Volume 34 · Issue 07 · 2018

stress ulcer after craniocerebral trauma, also known as Cushing's ulcer, can involve the terminal esophagus, stomach and proximal duodenum. The ulcer is usually deep and penetrating^[1]。 Stress ulcer used to be one of the common complications in patients with craniocerebral trauma, with an incidence rate of 16% ~49%, which increased the mortality rate of patients^[2,3]。 Since the beginning of this century, due to the improvement of standardized treatment level of severe craniocerebral trauma and the application of acid suppressant, the incidence and mortality rate of stress ulcer have decreased significantly.

To investigate the indication and outcome of vessel suture technique for treatment of blood blister-like aneurysms.

Eight cases with blood blister-like aneurysms(BBA) admitted to Department of Neurosurgery, Fuxing Hospital Affiliated to Capital Medical University from March 2008 to June 2016 were enrolled.Among them, Hunt-Hess grade Ⅰ-Ⅱ was reported in 6 patients and grade Ⅲ in 1. BBA of the internal carotid artery (ICA) occurred in 5 cases, BBA of middle cerebral artery (MCA) in 2 cases, and BBA of anterior cerebral artery (ACA) in 1. The parent artery proximal to BBA was dissected based on the BBA location, size and the site as well as feature of vessel wall. The parent artery of BBA was temporarily clipped followed by identification of lacerative site and feature after removal of hemorrhage in patient with subarachnoid hemorrhage. Two to three sutures were performed with wall resection of BBA for lesion of over 3 mm and direct suture was performed without wall resection of BBA for lesion of less than 3 mm. The distance between tissue edge and the needle hole was feasible when it was 2-3 times the thickness of normal vessel wall.

All 8 patients recovered to normal life without neurological symptoms. Satisfactory sutures in all patients with BBA revealed no arterial stenosis and residual BBA on the postoperative digital subtraction angiographies in 4 patients and CT angiograms in 4 patients. None of the 8 patients reported any symptoms related to suture of BBA. Based on the modified Rankin Scale(mRS), the mRS scores of 0-2 were reported in 7 patients and 1 patient with ICA BBA had the mRS score of 3 and reported memory decline at follow-up lasting for 1.9-4.1 (mean 2.9±0.6) years.

The vascular suture appears to be an effective treatment modality for patients with ICA BBA and BBA affecting 1/3 of vascular perimeter. There might be risk of stenosis associated vascular suture for BBA affecting over 1/3 of vascular perimeter.

To evaluate the mid-to long-term effect of gamma knife radiosurgery (GKS) for the treatment of brainstem arteriovenous malformations (AVMs) and to analyze its related influencing factors.

We retrospectively studied 57 patients with brainstem AVMs undergoing GKS between 1995-2011 at Beijing Neurosurgical Institute Gamma Knife Center. The lesions were located in midbrain in 38 cases, pons in 15 cases and medulla oblongata in 4 cases. The treatment volume was 0.1-22.4 cm³ (median: 1.1 cm³). The marginal prescription dose was 12-20 Gy (mean: 15.0±1.5 Gy). After the initial Gamma procedure, 8 patients had a second treatment of GKS for AVM residuals. Investigation was conducted on the long-term effect and related influencing factors of single treatment result.

A total of 57 patients recieved clinical follow-up ranging from 12 to 192 months (median: 67 months). There were 49 patients who showed improvement or remained stable based on modified Rankin scale. Permanent neurological deficits due to adverse radiation effects (AREs) developed in 2 (3.5%) patients post treatment. Eight (14.0%) patients experienced 11 times of hemorrhage post treatment. The overall annual hemorrhage rate was 4.0%. Obliteration of the AVMs was eventually documented in 31 patients base on MRI result at a median of 35 months (range: 12-72 months), subtotal obliteration in 8 and residual in 18. The rates of documentation of total obliteration were 44.2% (19/43), 75.0% (27/36) and 80.0% (28/35) at 3, 5 and 10 years post surgery, respectively. Multivariate analysis revealed that the location in brainstem (superficial/deep, HR=2.268, 95% CI: 1.032-4.983, P=0.042) and smaller volume of AVMs (≤2 cm³/>2 cm^3,HR=1.360, 95% CI: 1.016-1.773, P=0.039) was associated with a higher rate of total obliteration on MR imaging.

