.

To study the of microsurgical treatment for patients with poor-grade aneurysms (Hunt-Hess Ⅳ-Ⅴ) associated with hematoma and to explore the best therapeutic opportunity.

A retrospective analysis of 18 consecutive patients who were diagnosed as poor-grade aneurysms combined with hematoma and underwent microsurgical treatment in Wuxi Clinical Medical School of Anhui Medical University between April 2010 and June 2013 was performed. Fifteen cases underwent microsurgical treatment within 24 hours, and 3 more than 72 hours.

All the aneurysms were occluded completely by CTA . The outcome was assessed by follow-up for 6-36 months. According to the Glasgow Outcome Scale, good recovery was observed in 4 patients, dissatisfied in 6, vegetative state in 4 and dead in 4. A poor outcome occurred in patients whose aneurysm diameter was more than 10 mm(P=0.035), intracerebral hematoma volume more than 50 ml(P=0.046) and with cerebral hernia(P=0.038) before operation. The outcome of ultra-early (within 24 hours) surgery patients was better than those received surgery over 72 hours. In 7 patients who accepted extraventricular drainage after the aneurysm was occluded, good outcome was achieved in 4, dissatisfied in 2 and 1 dead. The efficacy was better than those patients not accepted extraventricular drainage (P=0.034).

Poor-grade aneurysm was a critical condition and the prognosis weas poor. The outcome had close relationship with the size of aneurysm, volume of hematoma and cerebral hernia before operation. The ultra-early (within 24 hours) surgery combined with extraventricular drainage could improve the prognosis of patients.

To explore the characteristics of CT manifestations and their clinical application in subarachnoid hemorrhage (SAH) induced by ruptured anterior communicating aneurysms (ACoA).

A group of patients suffered from SAH with ruptured ACoA were reviewed from 1997 to 2013. A total of 405 ACoAs were clipped. According to the CT manifestations of the hemorrhage, SAH was classified into 5 types. Statistical analysis was performed to assess the relativity between this CT classification and the Hunt-Hess scale, the clinical outcomes as well as delayed cerebral ischemia(DCI).

Among 279 cases ofⅠ-Ⅲ types, 266 cases (95.3%) were cured, 8 (2.9%) died. Among 126 cases of Ⅳ-Ⅴ types, 93 cases(73.8%) were cured, 19 (15.1%) died. The CT classification (Ⅰ-Ⅴ) was positively correlated with the patients′ prognosis (cure - death)(P<0.01), which became poor with the gradual increase of CT classification. Among 279 cases ofⅠ-Ⅲ types, 267 cases(95.7%) were Hunt - Hess classification levels (Ⅰ-Ⅲ) , 12(4.3%) were Hunt - Hess classification levels (Ⅳ - Ⅴ) . Among 126 cases of Ⅳ -Ⅴ types, 87 cases(69%) were Hunt - Hess classification levels (Ⅰ-Ⅲ), 39(31.0%) were Hunt - Hess classification levels (Ⅳ-Ⅴ) . The CT classification (Ⅰ-Ⅴ and the types with Hunt - Hess classification levels (Ⅰ-Ⅴ) were positively correlated(P<0.01). The morbidity of patients whose CT classifications wereⅠ-Ⅴ was 2.70%, 5.43%, 12.39%, 16.36% and 6.25% respectively.

The CT classifications of SAH in ruptured ACoA had comparatively higher Clinical value in predicting the patients′ prognosis. It should be noted that early diagnosis and microsurgical operation skills were important for the improvement of the patients′ prognosis. The CT classifications of SAH in ruptured ACoA which had guiding significance in predicting DCI had a good correlation with Hunt - Hess classification and the patients′ prognosis.

To investigate the microsurgical treatment strategies of ruptured tiny aneurysm.

A retrospective analysis of 14 cases of ruptured intracranial tiny aneurysm was performed. The clinical data included the digital subtraction angiography information of the position and anatomical location of aneurysms, the operation treatment and prognosis.

The anatomical location of aneurysm: 3 cases of anterior communicating artery, 4 posterior communicating artery, 3 internal carotid artery, 2 middle cerebral artery, and 2 posterior inferior cerebellar artery. The Hunt-Hess: Ⅰ ~ Ⅱ 12 cases, 2 grade Ⅲ. Twelve procedures were performed through pterional approach, 1 posterior median approach, and 1 retrosigmoid approach. The follow-up (mean 3 months) results using the modified Rankin score (MRs): 8 patients with MRs 0, 2 MRs 1, 2 MRs 2, and 1 MRs 4. One case died because of reruptured aneurysm.

