Volume 33 · Issue 11 · 2017

The diagnosis and treatment of craniopharyngioma is one of the major challenges facing neurosurgery. Because the tumor is deep and the adjacent structure is complex and important, surgery or radiotherapy may cause serious damage to important structures such as optic chiasm and hypothalamus, so the clinical treatment of this disease is often difficult, dangerous and heavy^[1,2]。 In addition to surgical techniques, the diagnosis and treatment of craniopharyngioma also tests the neurosurgeon's comprehensive technical ability in preoperative evaluation, postoperative management and long-term complication management. In the past few decades, the comprehensive treatment level of craniopharyngioma, such as surgical treatment, radiotherapy and drug treatment, has made great progress, and the treatment effect has been greatly improved^[3,4,5]。 However, the recurrence rate and complication rate of tumor are still very high, which seriously affects the quality of life of patients. There are still many technical difficulties and theoretical problems that need in-depth research and innovative tackling to solve this problem. At the same time, with the rapid development of modern science and technology, new theories, new technologies and new methods are constantly emerging, which provides a good opportunity for the improvement of the basic and clinical research level of craniopharyngioma. Efforts to strengthen the research in this field will further promote the comprehensive research and clinical diagnosis and treatment level of craniopharyngioma.

To discuss the choice strategies of surgeries approaches for the resection of craniopharyngiomas.

The clinical data of 128 patients were retrospectively reviewed who presented with craniopharyngiomas and underwent operations at Neurosurgery Department of Beijing Tiantan Hospital, Capital Medical University, between August 2007 and March 2017. Craniopharyngiomas were classified into 4 types based on tumor locations: intrasellar type, intra-suprasellar type, suprasellar type and intra-third-ventricle type. The surgical approaches included EEA (endoscopic endonasal approach), lateral subfrontal approach, pterional approach and transcallosal interforniceal approach. With regard to the approaches used for the tumors, 28 were resected via lateral subfrontal approach, 19 via pterional approach, 8 via transcallosal interforniceal approach and 73 via EEA.

For all 128 cases, gross total resection (GTR) was achieved in 91 (71.1%), near-total resection (NTR) in 35 (27.3%) and partial resection (PR) in 2 (1.6%). For the intrasellar type of tumors, GTR was achieved in 19. For the intra-suprasellar type of tumors, GTR was achieved in 33 and NTR in 15. For the suprasellar type of tumors, GTR was achieved in 28, NTR in 19 and PR in 1. For the intra-third-ventricle type of tumors, GTR was achieved in 11, NTR in 1 and PR in 1. The complication rate of moderate or severe diabetes insipidus (DI), panhypopituitarism and electrolyte disturbances was 40.4% (19/47) for lateral subfrontal approach and pterional approach, 11.0% (8/73) for EEA and 25.0% (2/8) for transcallosal interforniceal approach, whose differences were statistically significant(P=0.001). No surgery-related deaths occurred among the 128 patients. Oculomotor nerve palsy was confirmed in 1 patient who underwent operation through the pterional approach. Postoperative hemorrhage occurred in 1 patient undergoing tumor resection through lateral subfrontal approach and hematoma removal. Leakage of cerebrospinal fluid (CSF) occurred in 4 patients who underwent the EEA approach and repair of the leak. During the follow-up period, tumor recurrence or regrowth occurred in 15 (11.7%) of the 128 cases. Tumor recurrence or regrowth was found in 2 of 19 (10.5%) intrasellar type tumors, 5 of 48 (10.4%) intra-suprasellar type tumors, 7 of 48 (14.6%) suprasellar type tumors and 1 of 13 (7.7%) intra-third-ventricle type tumors.

The tumor location seems to be the primary key point for choice of surgical approach of craniopharyngiomas. Evaluation of associated damage to hypothalamus is the second key point in approach choice.

To explore the characteristics and guidance for surgical treatments of various types of craniopharyngiomas classified by QST.

A total of 117 cases of primary craniopharyngiomas admitted to Department of Neurosurgery, Nanfang Hospital, Southern Medical University from January 2010 to January 2012 were enrolled into this study. The patient's age, gender, pathologies, surgical approaches, operative situations, tumor size, hydrocephalus, QST classifications, endocrine levels and follow-up data were collected.

The rate of gross total resection was 100% in 117 patients. The follow-up time ranged from 60 to 86 months (mean: 69.6±13.8 months). The ages, pathologies, hydrocephalus, endocrine levels, surgical approaches and prognosis of different patients classified by QST had statistical significance (all P<0.05). The Q-type craniopharyngioma which was all adamantinomatous most commonly attacked children, while all squamous craniopharyiomas were S and T types and commonly affected adults. Patients of T type showed higher probability of developing hydrocephalus than S and Q types(both P<0.05). However, in terms of anterior pituitary function, S type was the best followed by T type and Q type was the worst. The rate of favorable prognosis was 91.5% (107/117) while unfavorable prognosis was 8.5% (10/117) and S type was the best. The tumor recurrence rate was 12.0% (14/117). There was no significant difference in the recurrence rate among patients with varying ages, tumor sizes, pathological types and QST types (all P>0.05).