Gamma knife seems safe and effective for treatment of brainstem AVMs. Patients might remain at risk during the latency period until obliteration was achieved. The small volume and superficial lesions are associated with relatively better results.

To evaluate the technical success and clinical functional outcomes of mechanical thrombectomy (MT) by Solitaire stent in anterior circulation occlusion involving varying locations.

We retrospectively reviewed 148 patients with anterior circulation occlusion who were admitted to Department of Neurosurgery, 101st Hospital of PLA and underwent MT from March 2015 to September 2017. According to locations, all patients were divided into internal carotid artery (ICA) group (n=42), middle cerebral artery (MCA) M1 group (n=70) and M2 group (n=36). Revascularization was evaluated with modified thrombolysis in cerebral infarction (mTICI). Clinical outcomes were assessed based on National Institutes of Health stroke scale (NIHSS) and modified Rankin scale (mRS). Baseline clinical and imaging variables, time from onset to recanalization, duration of the procedure, revascularization, perioperative complications and mRS at 90 d post stroke were documented.

The results of mTICI 2b or 3 was achieved in 96 (64.9%) cases and there were no significant differences among the 3 groups [66.7%(28/42), 71.4%(50/70), 50.0%(18/36), P=0.091]. Overall, 76 out of 148 (51.4%) patients experienced favorable clinical outcome (mRS of 0-2) with no significant difference among the 3 groups [42.9%(18/42), 58.6%(41/70), 47.2%(17/36), P=0.231]. In ICA and M1 groups, favorable clinical outcome was more often seen in patients who achieved successful recanalization (ICA: 57.1% vs. 14.3%, P=0.009; M1: 70.0% vs. 30.0%, P=0.003). In patients with M2 occlusions, favorable clinical outcome was reported in 55.6% (10/18) of cases with successful recanalization and 38.9% (7/18) of those with unsuccessful recanalization, which had no significant difference (P=0.514).

There seems to be no statistically significant difference in the recanalization or clinical outcomes among ICA, M1 and M2 cases that underwent treatment with Solitaire stent. The beneficial effect of endovascular reperfusion using Solitaire stent might more pronounced for patients with ICA and M1 occlusions than for patients with M2 occlusions.

To investigate the risk factors of intracerebral hematoma(ICH) and/or intraventricular hemorrhage(IVH) with varying extent due to ruptured AComA (anterior communicating artery) aneurysms.

Between December 2007 and January 2016, a total of 480 consecutive patients with ruptured AComA aneurysms were admitted to Department of Neurosurgery, the First Affiliated Hospital, Wenzhou Medical University and enrolled into this retrospective study. Among them, embolization was conducted in 244 cases, clipping in 172 and conservative treatment in 64. All 480 cases were divided into the SAH (subarachnoid hemorrhage) group (n=195) and ICH and/or IVH group (n=285). Single and multiple variate logistic regression were used to identify the risk factors associated with ICH and/or IVH due to rupture of aneurysms.

The single-variate analysis revealed significant differences in the gender, age, aneurysm projection between 2 groups (all P<0.05). The multivariate analysis showed that the age (OR=1.025, 95% CI: 1.009-1.041, P=0.002) and aneurysm projection (OR=1.698, 95% CI: 1.092-2.639, P=0.019) were associated with ICH and/or IVH following rupture of aneurysms.

The age and aneurysm projection seem to be significantly associated with ICH and/or IVH induced by ruptured AComA aneurysms. In clinical practice, close attention should be paid to the elderly patients and those with aneurysms projecting to the posterior.

To compare the surgical outcome of intracerebral hematoma drilling and drainage for hypertensive intracerebral hemorrhage (HICH) using robotized stereotactic assistant(ROSA)-assisted and stereotactic framework.

A retrospective study was conducted on 368 patients with HICH who underwent hematoma drilling at Department of Neurosurgery, General Hospital of Shenyang Military Command from March 2015 to April 2017. According to the surgical method, all cases were divided into the stereotactic frame group (group A) and ROSA group (group B). Comparison was conducted on the treatment outcome of those 2 surgical methods for HICH.