The clipping of aneurysm was important for the treatment of ruptured tiny aneurysm. The procedure should be performed according to the shape and position of the aneurysm to improve the prognosis of patients with life quality.

To explore the efficacy of early lamina terminalis fenestration in the treatment of acute hydrocephalus after aneurismal subarachnoid hemorrhage.

Ninety-eight patients of acute hydrocephalus after aneurismal subarachnoid hemorrhage who were treated by clipping were retrospectively analyzed. These cases were divided into two groups, including aneurysm clipping group alone (42 cases) and clipping with lamina terminalis fenestration group(56 cases). The improving rate of acute hydrocephalus and the incidence rate of shunt-dependent hydrocephalus after surgical treatment were compared between two groups.

All surgical clipping procedures were performed within 72 hours after aneurysm rupture. Ultimately, 46 cases of acute hydrocephalus patients acquired improvement and 27 cases developed to chronic hydrocephalus after surgical treatment among 98 patients. Fourteen cases of acute hydrocephalus patients in aneurysm clipping group were improved (the improvement rate was 33.3%) and 14 cases developed into shunt-dependent hydrocephalus (the incidence rate was 33.3%). Thirty-two cases of acute hydrocephalus patients in lamina terminalis fenestration after aneurysm clipping group were improved (the improvement rate was 57.1%) and 13 cases developed into chronic hydrocephalus (the incidence rate was 23.2%). The acute hydrocephalus improvement rate and shunt-dependent hydrocephalus incidence rate in posterior circulation aneurysm group were statistically difference between aneurysm clipping group and lamina terminalis fenestration after aneurysm clipping group(P<0.05), but not in anterior circulation aneurysm group (P>0.05).

The efficacy of early lamina terminalis fenestration in the treatment of acute hydrocephalus after aneurismal subarachnoid hemorrhage was effective in posterior circulation aneurysm clipping.

To evaluate the application of robotized stereotactic assistant(ROSA) navigated intracranial electrode implantation in precise epileptogenic zone localization.

The data of 40 patients with drug-resistant epilepsy in Beijing Sanbo Brain Hospital from March 2012 to September 2013 who underwent ROSA navigated implantation of intracranial electrode for localization of epileptogenic zone were collected. The demographics, noninvasive clinical data, complications and seizure outcomes after surgical resection were prospectively collected and analyzed.

Thirty-nine patients proceeded video-electroencephalography (V-EEG) without distraction. 1 patient experienced intracranial hemorrhage caused by the implantation. The electrodes were preserved for 4-34 days (mean 11.4 days), and 2-38 clinical seizures were observed with a mean of 9.9. There was no cerebrospinal fluid leak, intracranial hematoma, electrodes fracture or patient death. There was 1 scalp infection. From the studied group of 39 patients, the area of seizure onset could be localized in 37 patients. 32 patients underwent surgical resection following stereo-electroencephalography (SEEG) evaluation and were followed-up for more than 6 months. In the group of 32 patients, 27 patients were reached EngelⅠclass, 2 EngelⅡ, 1 Engel Ⅲ and 2 Engel Ⅳ.

For intractable epilepsy, when non-invasive assessments couldn′t find the epileptogenic foci, intracranial electrode implantation combined with long-term V-EEG was an effective method to localize the epileptogenic foci, especially the ROSA navigated stereotactic electrode implantation, which was a microinvasive, short-time, less-complication, safe-guaranteed and precise technique.

To explore the disease characteristics and clinical treatment of lumbosacral spinal myxopapillary ependymoma.

The data of 50 patients with lumbosacral spinal myxopapillary ependymoma in our department from Jan. 2008 to Nov. 2013 were analyzed respectively. All the patients were treated by microsurgery. The patients without total removal and younger than 18-year-old were treated with adjunctive radiotherapy.

Total removal was achieved in 43 cases and subtotal in 7. 3 subtotal removal cases were treated with adjunctive radiotherapy. There was no died patient. The mean follow-up period was 17.3 months. The neurological function was improved in 37 cases(74%), without change in 9(18%), and deteriorated in 4(8%). Four patients developed tumor local recurrence and two developed tumor disseminated recurrence.The patients who were treated with adjunctive radiotherapy had no recurrence.

