Volume 34 · Issue 02 · 2018

In the world, reducing the high disability and death rate of severe traumatic brain injury (sTBI) has been the direction of medical efforts. China has a vast territory, and the differences in region, economy, culture and concept lead to great differences in the clinical treatment of sTBI. Especially for some trauma centers below the county level, there is still a lot of room for improvement in the treatment of sTBI. In order to standardize care and guide treatment, the Brain Trauma Foundation (BTF) published the latest treatment guidelines for sTBI in 2016, the Guidelines for the Treatment of Severe Craniocerebral Trauma (Fourth Edition)^[1]。 Immediately, information platforms such as Chinese Journal of Neurosurgery successively released relevant interpretations of the new guidelines in 2017^[2]。 This article combines the new guidelines and the author's experience and lessons on clinical management of sTBI for more than 30 years, and focuses on the practical problems encountered by clinicians in the whole medical management of sTBI and the specific measures taken, with the purpose of promoting and promoting the standardization of medical management of sTBI in China.

The annual incidence rate of glioma in China is (3~6.4) /100,000, and the annual death number reaches 30,000^[1,2]。 The incidence rate of malignant glioma is 5.8/100,000, and the 5-year mortality rate is second only to pancreatic cancer and lung cancer among systemic tumors^[3]。 Among the primary malignant central nervous system (CNS) tumors, glioblastoma (GBM, WHO grade IV) has the highest incidence, accounting for 46.6%, about 3.20/100,000; Followed by diffuse astrocytoma with an incidence of 0.51/100,000^[4]。

To reveal the relationship of outcome to intracranial pressure in traumatic brain injury patients.

Clinical data of 50 patients with traumatic brain injury (TBI) admitted to Neurosurgical Intensive Care Unit, Renji Hospital, Shanghai Jiaotong University School of Medicine from November 2016 to October 2017 were retrospectively analyzed. All of them received intracranial pressure (ICP) and arterial blood pressure (ABP) monitoring and the ICP-derived parameters were monitored by Neumatic DCR system. The 50 TBI patients were divided into the group of poor prognosis [Glasgow Outcome Scale (GOS) Ⅰ-Ⅱ, n=20] and the group of good prognosis (GOS Ⅲ-Ⅴ, n=30) according to GOS at discharge. We analyzed and compared various ICP-derived parameters between those two groups. The receiver operating characteristic (ROC) curve was used to assess the outcome predictive power of the parameters.

(1) Compared with those in group of good prognosis, patients in poor prognosis group tended to have higher ICP (26.2±13.4 mmHg vs. 14.0±5.6 mmHg), higher pressure reactivity index (PRx, 0.48±0.21 vs. 0.12±0.08) and closer ICP-ABP wave amplitude correlation (IAAC, 0.14 vs. 0.01), while their cerebral perfusion pressure (CPP) was lower than control (48.9±19.9 mmHg vs. 81.1±6.9 mmHg, all P<0.01). The difference in RAP (correlation coefficient between AMP amplitude and mean ICP) between the two groups was not statistically significant (P>0.05). It was suggested by multiple logistic regression that ICP (OR=2.187, 95%CI: 1.079-4.431, P=0.031) and PRx (OR=21.608, 95%CI: 3.012-155.014, P=0.002)were two risk factors associated with poor outcome in TBI patients. (2) ICP dose in poor prognosis group under either threshold of 22 mmHg (D_ICP22) and 20 mmHg (D_ICP20) was higher than that in good prognosis group (P<0.05). The area under curve (AUC) of ROC was 0.70 for D_ICP20 and 0.71 for D_ICP22. PRx dose in poor prognosis group under either threshold of 0.25 (D_PRx0.25) and 0.05 (D_PRx0.05) was higher than that in good prognosis group (P<0.05). The area under curve (AUC) of ROC was 0.97 for D_PRx0.25 and 0.96 for D_PRx0.05.

ICP and PRx are two risk factors associated with poor outcome in TBI patients. Both ICP and PRx doses could help predict the outcome of death or vegetative state in TBI patients and PRx dose seems to have a relatively higher accuracy.

To investigate the incidence and risk factors of hospital acquired pneumonia (HAP) among patients with severe traumatic brain injury (TBI).

The clinical and imaging data of 114 adult patients diagnosed as severe TBI were retrospectively reviewed who underwent treatment at Department of Neurosurgery, Beijing Tiantan Hospital, from March 2016 to March 2017. Factors analyzed included the age, gender, mechanisms of injury, CT scan before admission, GCS (Glasgow Coma Scale) scores, pupil changes, tracheal intubation or tracheostomy, central nervous system (CNS) infection, duration of mechanical ventilation and antibiotic drug use. Comparison of variables between groups with tracheal intubation and tracheostomy, early and late tracheostomy were conducted.