There was no statistically significant difference in gender, age, preoperative GCS (Glasgow coma scale), time interval from bleeding to operation and bleeding volume between 2 groups (all P>0.05). The operating time (27.3±8.4 min) and incidence of rebleeding (1.7%, 3/172) were lower in group B than those in group A [operation time: (44.2±7.7) min, incidence of rebleeding: 8.7% (17/196)] (bothP<0.01). In group A, 12 (6.1%) patients developed postoperative intracranial infection and none had intracranial infection in group B and there was statistically significant difference between the 2 groups (P=0.001). The extubation time in groups A and B was (2.5±0.7) days and (1.2±0.5) days post opeartion, respectively, which were significantly different (P<0.001). The 30-day mortality rate in group B (2.3%, 4/172) was lower than that in group A (9.2%, 18/196) (P=0.006).

Compared with stereotactic frame-assisted surgery, ROSA-assisted operation seems to be associated with shorter operation duration, earlier extubation time, and lower incidence of postoperative rebleeding, intracranial infection and 30-day mortality rate for HICH patients, which is thus worthy of clinical promotion.

To evaluate the safety and short-term efficacy of cerebral revascularization combined with aneurysm clipping or embolization for the treatment of moyamoya disease complicated with ruptured aneurysms.

Five moyamoya patients(6 aneurysms) with ruptured aneurysm underwent cerebral revascularization combined with aneurysm clipping or embolization from December 2015 to October 2017 at Department of Neurosurgery, Nanfang Hospital, Southern Medical University. Two patients were treated by STA-MCA bypass combined with endovascular embolization of aneurysm. Three patients (4 aneurysms) were treated with aneurysm clipping and EC-IC revascularization.

Intraoperative DSA revealed total obligation of the 4 clipped aneurysms and the other 2 embolized peripheral aneurysms. All of the 5 bypass grafts showed good patency. The 5 patients recovered well after surgery although 1 patient showed asymptomatic infarction on post-operative MRI. All patients received clinical follow-up (5-24 months) and were evaluated with the Glasgow outcome scale(GOS). Five patients showed good outcome (GOS Ⅴ or Ⅳ grade). Five patients received MRA follow-up. Three out of them received both DSA and MRA follow-up and showed no reoccurrence of aneurysm and good patency of the graft.

Cerebral revascularization combined with aneurysm clipping or embolization could be effective for moyamoya diseases with ruptured cerebral aneurysms and showed good short-term results.

Moyamoya disease is a chronic progressive stenosis or occlusive cerebrovascular disease. Its pathophysiological changes are mainly the stenosis and occlusion of the main artery of the anterior circulation gradually aggravated, the abnormal vascular network of compensatory hyperplasia appeared at the base of the skull, and the posterior circulation and external carotid artery compensated^[1]。 The clinical manifestations of moyamoya disease mainly include ischemia and hemorrhage. Ischemic moyamoya disease is an important type of moyamoya disease in adults, and may evolve into cerebral hemorrhage. This study retrospectively analyzed the clinical data of 53 patients with ischemic moyamoya disease treated with combined surgical revascularization in the Department of Neurosurgery of Sichuan Provincial People's Hospital from August 2010 to August 2016.

At present, intracranial hypertension and hydrocephalus caused by spontaneous cerebellar hemorrhage are still the two major factors that threaten patients' life, and they are also critical and severe diseases in neurosurgery. The clinical effect of surgical treatment of spontaneous cerebellar hemorrhage is not ideal, especially in elderly patients with multiple chronic diseases. With the development of clinical imaging technology and equipment, the use of hard and soft channel puncture to drain intracerebral hematoma is gradually popularized. However, there are different literature reports on the surgical methods, auxiliary tools and surgical results of spontaneous cerebellar hemorrhage^[1]。 From September 2014 to June 2016, 36 patients with spontaneous subtentorial cerebellar hemorrhage were treated in the Department of Neurosurgery of Heze Municipal Hospital. During the operation, quadrants and protractors were used to assist in positioning, puncture and drainage of hematoma, and satisfactory results were obtained, which are reported as follows.