QST classification based on originating location and membranous concept is related to clinical symptoms of craniopharyngiomas, which could not only provide basis for choice of surgical approaches but also indicate the difficulty and prognosis of treatment.

To present our surgical experiences with management of craniopharyngiomas (CPs) by endoscopic endonasal approach.

A retrospective review was conducted on clinical data of 90 patients who were treated for CPs by endoscopic endonasal approach from January 2012 to December 2016 at the Department of Neurosurgery, the first Affiliated Hospital of Nanchang University. All patients were analyzed in terms of treatment effect, complications, and follow-up results.

Total removal of the tumors were completed in 76 cases (84.5%), subtotal removal in 12 cases (13.3%), and partial resection in 2 cases (2.2%). The pituitary stalks were identified in 76 cases during surgery and severed in 46 cases (60.5%). Postoperative visual acuity was improved in 40 cases, 18 cases remained at the preoperative level, and symptomatic worsening occurred in 1 case. New worsening of the anterior pituitary function was reported in 32 cases (35.6%), all those cases with preoperative panhypopituitarism were unchanged. New diabetes insipidus occurred in 56 cases, and transient diabetes insipidus after operation occurred in 30 patients, and long-term diabetes insipidus occurred in 26 cases. Postoperative cerebrospinal fluid (CSF) leak was reported in 6 cases accompanied with intracranial infection. All those cases were repaired under endoscope again and success was achieved in 5 cases. Perioperative mortality rate was 4.4%. A total of 77 patients were followed up for 5-50 months with an average of 23.1±13.3 months, and 65 patients (84.4%) returned to normal life. Obesity developed in 12 patients. There were 2 recurrent cases and no deaths during follow-up.

Binastril, bimanual, extended endonasal approach serves as the foundation of endoscopic craniopharyngioma resection. Under endoscopy, anatomical relationship of the tumor to the stalk, hypothalamus, perforating vessels could be confirmed precisely. The same principles in tumor resection are followed as in microscopic surgery, which is the basis of high-quality excision of craniopharyngiomas purely under endoscope. Good reconstruction of skull base is an important technique to prevent postoperative CSF leakage.

To explore the endoscopic endonasal approach assisted with various new techniques in the surgical treatment of suprasellar craniopharyngiomas.

Nighty-one patients (55 males, 36 females) with suprasellar craniopharyngiomas were recruited from September 2012 to December 2016, retrospectively. Endoscopic endonasal trans-tuberculum approach was applied in all patients at Neurosurgery Department of Huashan Hospital, Fudan University. After operation, all patients were asked to take regular follow-up including endocrine exams and sellar contrast MRI.

Among the 91 cases, 53, 25 and 13 cases achieved gross-total, subtotal and partial resections, respectively. Other complications included intracranial infection (3 cases) and electrolyte disturbance (3 cases). Sixty-eight (74.7%, 68/91) patients obtained anatomic preservation of pituitary stalk postoperatively.Among 62 patients with original visual impairment, 35 cases (56.5%, 35/62) were improved to different extent. Postoperative complications included cerebrospinal rhinorrhea (3 cases), intracranial infection (3 cases), serious electrolyte disturbance (3 cases), hypothalamic dysfunctions (2 cases), intracranial hemorrhage (2 cases), epistaxis (2 cases) and loss of vision (1 case). All the cases were confirmed craniopharyngiomas pathologically. The follow-up period ranged from 3 months to 54 months (mean: 18.0±9.7 months). Endocrine exams indicated new-onset hypoadrenalism in 34 cases, hypothyroidism in 30 cases, hypogonadotropic hypogonadism in 15 cases and posterior hypopituitarism in 18 cases. Eight cases with residual tumors underwent radiotherapy and 2 recurrent cases received the second operation during contrast MRI follow-up.

Endoscopic endonasal surgery demonstrates good results in suprasellar craniopharyngiomas, which is advantageous in facilitation of maximal and safe tumor exposure and protection of the pituitary stalk.

To investigate the clinical outcomes in children with recurrent craniopharyngimas after microsurgical resection of the tumors.

The clinical outcomes of 73 cases of recurrent childhood craniopharygngiomas from April 2008 to December 2014 were retrospectively analyzed. All patients underwent microsurgical resection of the tumors at Neurosurgery Department of Sanbo Brain Hospital, Capital Medical University.