The incidence of HAP after admission was 23.8%. Past history of pulmonary diseases, tracheal manipulation, CNS infection, diffuse axonal injury were considered as risk factors of HAP. Patients in tracheal intubation group had significantly fewer days of ventilator use and shorter stay at hospital, lower incidence of HAP compared with tracheostomy group. Patients with early tracheostomy had lower incidence of skull fracture, shorter hospital stay and less expenses, while their incidence of HAP and outcomes were not significantly different from those with late tracheostomy.

Pulmonary diseases, related tracheal manipulation, CNS infection and diffuse axonal injury could be the risk factors for HAP in patients with severe TBI. Early tracheostomy might not reduce the risk of HAP, while it could significantly decrease the incidence of skull fracture, the length of hospital stay, antibiotic usage and medical expenses.

To explore the incidence and related risk factors for stress ulcer (SU) bleeding in neurocritical patients at multiple centers.

We retrospectively analyzed the data of neurocritical patients at Department of Neurosurgery of 12 hospitals in China, which consisted of the patient’s age, diagnosis, past medical history and 17 potential associated risk factors including duration of mechanical ventilation, gastrointestinal (GI) ulcer or bleeding history, GCS (Glasgow coma scale), duration of neurosurgical operation, intracranial infection, stroke, traumatic brain injury, intracerebral hemorrhage, history of brain tumor operation, resuscitation of heart, lung and brain, shock, hepatic failure, renal failure, multiple organ failure, acid base imbalance, high dose of corticosteroids, administration of anticoagulant and antiplatelet drugs. Univariate analysis was conducted with Log-rank and multivariate analysis was performed using the Cox proportional hazard model.

A total of 1 416 patients were enrolled into this study, among whom 182 cases (12.9%, 95% CI: 11.2-14.7) developed SU. The incidence of GI bleeding (10 cases) was 0.7% (95% CI: 0.3-1.3). Multivariate analysis showed that mechanical ventilation lasting over 48 hours (RR=0.526, 95% CI: 0.381-0.726, P<0.0001) and use of anticoagulants (RR=0.458, 95% CI: 0.327-0.643, P<0.0001) were independent risk factors for SU bleeding in neurocritical patients. The patients with history of GI ulcer or bleeding (RR=0.082, 95% CI: 0.016-0.411, P=0.0023) had higher chance of developing SU bleeding.

SU bleeding is not uncommon in neurocritical patients and cautions should be warranted particularly for those with risk factors.

To evaluate the prognostic value of coagulation tests for in-hospital mortality of patients with traumatic brain injury (TBI).

We retrospectively analyzed the data of TBI patients who were admitted to Neurosurgery Department of Huashan Hospital, Fudan University, from December 2004 to June 2015. Two models were developed based on the admission characteristics. Model A included predictors such as age, Glasgow Coma Scale (GCS) score, pupil reactivity, type of injury, hemoglobin and glucose levels. Model B included the predictors in model A as well as coagulation test results. Performance of the models was assessed according to discrimination by means of the c statistic (equivalent to the area under the receiver operator characteristic curve) and calibration using the Hosmer-Lemeshow (H-L) goodness-of-fit test.

A total of 2, 319 patients were enrolled into this study. Among them, 432 (18.63%) patients developed coagulopathy after TBI. The prevalence of acute traumatic coagulopathy was associated with the severity of brain injury. The percentage of platelet count<100×10⁹/L, international normalized ratio (INR)>1.25, prothrombin time (PT)>14 sec, activated partial thromboplastin time (APTT)>36 sec, D-dimer>5 mg/L and fibrinogen (FIB)<1.5 g/L were also closely related to the severity of brain injury (AllP<0.05). Age, pupillary reactivity, GCS score, epidural hematoma (EDH), and glucose levels were independent prognostic factors for in-hospital mortality in model A. Age, pupillary reactivity, GCS score, EDH, glucose levels, INR>1.25 and APTT>36 sec exhibited strong prognostic values in model B (P<0.05). Discrimination and calibration were good for the development group in both prediction models. However, the external validation test showed that calibration was better in model B than in model A for patients from the validation population (Hosmer-Lemeshow test,P=0.152 vs. P=0.046, respectively).

The coagulation function could serve as independent prognostic factor for in-hospital mortality of patients with traumatic brain injury. Incorporating the coagulation tests might improve the predictive power in relevant model.