The incidence of hypertensive intracerebral hemorrhage increases gradually, the mortality and disability rate are high, and there is a tendency of younger people^[1]。 The volume of hematoma directly determines the clinical symptoms and prognosis of patients^[2]Determining the influencing factors of hematoma volume and targeted prevention and treatment may improve the prognosis of patients. However, the risk factors for hematoma volume in young patients with hypertensive intracerebral hemorrhage are currently unknown. In this study, multiple regression analysis was performed on multiple potential influencing factors of cerebral hemorrhage, and it was found that systolic blood pressure and triacylglycerol levels at admission were independent risk factors for hematoma volume of cerebral hemorrhage in young patients, which are reported below.

To investigate the effectiveness and safety of combined application of neuronavigation and yellow fluorescein-guided techniques in the treatment of brain gliomas.

A total of 37 cases of brain gliomas admitted to Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from March 2014 to March 2016 were enrolled into this retrospective study.All cases were divided into supratentorial (n=21) and brainstem (n=16) groups by location as well as adult (n=25) and child (n=12) groups by age. Fluorescein-guided surgery were conducted (5.0 mg/kg and 2.5 mg/kg of sodium fluorescein administered before dura opening in adult and child groups, respectively). Following the resection, the tumor boundary was evaluated with neuronavigation. Analysis was conducted about the consistency between neuronavigation and fluorescein-guided techniques. The patient’s KPS (Karnofsky performance status scale) was documented and analyzed at admission, discharge and 6-month follow-up.

Among the total 25 adult cases, 23 reported satisfactory fluorescence results, while 11 out of 12 child cases reported satisfactory results. There were 5 cases showing non-consistency between yellow fluorescein enhancement and neuronavigation which included 4 from supratentorial group and 1 from brainstem group. Statistical analysis showed no significant differences in satisfactory rate of imaging between adult and child groups (P=0.704) and significant differences of consistency between supratentorial and brainstem groups (P=0.029). Total resection was achieved in 30 out of 37 cases. The average KPS at 6-month follow-up was significantly higher than that at admission(P=0.003).

The consistency between neuronavigation and fluorescein-guided technique seems to be higher in brainstem group than in supratentorial group. Half dose of sodium fluorescein (2.5 mg/kg) might be enough for pediatric patients. Combined uses of neuronavigation and yellow fluorescein-guided techniques could contribute to better clinical outcomes in patients of brain gliomas.

To discuss the surgical techniques and therapeutic effect of deep brain stimulation of anterior nucleus thalamus for refractory partial epilepsy.

Eight drug-resistant partial epilepsy patients, with no indication of respective surgery, were treated at Neurosurgery Department of Beijing Tiantan Hospital, Capital Medical University from March 2015 to November 2016 and retrospectively enrolled into this study. The seizure frequency, severity of seizure, quality of life, depression and anxiety status and other clinical outcome features in pre-surgical and post-surgical periods were analyzed.

Eight patients with refractory partial epilepsy were followed up for 18.0±2.4 months. The seizure frequency post surgery was significantly reduced (36.4±13.4 times per month prior to operation, 13.9±6.2 times per month post operation, P=0.012) and the remission rate was 54.3%±7.4%. The severity of seizure was improved based on the Liverpool seizure severity scale (38.4±5.3 points prior to operation, 22.3±4.9 points post operation, P=0.001) and the remission rate was 46.0%±8.4%. The quality of life was significantly improved based on the Quality of Life in Epilepsy Inventory-89 (71.2±2.7 points prior to operation, 80.0±2.9 points post operation, P=0.001) and the improvement rate was 12.6%±2.3%.

For patients with refractory partial epilepsy without indication of respective surgery, deep brain stimulation of anterior nucleus thalamus might have certain treatment effect, which still needs further clinical research.

To discuss the role of transcranial electrical stimulation facial nerve motor evoked potentials (TCE-FNMEP) in resection of large acoustic neuromas.