Total removal was the most effective treatment for lumbosacral spinal myxopapillary ependymoma. The patients without total removal and younger than 18-year-old might need adjunctive radiotherapy and could get excellent or good clinical effects.

To explore the effects of ACNU combined with CDDP in malignant glioma treatment, and analyze the clinical validity and safety of drug combination, and to investigate theory evident for the clinical treatment with neoadjuvant chemotherapy.

(1) Analyzed the short-term effects and one year survival rate of ACNU and cisplatin intravenous infusion for 72 h and temozolomide (TMZ) chemotherapy retrospectively. (2)Assessed chemotherapy-related toxicity of different groups.

(1)The short-term effect of ACNU and cisplatin combination chemotherapy was better than that of TMZ therapy, the partial response rate of the former was 56%, while the later was only 6%(P<0.01), but there was no significant difference in one-year survival rate between two groups(28% versus 19%) (P>0.05). (2)The myelosupression was higher in ACNU and cisplatin combination chemotherapy group (grade Ⅲ leucopenia and thrombocytopenia was 72% and 56% respectively)than that in TMZ therapy group(grade Ⅲ leucopenia and thrombocytopenia were all 0%), but it was tolerable. The other side effects including myelosuppression, damage of liver and kidney were all mild in both groups.

ACNU and cisplatin combination chemotherapy was not better than TMZ in one-year survival time or toxicity. But it showed special advantages in short-term effect which could reduce tumor invasion in a short time range. This made it more suitable for neoadjuvant chemotherapy to improve the total tumor removal rate and get lower recurrence rate.

To discuss the value of the preoperative image assessment and surgical strategy of parasagittal meningiomas in central gyrus region, in order to raise the resection rate of tumors and surgical effects.

25 patients with parasagittal menigioma in central gyrus region were examined by routine MRI and MRV to evaluate the blood supplies of the tumor, degree of involvement of the sagittal sinuse and collateral veins. During the operation, a frontoparietal cross-midline horseshoe incision was performed. The parasagittal blood supplies were blocked at first and then the tumors were removed piece by piece. The Rolandic veins and compensative veins were protected. The sagittal sinuses were appropriately dealt with.

The visualization of 25 parasagittal meningiomas in central gyrus region invading the sagittal sinuses and the draining veins was achieved through MRV and MRI scanning. The results were highly coincidence with the findings in the operation.18 tumors were removed with SimpsonⅡgrade, and 7 Simpson Ⅳ. Postoperatively, 5 patients developed hemiparesthesia, 3 hemiparesis, and 2 mental disorders. All the complications were recovered satisfactorily during follow-up period.

Sufficient preoperative imaging evaluation, MRV combined with conventional MRI, could sensitively show the degree of involvement of the sagittal sinus and collateral veins. Skillful microsurgical technique was helpful to protect important drainage veins, collateral veins and sinuses, and increase surgical outcome in patients with parasagittal menigioma in central gyrus region.

To sum up the clinical experiences of the application of 3D reconstruction model and intraoperative monitoring in posterior restoration for the treatment of complex craniocervical junction deformity.

The clinical data of 21 patients with irreducible atlantoaxial dislocation were analyzed retrospectively, including imaging data, 3D reconstruction model in craniocervical junction and Japanese Orthopedic Association (JOA) scores. The average JOA score was(7.61±3.22)preoperatively. The posterior restoration and screw-rod (plate) internal fixation techniques were adopted in all the cases. Intraoperative monitoring techniques included SEP and EMG. The surgical outcomes were evaluated according to JOA scores and imaging examination.

The postoperative imaging examination showed that fixed system and atlantoaxial restoration were performed well in 19 cases and badly in 2. The bony fusion was performed well in 16 cases and badly in 1. There was no death. The clinical symptoms were improved to different extents postoperatively. There was no severe complication. All the patients were followed-up for median period of 10.6 months, ranged from 6 to 34 months. The average JOA score was(11.67±3.16), which was significantly improved (t=-5.356, P<0.01) compared with that before operation.

Posterior restoration and screw-rod (plate) internal fixation techniques combined with modern imaging evaluation, 3D reconstruction model and intraoperative monitoring techniques could be helpful for good clinical results in the treatment of complex craniocervical junction deformity.

To investigate the changes of metabolic rate in patients with severe traumatic brain injury under hypothermia state, and to assess the effect of hypothermia treatment with the metabolic rate in brain injury patients.