To explore the clinical outcomes and therapeutic methods of neurosurgical intensive care for patients with severe aneurysmal subarachnoid hemorrhage (aSAH).

The clinical data of 160 patients with severe aSAH were retrospectively analyzed who were admitted to Neurosurgical ICU of Neurosurgery Department at Xuanwu Hospital of Capital Medical University from March 2015 to March 2017. All patients were treated with bundle therapy based on step-wise protocol under multimodal monitoring to protect brain against damage. The follow-up was carried on at outpatient department or by phone at 30 d after discharge. The incidence of complications during treatment and GOS (glasgow outcome scale) were documented. The incidence of complications and the risk factors related to the prognosis were analyzed.

The length of stay (LOS) of 160 patients at ICU was 9-42 d (mean: 16.9±7.5 d). In this series, cerebral vasospasm were reported in 38.1% (61/160) of the patients, cerebral infarction in 25% (40/160), pulmonary infection in 60.6% (97/160), abnormal liver function in 31.3% (50/160), hypoproteinemia in 58.8% (94/160), anemia in 51.9% (83/160), and electrolyte imbalance in 78.1% (125/160) of the patients. The incidence of most complications, including lung infection, liver dysfunction, hypoproteinemia and anemia, was elevated with the increase of Hunt-Hess scale (P<0.05). 10 deaths during hospitalization.150 patients were followed up, 4 deaths during follow-up.Among 160 patients, 41.3%(66/160) had favorable ourcomes and 58.7%(94/160) had unfavorable ourcomes.Multivariate Logistic regression analysis showed that Hunt-Hess scale (OR=0.117, 95% CI: 0.054-0.252, P<0.001) and electrolyte disturbance (OR=0.306, 95% CI: 0.108-0.867, P=0.026) were major risk factors related to the prognosis of patients.

The bundle therapy based on step-wise protocol under multimodal monitoring could help improve the outcomes of patients with severe aSAH at neurosurgical intensive care unit.

To investigate the clinical characteristics, diagnosis and treatment strategies of post-traumatic occlusion of internal carotid artery.

The clinical data of 3 patients with post-traumatic occlusion of internal carotid artery were analyzed retrospectively who underwent treatment at neurological intensive care unit of Affiliated Hospital of Logistics University of Chinese People’s Armed Police Forces from April 2016 to March 2017.

Among the 3 patients with massive cerebral infarction treated successfully, 1 underwent conservative treatment and the other 2 received decompressive craniectomy and internal decompression. Followed up for 5-12 months, the patients showed the GOS (Glasgow outcome scale) score of 4 in 1 case and 3 in 2 cases.

Post-traumatic occlusion of internal carotid artery is relatively rare and easy to be misdiagnosed, which often results in massive cerebral infarction and its prognosis seems to be very poor. Reasonable application of MRI, MRA, CTA and DSA could be helpful for early diagnosis. The major treatment includes early antiplatelet therapy, endovascular treatment and large decompressive craniectomy. Early diagnosis and treatment are important to its prognosis.

To investigate clinical features and surgical treatment of various types of recurrent acoustic neuromas.

The clinical data of 29 patients with recurrent acoustic neuromas were analyzed retrospectively who were admitted to Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2010 to October 2016. Those cases recurring following primary total removal were classified as total resection relapse group (11 cases) and those recurring after incomplete resection were classified as non-total resection relapse group (18 cases). Multiple parameters were compared including the mean age, the mean maximal diameter of primary and recurrent tumors, cystic/solid ratio, re-operation interval, postoperative complication, facial nerve function (House-Brackmann facial nerve function grading system) between the two groups.

The mean age in the total resection relapse group was higher than that in non-total resection relapse group (52.2±10.8 years vs. 33.0±5.5 years, P<0.05), and the mean re-operation interval of the former is greater than that of the latter (93.3±30.0 monthsvs. 45.0±15.6 months, P<0.001). There was no difference in the mean maximal diameter of primary or recurrent tumor, cystic/solid ratio, complication rate, reservation rate of good facial nerve function between the two groups (allP>0.05). The follow-up time of 29 cases ranged from 3 to 37 months, and the mean follow-up time was 11.7±3.1 months. Among them, the tumors in 28 cases were totally removed and the remaining 1 case underwent near-total resection. The facial nerves were anatomically preserved in 27 cases (93%, 27/29), and the practical hearing was preserved in 2 cases (7%, 2/29). The good reservation rate of facial nerve function was 41% (12/29).