Total removal of the tumor was achieved in 64 (87.7%) of the 73 patients and the subtotal resection rate was 12.3% (9 cases). The perioperative mortality was 2.7% (2 cases). A total of 52 patients were followed up from 6 to 93months, with the median of 45 months. The tumor recurrence rate was 36.5% (19/52) during the follow-up period. For those patients whose tumors were removed totally, the tumor recurrence rate was 30.2% (13/43), and it was 66.7% (6/9) for those whose tumors were removed subtotally. There was statistical difference between the two groups (P=0.039). The fatality rate was 13.4% (7/52) during the follow-up. We used the Karnofsky Performance Scale to assess the life quality of the 45 children. The results showed that 4 children scored 100 points, 35 scored 90, 3 scored 80, 2 scored 60, and 1 scored 40. There were 26 (50.0%, 26/52) children demonstrating significant growth retardation, 24 (46.2%, 24/52) needed oral desmopressin to treat diabetes insipidus, and 5 (9.6%, 5/52) showed significant obesity.

Microsurgical resection of recurrent craniopharyngiomas in children may result in good outcomes. The treatment of postoperative hypothalamic-pituitary deficiency is still a challenge.

To investigate review the surgical outcomes of aggressive resection and the significance of preservation of hypothalamic structures of 1 182 cases of craniopharyngiomas (CP).

A total of 1 182 CP cases were retrospectively enrolled into this study who underwent operations at Department of Neurosurgery, Fu Xing Hospital, Capital Medical University and Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University between April 2004 and December 2016. The surgical approaches and prognosis were summarized. The relationship between preservation of hypothalamic structures and tumor calcification, diabetes insipidus (DI) or recurrence of the tumor was investigated.

Total, subtotal, and partial tumor removal was achieved in 89.6%(1 059 cases), 6.5%(77 cases), and 3.9%(46 cases) of all patients, respectively. There were 23 (1.9%) perioperative deaths. A total of 836 (70.7%) patients were followed up for 2.0-18.0 years with an average of 3.7±2.1 years. Among 430 patients with preoperative visual impairment, the visual acuity was improved in 31/91 (34.1%) patients and the visual field was improved in 225/339 (66.4%) patients. A total of 689/863 (82.4%) patients recovered to normal life. DI deteriorated in 57/81 (70.4%) cases and newly-onset DI occurred in 289/1 101 (26.2%) patients. Total pituitary stalk(PS) preserration were achieved in 578/1 182(48.9%) patients.The rate of PS preservation was significantly lower in patients with calcified tumors compared with that in patients with non-calcified tumors (P<0.001). PS preservation was responsible for DI (P<0.001), but no difference in the tumor recurrence rate was observed between PS preservation and non-reservation cases (P>0.05). The rate of recurrent tumor was lower in patients with total tumor removal than that in patients with subtotal tumor removal. The survival rates at 2 years and 6 years post surgery were higher in patients with total tumor removal than those in patients undergoing subtotal tumor removal (both P<0.05).

Radical microsurgical total resection seems to be an effective treatment for CP without strict limits on distinct feature of each individual tumor. The surgical approach depends on a direct and broader visualization of CP located in the midline with preservation of hypothalamic structures by identifying hypothalamic structures as landmarks. Patients could achieve good outcomes following total resection of CP.

To investigate the clinical significance of inflammatory reaction in craniopharyngiomas.

Antibody microarray was employed for detection of inflammatory cytokines expression in craniopharyngiomas and other common tumors in sellar region (including the pituitary adenoma, meningioma, pilocytic astrocytoma). The methods of qPCR and ELISA were further used for verifying the expression of inflammatory factors in each group. At the same time, the mouse brain neuron cell line (CATH.a) was treated with supernatant of the primary culture medium of craniopharyngiomas, and the apoptotic state of neurons was explored by flow cytometry.

The craniopharyngioma was more likely to have an inflammatory response than other sellar tumors. The results of antibody microarray showed that the relative expression levels of monocyte chemotactic protein-1 (MCP-1), interleukin 6 (IL-6) and interleukin 1 (IL-1) in adamantinomatous craniopharyngiomas (ACP) (7±1, 6±1, 8±2) were significantly higher than those in papillary craniopharyngiomas (PCP) (2±1, 2±1, 2±1), pilocytic astrocytomas (2±1, 1±0, 2±1), pituitary adenomas (1±0, 2±1, 2±1) and meningiomas (1±0, 1±0, 1±0) (all P<0.05). The qPCR results further verified that the transcriptional levels of 3 inflammatory factors mentioned above in ACP (180±24 pg/ml, 266±19 pg/ml, 243±31 pg/ml) were significantly higher than those in PCP (68 ±14 pg/ml, 98 ±29 pg/ml, 154±21 pg/ml), pilocytic astrocytomas (60±14 pg/ml, 142±29 pg/ml, 149±39 pg/ml), pituitary adenomas (180±24 pg/ml, 266±19 pg/ml, 134±27 pg/ml) and meningiomas (56±14 pg/ml, 89±19 pg/ml, 121±21 pg/ml) (allP<0.05), while Elisa results showed that three kinds of inflammatory factors in the ACP primary cell culture medium supernatant (168±19 pg/ml, 155±34 pg/ml, 228±31 pg/ml) were significantly higher than those in PCP (66±24 pg/ml, 89±19 pg/ml, 112±21 pg/ml) (allP<0.05). After CATH.a cells were stimulated by ACP medium supernatant, their apoptosis increased significantly, while the promotion of apoptosis by supernatant of PCP medium was not obvious. Immunohistochemistry results showed that the inflammatory response in ACP tissue was characterized by infiltration of macrophage inflammatory cells; and activated microglias were observed in the front area between tumor and the third ventricle floor.