Patients with severe brain injury in ICU were enrolled in the study during January 2012 to January 2014. Eighty-three patients were randomly divided into mild hypothermia group (42 cases) and normal group (41 cases). The rectal temperature of mild hypothermia group was controlled in the range of 32 ℃ to 35 ℃ at the first 5 days; while the control group within the normal range (36.5-37.2 ℃). Both groups were measured the resting energy expenditure (REE, kJ/d) with a metabolic cart three times a day.

The REE of the mild hypothermia group was significantly lower than that of the control group. The REE of the mild hypothermia group was at a low level at the first five days, which was about 60-70% of that of the normal group. The good recovery rate of the treatment group was significant higher than that of the control group [59.52%(25/42) vs. 34.15%(14/41), P<0.05, on discharge]and [73.5%(25/34) vs. 46.9%(15/32),P< 0.05, on three months after injury]. But there was no significant difference between two groups in the incidence of pneumonia(P>0.05).

In the range of 32 ℃ to 35 ℃, the REE was greatly reduced (nearly about 60-70% of the normal group), which might change the clinical outcomes in severe brain injury patients.

To analyze the the radiographic and clinical features of the internal carotid artery (ICA) anomalies.

The clinical and radiographic characteristics were retrospectively analyzed in cases of ICA anomalies screened from our intervention database in changhai hospital from september 2009 to september 2014.

Totally, 6 female patients were included with average age of (45±13) years old. The clinical manifestations included subarachnoid hemorrhage in 1 cases, asymptomatic complaint in 1, cerebral infarction in 1, dizziness in 2 and headache in, Unilateral dysgenesis was observed in 2 cases and bilateral in four with 2 cases of dysgenesis of vertebral artery. Intracranial aneurysm was observed in 4 cases and 1 complicated with dural arterial venous fistulous. Endovascular treatment was performed in 2 patients and coupled with bypass surgery in one. Risks control was performed in 2 patients. No adverse event was observed.

The diagnosis of ICA anomalies was based on the morphology of carotid canal. Multiple intracranial vascular disorders might be complicated. Thorough analysis of radiographic features was beneficial to decision-making for clinical practice.

To explore the clinical characteristics, pathogenesis, surgical treatment and efficacy of rare trigeminal neuralgia secondary to hydrocephalus.

Five patients with trigeminal neuralgia secondary to hydrocephalus were analyzed retrospectively from January 2009 to July 2013. The MRI of brain showed hydrocephalus with Chiari′s malformation in 1 case, and significant expansion of the lateral ventricle accompanying with normal morphology of the fourth ventricle in the other four cases. All patients underwent ventriculoperitoneal shunting (VPs).

Trigeminal neuralgia was completely disappeared in these five patients: the facial pain disappeared immediately in 2 patients and disappeared after 3 days with VPs in 3 patients. There was no surgical complication. During follow-up, the ventricular system returned to normal, without recurrence of trigeminal neuralgia.

Trigeminal neuralgia secondary to hydrocephalus was rare. Surgical treatment of hydrocephalus might be the first choice of treatment for trigeminal neuralgia with hydrocephalus.

primary melanocytic neoplasms (PMNs) of the central nervous system are a group of diffuse or localized benign or malignant tumors originating from the leptomeningeal^[1]。 Intraspinal PMN is clinically rare, Li Yong et al.^[2]Three cases were reported, accounting for only 0.34% of 870 cases of intraspinal tumors in the same period. The clinical incidence of PMN is low, and its clinical manifestations are often uncharacteristic. Like other spinal canal tumors in symptoms and signs, it is a symptom of spinal cord compression without obvious specific signs. In this paper, four cases of intraspinal PMN admitted to the Department of Neurosurgery of Beijing Tiantan Hospital affiliated to Capital Medical University from November 2011 to June 2014 were clinically analyzed, and the reports are now as follows.