The mean re-operation interval after incomplete removal of acoustic neuroma is significantly shorter than that following total removal. In terms of preservation of neurological function, total resection of tumors in primary operation seems to be optimal for patients. Early surgery might be suggested for recurrent acoustic neuromas.

To discuss the clinical characteristics and prognostic factors of primary spinal cord glioblastomas.

A total of 14 patients with primary spinal cord glioblastomas who underwent surgical treatment from January 2008 to December 2015 at Department of Neurosurgery, West China Hospital, Sichuan University were retrospectively analyzed. The clinical features were summarized and influencing factors of outcomes were investigated.

Among the 14 patients, 4 received gross total resection, 5 received partial resection, and biopsy was conducted in 5 cases. Nine cases received postoperative radiotherapy and chemotherapy, 3 received chemotherapy only, and 2 did not undergo radiotherapy or chemotherapy. The median follow-up period was 15 months (range: 5-26 months), and the 1- and 2-year survival rates were 79% (11/14) and 7% (1/14), respectively. The median overall survival (OS) was 15 months, and the median progression free survival (PFS) was 8 months. Log-rank univariate analysis showed that age and postoperative radiotherapy were influencing factors for OS and PFS (all P<0.05). Preoperative Karnofsky performance scale (KPS) was the influencing factor of OS (P=0.033) rather than PFS (P=0.106). The OS and PFS had no correlation with gender, tumor resection degree or pathological results (all P>0.05). Univariate Cox regression analysis showed that age and postoperative radiotherapy affected the OS and PFS of the patients (allP<0.05), while preoperative KPS score only affected OS (P=0.046). Multivariate Cox stepwise regression analysis showed that postoperative radiotherapy was the only factor affecting OS and PFS (all P<0.05) and the survival time in the radiotherapy group was longer than that in the non-radiotherapy group.

Primary spinal cord glioblastoma is rare and its prognosis seems poor. The extent of tumor resection has no correlation with the outcome. Postoperative radiotherapy could prolong the survival of patients to certain extent.

To study the timing of surgical resection of congenital dermal sinus complicated with the infection of central nervous system.

We retrospectively analyzed 10 cases of congenital dermal sinus complicated with the infection of central nervous system admitted to Department of Neurosurgery, Shanghai Children’s Medical Center between October 2005 to December 2015. Among them, 5 cases had appropriate antibiotic administration prior to operation and underwent surgery immediately after infection was controlled. The other 5 cases received surgical treatment when the infection was not controlled.

Among the 10 cases, infection was effectively controlled and no recurrence was observed. Compared with that in patients with uncontrolled infection, the average operative time was reduced by 1.3±0.3 hours in 5 cases who had the operation after the infection was preliminarily controlled. The number of opened vertebral segments was less and the recovery of neurological function was better in patients with controlled infection. The average length of hospitalization was 16 days longer in infection-controlled than infection-uncontrolled patients.

Appropriate antibiotic administration prior to operation and immediate surgery following controlled infection could reduce operative difficulty and surgical trauma and facilitate recovery of neurological function. However, it might increase length of hospitalization and treatment costs.

To explore the potential reasons of cerebral infarction caused by accidental incarceration of aneurysm-adjacent branches with temporary clips, and to give guidance to the appropriate application of temporary clips.

A retrospective analysis was conducted on the clinical data of 10 patients with accidental incarceration of branches of parent artery or aneurysm-adjacent perforator vessels who were admitted to Department of Neurosurgery of Fuzhou General Hospital from January 2004 to December 2016. Under microscopes, we observed the definite lesions of branches and perforator vessels during the procedures, features of temporary clips and the intraoperative procedure, and postoperative cerebral infarction with varying degrees in corresponding territories. Two cases of posterior communicating artery aneurysm and 2 cases of carotid bifurcation aneurysm were found on the extracranial superior mesenteric artery adventitia with varying degrees of atherosclerosis, misclipping occurred at the anterior pre-choroidal artery, recurrent artery of Heubner and lenticulostraiate artery. For 4 cases of anterior communicating artery aneurysms and 2 cases of middle cerebral artery aneurysm, mis-clipping was found at A1 or A2 and M1 segments adjacent to perforation.

Among the 10 patients, CT review 2-4 days post surgery demonstrated cerebral infarction with varying degrees adjacent to the aneurysm branches, perforating branch of blood supply. Disturbance of consciousness occurred in 2 cases. Compared with preoperative state, short-term significant decrease in strength of limb muscles was observed in 5 cases, incomplete motor aphasia in 1 and asymptomatic cerebral infarction in 2. At follow-up ranging from 4 months to 3 years, 2 cases reported dementia and 2 cases had permanent hemiplegia, out of which 3 were disabling and needed long-term care.