In a retrospective clinical study, 58 patients with large acoustic neuroma were investigated at Department of Neurosurgery, Tianjin HuanHu Hospital form July 2016 to March 2017.All patients were investigated by facial nerve motor evoked potentials elicited by multi-pulse transcranial electrical motor cortex stimulation. For recording, the same electrode set-up was used as for continuous EMG (electromyogram) monitoring of the orbicularis oculi, oris muscles and mentalis. Pre-surgical (dura opening), intraoperative and post-surgical (dura closing) TCE-FNMEP amplitudes and latencies were documented. End (dura closing) to start (dura opening) amplitude ratios were compared to early-term (1 day post surgery) facial nerve function by House-Brackmann (H-B) grading.

Fifty-one (87.9%, 51/58) patients obtained total tumor resection and 7 (12.1%, 7/58) achieved subtotal resection. All patients had anatomical preservation of facial nerves. There was no death in this series. Reliable TCE-FNMEPs were obtained in all patients. At 1 day post operation, 48 out of 58 case were graded as H-B Ⅰ-Ⅱ, the range of TCE-FNMEP amplitude ratio was 47.6%-100.0%, and the median was 85.4%. Five cases were graded as H-B Ⅲ, the range of TCE-FNMEP amplitude ratio was 43.2%-55.8%, and the median was 45.4%. Three cases were graded as H-B Ⅳ, the range of TCE-FNMEP amplitude ratio was 31.4%-53.2%, and the median was 33.6%. Two cases were graded as H-B Ⅴ-Ⅵ, the range of TCE-FNMEP amplitude ratio was 6.1% and 11.3%, respectively. There was a negative correlation between TCE-FNMEP amplitude ratio and early post-surgical HB grading (r=-0.611, P<0.01).

TCE-FNMEP seems to be highly reliable in predicting early postoperative facial function in resection of large acoustic neuromas and could be a valid protection technique of facial nerve.

To examine the radiographic efficacy of indirect decompression of oblique lumbar interbody fusion (OLIF) for lumbar degenerated disease.

Thirty consecutive patients were enrolled into this study who presented with lumbar degenerated disease and underwent OLIF without posterior decompression from October 2016 to April 2017 at Neurosurgery Department of Xuanwu Hospital, Capital Medical University. The imaging, clinical efficacy and complications were retrospectively reviewed. X-Ray, CT scan and MRI before operation and at the last follow-up were evaluated. The cross-sectional area (CSA) of the thecal sac was measured on T2WI axial MRI. The disk height (DH), cross-sectional height (CSH) of intervertebral foramina and cross-sectional areas of intervertebral foramina (CSAF) were measured on sagittal view of CT. Visual analog scale (VAS) score, Oswestry disability index (ODI) and medical outcome study 36-item short-form health survey (SF-36) were evaluated before operation and at the last follow-up.

A total of 62 lumbar levels of OLIF fusion in 30 patients were performed successfully without severe complications. Our follow-up study lasted 9-15 months with an average of 12.5±2.3 months.The mean CSA increased from 0.82±0.34 cm² preoperatively to 1.38±0.37 cm² postoperatively, DH increased from 0.68±0.24 cm preoperatively to 1.13±0.29 cm postoperatively, CSH increased from 1.53±0.25 cm preoperatively to 2.05±0.32 cm postoperatively, and CSAF increased from 1.12±0.28 cm² preoperatively to 1.80±0.37 cm² postoperatively (all P<0.01). The VAS, ODI and SF-36 scores were significantly improved after surgery (allP<0.05). There was no spinal nerve, major vessel, peritoneal, or urinary injury. Only 1 patient showed symptoms related to psoas invasion.

Significant improvements in CSA, DH, CSH and CSAF could be obtained following OLIF surgery for degenerated lumbar disease with good clinical and imaging outcomes.

To study the situation of nosocomial infection and drug resistance of acinetobacter baumanniinii (ABA) at a neurosurgical center.

A retrospective analysis was conducted about the data of ABA and its rate of drug resistance from the inpatients at Department of Neurosurgery, the First Affiliated Hospital of Army Military Medical University from January 2012 to September 2017. The minimum inhibitory concentration method was used to compare the resistance of ABA to 21 common antibiotics. The change trend of drug resistance of ABA in the past 6 years was analyzed.