Inflammatory reaction could be found in the craniopharyngioma and the levels of MCP-1, IL-6 and IL-1 were higher in ACP than PCP. The inflammatory reaction of craniopharyngioma seems toxic to CATH.a cells.

To assess the long-term outcomes of stereotactic intracystic brachytherapy for the treatment of cystic craniopharyngiomas.

A total of 141 consecutive patients with cystic craniopharyngioma treated by stereotactic intracystic phosphorus-32 at Department of Neurosurgery, Navy General Hospital of PLA from January 1996 to December 2015. There were 85 males and 56 females and the mean age was 40.1 years (range: 3-72 years). The calculated cumulative beta dose aimed at the inner surface of the cyst wall was 250 Gy.

All patients were followed up for 1.0-19.5 years with an average of 9.7±4.5 years. The decreased visual acuity had improved in 68.6% (59/86) of the patients in long-term result. The total tumor response rate was 86.5% (122 cases) including the total response accounting for 44.0% (62 cases), partial response accounting for 36.2% (51 cases) and stable response accounting for 6.3% (9 cases). The rate of no response was 13.5% (19 cases). The recurrence rate was 17% (24 cases). The side effects that occurred during follow-up period included worsening of visual acuity in 13 (9.2%), the third nerve palsy in 2 (1.4%), internal carotid artery occlusion in 1(0.7%), new-onset sexual dysfunction in 5 (3.5%), diabetes insipidus in 7 (5.0%), obesity in 12 (8.5%) and cognitive dysfunction in 10 (7.1%) patients, respectively. The late complication rate was 35.5% (50/141). The mean survival after treatment was 120 months. The actuarial 5-, 10- and 15-yr survival rates were 97.9% (138 cases), 92.9% (131 cases) and 89.3% (126 cases), respectively.

Stereotactic intracavitary brachytherapy is a valuable treatment alternative for cystic craniopharyngioma, particularly for patients with high surgical risk and recurrent tumors.

To explore the treatment efficacy of variable frequency stimulation (VFS) of subthalamic nucleus (STN) on freezing of gait (FOG) in patients with Parkinson's disease (PD).

Seven patients with PD were treated by VFS from May 2016 to July 2017 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University. Those patients had failed to improve their FOG with STN stimulation with high frequency stimulation (HFS). All patients were followed up at the outpatient clinic following VFS-STN stimulation. The third part of Unified Parkinson's Disease Rating Scale (UPDRS-Ⅲ) and Freezing of Gait Questionnaire (FOGQ) were employed to explore the treatment efficacy on the patient's motor and gait improvement.

In the early stage of VFS, the UPDRS-III score was significantly lower than that in baseline (23.3±8.1 vs. 45.3±7.2, P<0.05), while there was no significant difference for HFS (31.0±10.0 vs,P>0.05). The FOGQ score was significantly lower than that in baseline(11.7±6.1 vs. 17.3±5.1,P<0.05). The improvement rate of FOGQ was significantly higher for VHS than that for HFS [(45.6±22.7)% vs. (13.8±10.9)%,P<0.05]. The follow-up time was 3-12 months (mean, 7.3±4.0 months). At this time, the UPDRS-III score was (19.9±7.0) and the improvement rate was (56.2±15.8)%, which was significantly higher than that for HFS (P<0.05) but was not significantly different from that in the early stage. The FOGQ score was (11.0±5.7). The improvement rate of FOGQ was (48.0±19.4)%, which was significantly higher than that in HFS (P<0.05) but was not significantly different from that in the early stage.

For relief of FOG in patients with PD, the effect of VFS could be more remarkable and stable.

To evaluate the efficacy of deep brain stimulation in treatment of generalized dystonia.