Cerebral infarction caused by accidental incarceration of branches or perforator vessels with temporary clips could be related not only to the incarceration duration, age and vascular sclerosis, but also to the over-contraction of small blood vessels and the closing force of a temporary clip. Therefore, caution should be warranted regarding those factors in the use of temporary clips.

To investigate the correlation between hemifacial spasm (HFS) with different offending vessels and essential hypertension (HTN).

A retrospective analysis was conducted on 267 patients of HFS who underwent microvascular decompression (MVD) from November 2015 to April 2017 at Neurosurgery Department of Affiliated Hospital of Logistics University of Chinese People’s Armed Police Force. A total of 88 cases had the comorbidity of HTN (HTN group), and 179 cases had no HTN (non-HTN group). The HFS patients were divided into 4 groups based on the offending vessels: anterior inferior cerebellar artery (AICA) (n=114), posterior inferior cerebellar artery (PICA) (n=85), vertebral artery (VA) (n=49) and multiple artery (MA) groups (n=19). Patients with HTN were also divided into 4 groups according to the offending vessels: HTN-AICA (n=32), HTN-PICA group (n=24), HTN-VA (n=22) and HTN-MA groups (n=10). The classifications as above were to analyze influencing factor of the incidence of HTN among HFS patients and correlation between HFS with different offending vessels and HTN by comparing the clinical data between HTN and non-HTN groups.

There was no statistical difference in the sex, side of HFS, course of HFS, effect and recurrence at follow-up between HTN and non-HTN groups (all P >0.05). The patient’s age and onset age of HFS in HTN group was significantly higher than those in non-HTN group (both P <0.001). Logistic analysis showed that the HFS onset age was the influencing factor for the incidence of HTN ( P <0.001), and the risk of HTN was elevated by 1.098 times as the HFS onset age increased by 1 year. The incidences of HTN in MA and VA groups were higher than those in AICA and PICA groups (52.6%, 44.9%, 28.1% and 28.2%, respectively, P =0.035). There was no statistical difference in the age, sex, HFS onset age and course of HFS, HTN onset age and course of HTN between the 4 HTN groups (all P >0.05), while the side of HFS was statistically different and there were more left-sided than right-sided patients in VA group ( P =0.033).

The HFS onset age is suggested to be an influencing factor of the incidence of HTN. The proportion of HTN was higher in VA and MA groups, and left-sided VA patients are more likely to present comorbidity of HTN.

To assess the feasibility and safety of keyhole approach for the anterior circulation aneurysms associated with intracranial hematomas.

Thirty-two patients with anterior circulation aneurysms associated with intracranial hematomas were admitted to Department of Neurosurgery at the First Hospital Affiliated to Fujian Medical University who underwent aneurysm clipping and hematoma evacuation via keyhole approach from December 2012 to August 2015. For patients with hydrocephalus and poor consciousness, external ventricular drainage was performed. Postoperative CT scan was performed within 24 hours, and CT angiography was performed within 72 hours. The clinical data were collected and analyzed. Functional outcomes were assessed according to the modified Rankin Scale (mRS) at 6 months post surgery.

Thirty-four cerebral aneurysms were successfully clipped and intracranial hematomas were evacuated via keyhole approach in 32 patients. Postoperative complications included hematoma expansion in 2 cases (6.3%), brain herniation in 4 (12.5%), pulmonary infection in 11 (34.4%), cerebral vasospasm in 12 (37.5%), cerebral infarction in 6 (18.8%), deep venous thrombosis in 1 (3.1%) and electrolyte disturbances in 6 (18.8%). External ventricular drainage (EVD)-related infections were observed in 4/16 (25.0%) patients. Intracranial infections were found in 2/16 (12.5%) patients without external ventricular drainage. No statistical significance was identified (P>0.05). With 3 deaths excluded, the functional outcomes were assessed at follow-up after 6-24 months, and the average follow-up period lasted 16.0±5.4 months. The outcome was assessed according to the modified Rankin Scale and the score of 6 was determined in 3 patients, 4 in 1, 3 in 1, 2 in 2, 1 in 9 and 0 in 16. Good recovery was reported in 84.4% (27/32) of the patients.

Keyhole approach for patients with anterior circulation aneurysms associated with intracranial hematomas seems to be a safe, feasible and minimally invasive procedure which is worth being promoted.