Brain abscess is a serious infection of the central nervous system. There are no guidelines for the treatment of brain abscesses, and many controversial issues need to be addressed, including the choice of surgical methods^[1]。 From January 1998 to February 2014, 76 patients with brain abscess were treated with stereotactic Ommaya capsule placement in the Department of Neurosurgery of the First Affiliated Hospital of Harbin Medical University. Now, the clinical data of this surgical method were retrospectively analyzed to explore the clinical value of this surgical method.

diffuse intrinsic pontine glioma (DIPG) is a glioma whose tumor center is located in the pons. It grows invasively without obvious boundaries, and the pons is enlarged in an oval shape on magnetic resonance imaging. Brainstem glioma can occur in midbrain, pons, medulla oblongata and cervical spinal cord, and can be divided into endophytic, exophytic, localized and diffuse in morphology. The incidence of diffuse endophytic brainstem glioma accounts for 60% ~75% of brainstem tumors, and DIPG accounts for more than 90% of pons glioma^[1,2]。 The prevalent population of DIPG was children, the average age of diagnosis was 7-9 years, and there was no difference in the incidence of male and female^[1,2]。 The prognosis is extremely poor, usually death within 10 months after diagnosis, and only 10% of children survive for more than 2 years^[3,4]。 The factors leading to this poor prognosis include the complex anatomical structure of the brainstem, the important anatomical location and the diffuse endogenous growth of the tumor^[5]； Over the past two decades, no chemotherapy regimen has improved children's survival^[6]； Various radiotherapy regimens can only temporarily relieve children's symptoms, but do not change long-term survival^[6]； At present, due to the low rate of autopsy and biopsy and the difficulty of modeling, further understanding of the molecular biological characteristics of DIPG is not conducive to the research of new targeted therapies and preclinical experiments^[7]。

Hypothalamic hamartoma is a rare neurological disease characterized by ridiculous epilepsy and precocious puberty, often accompanied by cognitive dysfunction and developmental abnormalities. Its essence is ectopic normal nerve tissue, usually present at birth. However, the pathogenesis of its symptoms is still inconclusive. Because of the variable location of the growth of hypothalamic hamartoma, the treatment of hypothalamic hamartoma has been controversial. In recent years, some progress has been made in related research at home and abroad, which is summarized as follows.

Tumor is one of the important killers that threaten human health. At present, people have a relatively systematic and comprehensive understanding of the molecular mechanism of tumor occurrence and development. However, with the continuous deepening of tumor research, the changes of tumor genetic material^[1]The existing theories have not been sufficient to elucidate many new phenomena discovered in recent studies, such as endothelial cells maintaining the properties of cancer stem cells^[2]The biological effects of tumor microenvironment and tumor cell plasticity on tumors and their relationship can explain these new findings^[3,4,5,6,7]。 In this paper, the relationship between cell plasticity and tumor microenvironment and tumor stem cells will be summarized and discussed, and the molecular mechanism of hypoxia, metabolic changes and acidic environment regulating the plasticity changes of tumor cells will be emphasized.

From January 2009 to September 2013, a total of 25 transvascular clips were used in 17 cases of intracranial aneurysm clipping in the Department of Neurosurgery, Affiliated Hospital of North Sichuan Medical College. The application experience is reported below.

severe traumatic brain injury (sTBI) is the leading cause of death and disability among young people in developed and developing countries^[1]。 Although the treatment level has been greatly improved through the unremitting efforts of several generations of neurosurgeons, basic research and other related personnel, in China, due to the restrictions of geography, transportation, concept and professional level, the clinical treatment effect of sTBI in different medical units is quite different, especially in some key links such as pre-hospital emergency treatment, emergency treatment and intensive care quality control of sTBI patients, there is a lack of clinical standardization, standardization and scientificity. The author has been engaged in clinical treatment and research of sTBI for many years. The following is a few experiences and thoughts on the treatment of sTBI patients for peers' reference.

Comrade Huang Keqing, former director of neurosurgery in Fujian Provincial Hospital, died at 4: 16 am on December 22, 2014 at the age of 83 due to ineffective treatment.

From November 6th to 8th, 2014, the 13th National Academic Conference of Neurosurgery Branch of Chinese Medical Association was held in Xiamen. Qi Guoming, Vice President of Chinese Medical Association, Zhang Hui, Director of Academic Conference Affairs Department, leaders of Fujian Province and Xiamen Municipal Health Planning Commission and Medical Association, and leaders of Fujian Medical University Affiliated Hospital and Xiamen University Affiliated Hospital attended the meeting and delivered speeches. Academician Zhou Liangfu, Honorary Chairman of Neurosurgery Branch of Chinese Medical Association, Academician Zhao Jizong, Former Chairman, and Professor Zhou Dingbiao, Chairman, gathered with more than 3,000 neurosurgeons from all over the country to exchange experiences, share results and talk about the future.