A retrospective analysis was conducted on 20 patients who were implanted with a PINS device at Department of Neurosurgery, Peking Union Medical College Hospital from July 2013 to September 2016. Among them, 13 cases were primary generalized dystonia and 7 cases had secondary generalized dystonia. The scores of Burke-Fahn-Marsden dystonia movement/disability were documented at baseline and at 3, 6, 12 months of follow-up. The rate of improvement was assessed at 12 months postoperatively to evaluate the effectiveness of the PINS DBS system. Comparison was conducted regarding the improvement of scores between groups with different targets and parameters of stimulation.

Compared with preoperative state, the improvement rates of median BFMDRS-M (Burke-Fahn-Marsden Dystonia Rating Scale-Movement) scores were 86.1% and 43.9% in patients with primary and secondary systemic dystonia at 12 months post surgery, respectively. The improvement rates of median BFMDRS-D (Burke-Fahn-Marsden Dystonia Rating Scale-Disability) scores were 66.7% and 44.4%, respectively, and there was significant difference between pre- and post-operative states (both P<0.001). There was no significant difference between the efficacy of GPi-DBS and that of STN-DBS in the treatment of systemic dystonia (P>0.05). However, the stimulation parameters of STN-DBS group were significantly lower than those of GPi-DBS group (allP<0.05) in terms of voltage, frequency and amplitude. The follow-up lasted 12-48 months. Only 2 cases developed dyskinesia as the adverse event which resolved or obtained improvement by the end of the study. No adverse effects were classified as severe.

The deep brain stimulation system domestically manufactured could significantly improve the symptoms of generalized dystonia and demonstrates safety and effectiveness.

To evaluate the long-term safety and efficacy of subthalamic nucleus deep brain stimulation (STN-DBS) with a PINS stimulator in Parkinson's disease (PD).

Fifty patients received PINS device implantation in the subthalamic nucleus from November 2009 to August 2012 at Neurosurgery Department of Beijing Tiantan Hospital, Capital Medical University and were retrospectively enrolled into this study. The effects of stimulation on motor score, activities of daily living, the levodopa-equivalent dose, and the side effects were analyzed for all 50 patients with PD undergoing bilateral STN-DBS based on the Unified Parkinson's Disease Rating Scale (UPDRS). The scores were collected at baseline in two conditions (off medication) and at 6 months, 1, 2, and 5 years of follow-up with stimulation in the absence or presence of medication.

The 50 patients were followed up for 5.0-7.5 years. At 6 months, 1, 2, and 5 years of follow-up, our results showed a significant decrease from baseline in both activities of daily living and motor scores (P<0.01); the daily levodopa-equivalent dose decreased compared with baseline (P<0.01). In the condition of medication off, the UPDRS Ⅲ scores decreased by 71%, 69%, 69%, 62% at 6 months, 1 year, 2 years, 5 years, respectively; and the improvement rates of UPDRS Ⅱ scores were 71%, 71%, 71%, 62%, at 6 months, 1 year, 2 years, 5 years, respectively. The daily levodopa-equivalent dose decreased by 31%, 37%, 35%, 27% at 6 months, 1 year, 2 years, 5 years, respectively. There was no death or intracranial hemorrhage in the study. Five patients suffered from transient mental and psychiatric disturbances. Two cases of infection, 1 case of cerebrospinal fluid leakage, 1 case of ptosis, and 1 case of dysphonia were observed during the follow-up. The 2 cases with preoperative dyskinesia had no significant improvement including 1 reported disappearance of dyskinesia and 1 with remaining dyskinesia following adjustment of programming parameters.

STN-DBS with the PINS device could significantly improve the motor symptoms and life quality of PD patients, which demonstrated safety and efficacy in long-term study.

deep brain stimulation (DBS) is an effective surgical treatment for Parkinson's disease (PD)^[1,2,3]。 Clinical studies have shown that domestic DBS stimulator can significantly improve the exercise (Ⅲ) score and daily living ability (Ⅳ) score of the unified parkinson's disease rating scale (UPDRS) in the "on" and "off" periods of PD patients, and prolong the "on" period^[4,5]。 Common targets of DBS in the treatment of PD include subthalamic nucleus (STN) and globus pallidus internus (GPi). At present, STN is mostly used in China. Although STN-DBS can significantly improve the symptoms of tremor and stiffness in PD patients, there are still some limitations on the improvement of dyskinetic symptoms. Therefore, this study used domestic DBS stimulator and GPi as the target to treat PD patients with dysmotor symptoms, and achieved good efficacy, which is reported as follows.