Posterior cerebral artery aneurysms accounted for only 0.7% ~2.3% of all intracranial aneurysms^[1,2]。 Due to the tortuous running of the posterior cerebral artery and the complex anatomical relationships around it, surgical treatment of such aneurysms tends to be at higher risk. With the development of endovascular therapy techniques and the improvement of materials, more and more such aneurysms are treated by endovascular routes. Compared with traditional surgical treatment, endovascular treatment has a lower complication rate, according to domestic and foreign literature^{[3,4,5,6,7,8,9]}。 Endovascular therapy includes embolization of aneurysms alone and embolization of combined tumor-bearing arteries. For P1 segment aneurysm, the author used simple embolization of the aneurysm to preserve the tumor-bearing artery; For P2 segment and its distal aneurysms, because most of them have the characteristics of dissecting aneurysms in imaging manifestations, in order to prevent postoperative recurrence, most surgeons use the simultaneous embolization of aneurysms combined with tumor-bearing arteries. This article retrospectively enrolled 20 patients with ruptured aneurysms of P1 segment of posterior cerebral artery and its distal end admitted to the Department of Neurosurgery of Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine from March 2010 to June 2016. According to the clinical characteristics of this disease, the safety and effectiveness of endovascular treatment were analyzed in combination with the literature.

Hydrocephalus is a common complication of subarachnoid hemorrhage (SAH), especially hydrocephalus caused by ruptured aneurysm, which mostly occurs within 72 hours after hemorrhage. The literature reported that the incidence of hydrocephalus can reach 12% ~41%^[1]Among them, about 50% of patients with combined hydrocephalus can resolve their own symptoms within 24 h, while 15% to 30% of patients can gradually develop chronic hydrocephalus, but the type of hydrocephalus is still unclear^[1,2,3,4,5]。 In the past, the treatment measures for hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) were mostly ventriculo-peritoneal shunt (VPS), but the shunt brought the discomfort of foreign body placement to patients and could produce various adverse reactions. endoscopic third ventriculostomy (ETV) has the advantages of no foreign body placement, simple operation and low complication rate. At present, it has replaced traditional shunt surgery as the first choice method for the treatment of obstructive hydrocephalus. Studies show that the success rate is 70% ~80%^[6,7]。 Because the treatment of hydrocephalus by ETV is simple, mature, less invasive, no foreign body is needed in the body, and CSF hydrodynamics is more in line with physiological requirements than VPS, it is widely accepted^[8]。 ETV can obtain good curative effect on obstructive hydrocephalus and communicating hydrocephalus (including normal pressure hydrocephalus)^[9,10]This provides a theoretical basis for the treatment of aSAH combined with hydrocephalus by ETV. This study analyzed the clinical data of 26 patients with hydrocephalus after aSAH who underwent ETV to investigate the efficacy and safety of ETV in the treatment of hydrocephalus after aSAH.

Hypertensive cerebral hemorrhage accounts for 10% ~15% of cerebrovascular diseases, has high disability rate and high mortality rate, and is considered to be the most devastating type of stroke^[1]。 The basal ganglia area is the most common site of bleeding. The lateral fissure-insular approach is a surgical method to enter deep lesions from natural anatomical spaces, which can reduce the traction and damage to brain tissue and blood supply arteries, so it has the advantage of minimally invasive treatment of hypertensive hemorrhage in the basal ganglia region. Water separation technique is a kind of separation technique in which warm physiological saline is injected into a fissure interface to be separated in the cranium by a syringe with a blunt needle, and the fissure is extended to facilitate further identification and separation of the interface^[2]。 Lateral fissure separation and hematoma boundary exposure are key steps in surgical separation of hypertensive hemorrhage in basal ganglia region through lateral fissure-insular approach. This study retrospectively included 29 patients with hypertensive hemorrhage in the basal ganglia area admitted to the Department of Neurosurgery of Jinhua Central Hospital from January 2012 to August 2013. All patients were treated by microsurgery through lateral fissure-insula approach, and the lateral fissure separation and hematoma boundary exposure were performed by water separation technique during the operation, with satisfactory results, which are reported below.

Ventriculo-peritoneal shunt is the most commonly used method for the treatment of hydrocephalus. Postoperative complications include shunt obstruction, infection and overshunt, among which shunt obstruction is the most common^[1]。 Obstruction can result from blockage, detachment, or rupture of the shunt device. At present, the diagnosis of shunt obstruction is mainly through clinical manifestations, imaging data and squeezing or puncturing the reservoir, but ultimately surgical exploration is required to confirm the diagnosis. Therefore, preoperative diagnosis of shunt obstruction is very important for clinical work. In this study, magnetic resonance phase cinematic imaging (Pc cine MRI) was used to examine the flow of cerebrospinal fluid (CSF) in the shunt, in order to provide a new method for the diagnosis of ventricular-peritoneal shunt obstruction.

To validate the specificity of CRT-Cy5 peptide in glioma animal model and provide experimental basis for its clinical application.

The human glioma cell line U87 was transfected with lentivirus H113 to obtain U87-MG H113 that stably expressed luciferase. The U87-MG H113 cells were injected into the caudate nuclei of mice.After 3 weeks, the signal of luciferase was detected by small animal imaging instrument after intraperitoneal injection of luciferin to testify U87-MG H113 glioma model.Twelve animals of orthotopic glioma were divided into PBS, Cy5-CRT, Cy5-CG7C groups according to random number table. PBS, Cy5-CRT and Cy5-CG7C (all in a dose of 0.1 mol/L, 200 μl) were intravenously injected into the mice of each group.The signal of luciferase was detected by small animal imaging instrument after intraperitoneal injection of luciferin. The Cy5 signal was detected at 24 h, 36 h, 48 h post injection.

(1) We successfully established cell lines that stably expressed luciferase whose intensity was positively correlated with the number of cells. (2) Three weeks later, 12 animals of orthotopic glioma were divided into PBS, Cy5-CRT, Cy5-CG7C groups. At 36 h post injection, the signal of luciferase of PBS, Cy5-CRT, Cy5-CG7C groups was 5.78±0.16、44.16±0.33、5.34±0.17, respectively. Signal analysis showed an 8 times increase of Cy5 signal intensity in Cy5-CRT group than the other 2 groups (P<0.005).

Cy5-CRT optical probe is enriched in glioma tissues rather than normal brain tissues and has potential values of clinical application.

To explore the mechanism of Akt1-associated enhancement of the chemoradiotherapy resistance of gliomas.

The immunofluorescence (IF) experiment was conducted to test the expression of ubiquitin-conjugating enzyme 2S (UBE2S) in the normal astrocytes and glioma cells (U87, U251, SF767 and U373). The Western blot was used to assess the differences of UBE2S expression in PTEN mutant and wild type glioma cell lines. To explore the role of PTEN/Akt signal pathway in UBE2S functions and the effect of UBE2S on the non-homologous end joining (NHEJ) repair, a constitutively activated Akt1 (Myr-HA-Akt1) and the UBE2S wild type or UBE2S T152A mutant were coexpressed. The flow cytometry (FCM) was used to test in the chemoradiotherapy sensitivity of the stable UBE2S knockdown glioma cells.

Compared with the normal astrocytes, UBE2S was overexpressed in the malignant glioma cells. The expression of UBE2S was more stable in the PTEN mutant glioma cell line. Akt1 phosphorylated UBE2S at T152, which promoted the stabilization of UBE2S. UBE2S interacted with Ku70 and Ku80, which increased the expression of Ku70 (P=0.009). The results of Western blot showed that the expression of Ku70, Ku80 and DNA-PKcs decreased significantly after knockdown of UBE2S expression (P<0.001). The results of FCM showed that the knockdown of UBE2S could enhance the chemoradiotherapy sensitivity of gliomas(P<0.001).

UBE2S is highly expressed in the malignant glioma. Akt1 physically interacts with UBE2S and phosphorylates UBE2S at T152, which is critical for the stabilization of UBE2S. The knockdown of UBE2S expression could retard NHEJ-mediated DNA repair and thus increase the sensitivity of chemoradiotherapy.

To investigate the apoptosis expression and role of calcium sensing receptor (CaSR) induced by traumatic brain injury (TBI) in rats.

Fifty-four healthy male SD rats were randomly divided into 3 groups: the control group, TBI group and inhibitor group (n=18). Each group was divided into 3 subgroups: 6 hours, 24 hours, and 72 hours (n=6). TBI animal models in the TBI and inhibitor groups were established using Feeney＇s method. CaSR antagonist NPS2390 (10 μmol/kg) was infused through caudal vein for 2 days before the establishment in the inhibitor group. Modified Neurological Severity Scores (mNSS) was used to evaluate the neurological behavior of rats in each group. Real-Time PCR was used to detect expressions of CaSR and Caspase-3 mRNA. Western blot was used to detect the protein expression of CaSR and Caspase-3 protein. TUNEL assay was used to detect neuronal apoptosis.