deep brain stimulation (DBS) has become a well-recognized neurosurgical treatment for Parkinson's disease, dystonia, essential tremor and other intractable movement disorders^[1,2,3]。 With the entry of DBS into China's medical market and the clinical launch of domestic DBS systems, the number of domestic patients receiving this therapy continues to grow^[4]。 There are many manufacturers and various product models of DBS nerve stimulators, namely implanted pulse generators (IPGs), currently on the market. Clinically, when imported IPGs are replaced with domestic models or domestic IPGs are replaced with new models, because the DBS extension leads of different manufacturers and the extension leads of the old models are not suitable for the newly implanted IPG connection ends, it is usually necessary to replace them with new extension leads. Improper operation may lead to hardware-related complications such as damage to the original implanted electrode, slipping of the extension lead, or bowstring phenomenon^[5,6]。 From April 2014 to August 2017, the Department of Functional Neurosurgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, replaced extension leads simultaneously in 22 patients who underwent domestic DBS IPG replacement surgery. Special lead electrode connection end protection and fixation methods and extension lead tunnel preparation methods were adopted. No complications related to surgical operation occurred in any case, which are reported as follows.

To analyze the resection methods of the 4th ventricle tumor resection and clinical effect through the telovelar approach and to explore the opening portion of the tela choroidea and the inferior medullary velum based on the characteristics of tumors.

The clinical data of 21 patients in the Neurosurgery Department of Nanjing Brain Hospital from January 2013 to December 2016 who underwent resection of the 4th ventricle tumors through telovelar approach were retrospectively analyzed. Among them, unilateral approach was employed in 18 patients and bilateral approaches in 3 cases.

Among the 21 patients, total resection was achieved in 17 cases and subtotal resection in 4 cases. The pathological results demonstrated the ependymoma in 12 cases, cavernoma in 3 cases, hemoblastoma in 2 cases, medulloblastoma in 2 cases and cholesteatoma in 2 cases. There was no death. The patients were followed up from 3 months to 2 years. The patients recovered well and had no long-term complications related to surgery.

The exposure of the 4th ventricle seems satisfactory through the telovelar approach without splitting the vermis. In most cases, the unilateral telovelar approach with merely the tela choroidea incision is adequate. That surgical procedure using the normal anatomical fissures could minimize brain injury and effectively prevent postoperative complications.

To investigate the technical details, safety, feasibility and clinical results of endovascular recanalization for non-acute internal carotid artery occlusion.

A retrospective analysis was conducted in 13 patients with non-acute internal carotid artery occlusion who underwent endovascular revascularization from June 2015 to May 2016 at Department of Neurosurgery, TEDA Hospital. The technical aspects of the procedure and angiographic predictors of success were analyzed.

The occluded artery was successfully recanalized in 12 of 13 patients (92%). There was no procedural or new cerebral ischemic event except for 1 case of symptomatic intracranial hemorrhage and 1 case of asymptomatic intracranial hemorrhage, which occurred post procedure and had no neurologic sequelae. CT perfusion was performed in 7 cases after operation, and the delay of perfusion was significantly improved. No new cerebral ischemic event was observed during the follow-up lasting from 3 months to 1 year. Symptoms were improved during follow-up in all patients with successful recanalization, and the improvement rate was 100%.

This preliminary study seems to demonstrate the safety and effectiveness of endovascular recanalization technique in the treatment of non-acute internal carotid artery occlusion, and the long-term effect needs further investigation. Complete preoperative evaluation and individualized technique of recanalization could help improve the surgical success rate.

To explore the application of transradial artery (TRA) approach in cerebral angiography.

A total of 300 patients, at Department of Neurosurgery of Wenzhou Central Hospital from September 2015 to May 2016, underwent cerebral angiography and were divided into TRA group (n=152) and transfemoral artery (TFA) group (n=148). The complication rates and image quality scores were compared between the groups.

In both groups, 1 patient suffered from cerebral infarction within 3 days. Two patients suffered from transient ischemic attach (TIA) in TRA group and 3 in TFA. No patient reported myocardial infarction in either group. There was no significant difference between the 2 groups (P>0.05). In TRA group, 5 patients had hematoma at the access site and 17 in TFA. One patient reported vessel dissection in TRA group and 10 in TFA. The occurrence rates of hematoma at the access site and vessel dissection in TRA group were significantly lower than those in TFA (P<0.05). No arteriovenous fistula occurred in TRA group and 1 was observed in TFA. No vessel occlusion occurred in either group. There was no significant difference between the groups (P>0.05). The mean score of the image quality of all 4 arteries was 11.58±0.90 in TRA group and 11.71±1.10 in TFA group. There was no significant difference between the 2 groups (P>0.05). The mean score of each artery was as follows: RCCA (2.96±0.23 in TRA; 2.94±0.35 in TFA), LCCA (2.93±0.30 in TRA; 2.97±0.16 in TFA), RVA (2.92±0.29 in TRA; 2.82±0.53 in TFA) and LVA (2.76±0.62 in TRA; 2.97±0.16 in TFA). The overall scores of all four arteries and the subscores of RCCA, LCCA and RVA had no significant difference between the 2 groups (P>0.05). The subscore of RVA of type Ⅲ aortic patients in TRA group was significantly higher than that in TFA group (P<0.05).

The image quality of TRA is comparable to that of TFA with low rate of hematoma at the access site and more comforts of the patient. Selective RCCA and RVA angiography may be more efficient in Type Ⅲ aortic arch via TRA.

hemangioblastoma (HB) is a benign vascular tumor composed of dense vascular plexus and tumor stromal cells, accounting for 2% of intracranial tumors and 10% of posterior fossa tumors. Clinically, it can be divided into sporadic HB and familial HB with genetic background^[1]。 Familial HB patients are associated with retinal hemangioma, renal cyst, pancreatic cyst, etc., which is called VHL (Von Hippel-Lindau, VHL) disease, and is closely related to VHL gene mutation^[2]。 Five patients with HB in the same family were treated in the Department of Neurosurgery, Affiliated Cancer Hospital of Zhengzhou University from July 1990 to April 2016. The reports are as follows.

To establish a method for detecting the PTPRZ1-MET fusion gene in patients with glioma via fluorescence in situ hybridization (FISH), and to explore its feasibility and clinical application.

The expression of PTPRZ1-MET fusion gene in glioma patients was detected by two-color FISH method. The result comparison was performed between FISH and polymerase chain reaction/Sanger sequencing (PCR/Sanger) to analyze the correlation of these two methods.

The results of PCR/Sanger and FISH methods showed that the percentage of PTPRZ1-MET fusion gene positive cells was greater than 20% in patients defined as PTPRZ1-MET positive with 30-cycle-PCR/Sanger; the percentage in patients defined as PTPRZ1-MET positive with 50-cycle-PCR/Sanger was about 10%; and the percentage was less than 5% in patients defined as PTPRZ1-MET negative in PCR/Sanger method. There was significant difference between any two groups (all P<0.05).

The detection of PTPRZ1-MET fusion gene in glioma patients with FISH method seems consistent with that of PCR/Sanger method, which indicates that the FISH method could serve as a supplementary tool in initial screening for the patient's diagnosis.

To explore the effects of the lentivirus-mediated over-expression of the IDH1-R132H mutant gene on the tumorsphere formation of glioma cells LN229.

The recombinant lentivirus vector IDH1 R132H mutant was packaged and then infected LN229, U87 and H4 glioma cell lines with lentivirus particles. Stably infected cell lines were established using puromycin resistance selection. The expression of IDH1 R132H mutant was observed using fluorescence microscope and estimated by Western blot. For evaluation of the abilities of LN229 cell to form tumorspheres after the transfection of IDH1 R132H mutant, a sphere growth assay was applied by culturing cells in serum-free medium plus B27 supplement, EGF and bFGF.

Sanger sequencing revealed that we got an IDH1 R132H mutant lentiviral expression vector successfully and green fluorescence was observed by fluorescence microscopy. Western blot analyses revealed protein expression of IDH1 R132H mutant in cells transfected with IDH1 R132H mutant which was absent in the control groups.Moreover, the sphere growth assay showed that the cells transfected with IDH1 R132H were recombined with lentivirus vectors and, compared with the control group, had lower tumorsphere formation abilities(P<0.05).

The expression of recombinant IDH1 R132H mutant vector mediated by lentivirus inhibits tumorsphere formation in glioma cells LN229, which suggests a potential role in the stemness of gliomas.

Puncture and drainage of intracranial hematoma has been widely used in clinical practice because it avoids further damage caused by incision, pulling and electrocautery of brain tissue. Since 2003, the neurosurgery department of Ganzhou Municipal Hospital has performed intracranial hematoma puncture and drainage by using brain CT patch to locate the best puncture point through CT scan, and achieved good therapeutic effect^[1]。 However, there are still some defects in the operation, such as the difficulty to grasp the puncture direction and angle after disinfection and towel spreading. Therefore, from January 2013 to November 2015, our hospital developed a brain puncture auxiliary frame on the basis of brain CT positioning patch, and performed intracranial hematoma puncture and drainage in 38 patients with intracranial hemorrhage with brain puncture auxiliary frame and brain CT positioning patch, and the curative effect was satisfactory, which is reported as follows.

hemangioblastoma (HB) is a benign tumor that occurs mostly in the cerebellum^[1]。 Von Hippel-Lindau disease (VHL) is a rare autosomal dominant genetic disorder involving multiple systems. Familial HB is the most common characteristic manifestation of VHL, which is mainly manifested as HB involving cerebellum, spinal cord, kidney, spleen and retina^[2,3]。 In February 2017, the Department of Neurosurgery, Fuxing Hospital affiliated to Capital Medical University admitted a patient with recurrent familial HB to explore the mechanism, clinical characteristics, diagnosis and treatment methods of the disease.