(1) The results showed that the mNSS scores in TBI group compared with the control group and inhibitor group were increased in 6 h, 24 h, 72 h after modeling (P<0.01). (2) In both TBI and inhibitor groups, the mRNA and protein expressions of CaSR and Caspase-3 reached the peak at 24h (P<0.01). Compared with the control group and the inhibitor group, the expression of CaSR mRNA and its protein were increased in the TBI group (P<0.01). The expression of Caspase-3 was higher in the TBI group than that in the control and inhibitor groups at 24 h only (P<0.05). (3) The results of TUNEL assay showed that apoptosis reached the peak level at 24 h after TBI model was made (P<0.05). The TBI group had more apoptotic cells compared with the other 2 groups (P<0.01). (4) There was a positive correlation between CaSR as well as Caspase-3 and neuronal apoptosis (r=0.300, P<0.05;r=0.371, P<0.01). The protein expressions of CaSR and Caspase-3 had a positive correlation (r=0.434, P<0.01).

CaSR may play an important role in neuronal apoptosis in the rat model of TBI.

Klippel-Feil syndrome is a group of congenital malformations characterized by cervical spine formation and segmentation disorders, which can be combined with developmental abnormalities of other systems such as the nervous system. Since Love and Kernohan first reported Klippel-Feil syndrome with dermoid cysts in 1936, the correlation between dermoid cysts and epidermoid cysts in the posterior fossa and Klippel-Feil syndrome has been gradually recognized. These cysts are usually located in the midline of the posterior fossa and can extend to the upper cervical vertebra, and a few can even extend to the upper thoracic segment^[1]。 Klippel-Feil syndrome with posterior cranial fossa dermoid cysts are more frequent, but epidermoid cysts are rare. Previous surgical treatment of posterior fossa epidermoid cysts and subcutaneous cysts complicated with Klippel-Feil syndrome usually used suboccipital midline approach, which affected the stability of cervical spine and was difficult to fix. In May 2013, the Department of Neurosurgery, the Third Affiliated Hospital of the Third Military Medical University admitted a patient with giant posterior fossa epidermoid cyst complicated with Klippel-Feil syndrome. The imaging findings were atypical. According to the clinical characteristics of the patient, the surgeon used occipital transtentorial approach to remove the cyst, and the effect was good. The specific reports are as follows.

Angioma is a rare disease derived from lymphatic vessels and blood vessels, also known as angiolymphangioma, which includes lymphangioma and hemangioma^[1,2]。 Angiomas are divided into two types: primary and secondary^[3]。 Angiomas tend to occur in the head and neck, and occur in the spinal canal is extremely rare^[1]。 This disease lacks specific clinical symptoms and signs, and can be diagnosed according to its pathological manifestations. Current treatment methods of angioma include surgical resection, radiotherapy, injection of sclerosing agent, etc^[4]。 In May 2016, a case of T was admitted to the Department of Neurotumor Surgery, Bethune First Hospital, Jilin University_10～12Patients with intraspinal epidural angioma are now reported as follows.

Subarachnoid hemorrhage (SAH) is a common cerebrovascular disease, and 85% of SAH is caused by ruptured aneurysms. Intracranial aneurysms can occur at any age, more in women than in men^[1,2]。 Pregnant women have unique hemodynamic characteristics and hormonal changes, which may be related to the occurrence, development and rupture of aneurysms^[3,4]。 The rupture of intracranial aneurysm during pregnancy and delivery can directly endanger the life of pregnant women, and can also lead to fetal distress and even intrauterine fetal death. The management of intracranial aneurysm in pregnant women should not only follow the diagnosis and treatment guidelines of neurosurgical specialty diseases, but also be careful of the potential harm brought to the fetus by corresponding treatment. The incidence of intracranial aneurysm rupture during pregnancy and delivery is low, and there is currently no standardized diagnosis and treatment guidelines specifically for this type of disease; Although the guidelines on aneurysmal subarachnoid hemorrhage (aSAH) have been issued in many countries, the diagnosis and treatment of intracranial aneurysms during pregnancy and delivery have not been solved. This article reviews the diagnosis and treatment of ruptured intracranial aneurysm during pregnancy and delivery, in order to provide evidence for neurosurgeons and obstetricians and gynecologists to diagnose and treat this kind of disease.

traumatic brain injury (TBI) occupies the second place in the incidence of systemic trauma, and the residual mortality occupies the first place. The preliminary statistical results included in the TBI database of 47 hospitals in China showed that among the patients with acute TBI, the mortality rate of severe TBI was 27.23%, and the death + plant survival + severe disability rate was 53.17%^[1,2]。 In recent years, although various medical monitoring and treatment technologies have been greatly developed, the treatment effect of TBI has not improved significantly.