Neurocutaneous melanosis, first reported by Professor Von Rokitanski in 1861, is a rare neurocutaneous syndrome with little difference in male to female ratios. Is a genetic disease caused by dysplasia of the embryonic neuroectoderm, characterized by large or multiple congenital melanocytic nevus and a large number of melanomas in the central nervous system^[1]。 Patients usually have skin melanotic nevus at birth, and then neurological symptoms such as epileptic seizures, intracranial hypertension, mental retardation, cranial and spinal nerve damage, etc. The disease progresses with gait disorders, and then loses the ability to walk. Most symptoms appear before the age of 2^[2]。 This article reports a child with neurocutaneous melanosis accompanied by temporal lobe epilepsy admitted to the Epilepsy Center of Yuquan Hospital of Tsinghua University in April 2016.

Plasma cell tumors are clonal plasma cell proliferation. Intracranial plasma cell tumors refer to plasma cell tumors that invade the skull, meninges and brain^[1]。 A patient with solitary myeloplasmacytoma of the skull was admitted to the Department of Neurosurgery of Huaihe Hospital of Henan University in January 2014. The report is as follows.

Maltese brucellosis is a zoonotic infectious allergic disease caused by Brucella infection. The main source of infection is sick animals and carrier animals. The disease spreads through the digestive tract, or through skin and mucous membrane contact, respiratory tract and other routes, and infects the human body can involve all systems in the whole body^[1,2]。 At present, brucellosis with intraspinal infectious granuloma as the main clinical manifestation is rarely reported at home and abroad. This article reports a case of Maltese Brucella intraspinal infectious granuloma, which provides a basis for clinical diagnosis and treatment.

Craniopharyngioma accounts for about 2% ~5% of primary intracranial tumors and 5.6% ~15% of children's intracranial tumors^[1]The annual population incidence rate is 1.3 per 1 million. Although the histological manifestations are benign tumors, the quality of life is often seriously affected by the damage of important structures such as optic nerve, hypothalamus and pituitary gland. Because of the deep location of the tumor and the complex and important adjacent structure, surgical treatment is extremely challenging^[2], resulting in low total resection rate, high recurrence rate and complication rate, low quality of life of patients, and its clinical efficacy still needs to be further improved. This article reviews the pathological classification, clinical classification and treatment modalities of craniopharyngioma.

spinal dural arteriovenous fistula (SDAVF) is an extremely rare disease, with an annual incidence rate of about 5~10/1 million^[1]The incidence of middle-aged and elderly men is high, with a male-female ratio of about 4: 1^[2]； It is the most common type of spinal vascular malformations, accounting for about 80%^[3,4]。 McCutcheon et al.^[5]Studies have confirmed that SDAVF is the direct communication between the arteries of the dura and the drainage vein. The drainage vein transmits pressure from the blood supply artery to the coronary venous plexus of the spinal cord, resulting in spinal venous hypertension, congestion and edema of the spinal cord tissue and spinal cord dysfunction^[6,7,8]。 In the early stage, SDAVF patients mainly showed sensory and motor abnormalities of both lower limbs. With the development of the disease, they were often accompanied by defecation and urination disorders, and male patients also had sexual dysfunction^[3]。 Due to the lack of specificity of the above symptoms, the early diagnosis of SDAVF is difficult, and it is often easily confused with spinal degenerative diseases, spinal cord tumors, myelitis, subacute combined degeneration of spinal cord and other diseases, resulting in misdiagnosis and missed diagnosis^[9,10,11]。 At present, with the popularization of spinal cord MRI and angiography, the diagnosis rate of SDAVF has improved significantly, and two mature treatment methods, microsurgery and endovascular embolization, have gradually formed. However, most patients have obvious spinal cord function before treatment. Damage, its prognosis is not ideal. A meta-analysis of the prognosis of patients with SDAVF showed that the symptom improvement rate of patients with SDAVF after surgery was only 55%, and the improvement rate of defecation and urinary function was only 38%^[12]。 In recent years, more and more scholars have begun to pay attention to the related factors affecting the prognosis of patients with SDAVF. This article summarizes the related studies on the prognostic factors of SDAVF patients in recent years as follows.

Primary hemifacial spasm (HFS) occurs more often than in adulthood, and is more common in unilateral onset. It is mainly manifested as paroxysmal involuntary twitching of the facial muscle, and the course of the disease is prolonged. Sometimes it can lead to smaller palpebral fissure and skewed mouth corners, which seriously affects the quality of life of patients. Because of the large population base in China, the incidence rate of this disease is about 18.6/100,000 population, and the number of patients is huge, so the diagnosis and treatment of primary HFS is of great significance.