A total of 1420 strains of ABA were isolated from 2012 to 2017. During the past 6 years, ABA detected at Department of Neurosurgery accounted for 10.7%-23.9% of the total bacteria detected. The proportion of ABA detected at Department of Neurosurgery was higher than that at the whole hospital (8.4%-14.3%). Except for 2014, the difference was statistically significant in 2012, 2013, 2015 and 2017 (P < 0.01). Compared with 2012, the resistance rate of ABA to ampicillin (all > 90.0%) and piperacillin (65.3%-88.2%) of penicillins was maintained at a high level for 2013-2017 years ( P < 0.01), but the resistance of penicillin with enzyme inhibitor, such as ampicillin-sulbactam (62.0%-80.7%) and piperacillin-tazobactam (65.5%-78.0%), was relatively low. Compared with ampicillin and piperacillin, the difference was statistically significant ( P < 0.001). After 2013, the resistance rates of ABA to cephalosporins, imipenem and meropenem exceeded 65%. The resistance rate of ABA to cefoperazone-sulbactam increased gradually and exceeded 50% after 2015. The proportion of multidrug-resistant ABA was also increasing year by year from 2012 to 2017 (36.3%-82.0%, P=0.000).

The proportions of ABA infection and its drug resistance at Department of Neurosurgery seem to be increasing. We should pay attention to prevention and control of those. Antibiotics need to be administered rationally with reference to the results of bacterial susceptibility.

To investigate the efficacy and influencing factors of different surgical treatment of bilateral chronic subdural hematomas.

A retrospective analysis was performed on 134 patients with bilateral chronic subdural hematomas treated with drilling and drainage from January 2011 to December 2016 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University. There were 30 patients undergoing unilateral surgery and 104 patients undergoing bilateral surgery. The differences in brain tissue restoration between 2 surgical strategies were compared. Resetting the bilateral brain tissues within 1 week postoperatively to a distance of less than 10 mm from the inner table of skull was defined as good recovery. The relevant factors that affected brain tissue resetting were analyzed.

Of the 134 patients, 52.2% (70) had a good brain tissue resetting within 7 days postoperatively, including 57.7% (60/104) in the bilateral surgery group and 33.3% (10/30) in the unilateral surgery group (P=0.023). Within 24 hours after surgery, the incidence of hematoma enlargement on one side was 63.3% (19/30) in the unilateral surgery group and 16.3% (17/104) in the bilateral surgery group (P<0.001). Within 7 days after operation, the cumulative incidence of hematoma enlargement on one side in the unilateral surgery group was 60.0% (18/30) and 6.7% (7/104) in the bilateral surgery group. The difference was statistically significant (P< 0.001). Multivariate logistic regression analysis showed that the surgical method (OR=0.251, 95% CI: 0.087-0.722, P=0.010) was an independent factor affecting brain tissue remodeling.

Compared with unilateral surgery, bilateral drilling drainage in the treatment of chronic subdural hematomas could improve the efficacy of restoration of bilateral brain tissues and help reduce the likelihood of hematoma enlargement after surgery.

To investigate the clinical value of MRI morphological analysis in identification of focal cortical dysplasia (FCD) in presurgical evaluation of epileptogenic zone (EZ).

We retrospectively analyzed the clinical data of 53 patients who were admitted to Epilepsy Center, Tsinghua University Yuquan Hospital and underwent surgical removal of epileptic foci and were pathologically confirmed as FCD Ⅰ or FCD Ⅱ. Morphometric analysis programme was used to post-process presurgical high-resolution MRI to obtain the gray-white matter junction imaging (MAP⁺ region) and statistical analysis was used to determine the consistency of the MAP⁺ region and surgical site and postoperative epilepsy control.

In this series, the probability of postoperative seizure-free (67.9%, 36/53) was higher in patients whose MAP⁺ regions were resected than that (7.5%, 4/53) in patients whose MAP⁺ regions were not resected (P=0.002). In the MRI-negative group, the probability of postoperative seizure-free (62.5%, 20/32) was higher in patients whose MAP⁺ regions were resected than that (9.4%, 3/32) in patients whose MAP⁺ regions were not resected (P=0.006). In the MRI positive group, MAP⁺ regional resection was not associated with the clinical outcome (P=0.352).

The gray-white matter junction imaging could improve the detection rate of FCD lesions, which might have clinical value in localization of EZ and resection of EZ and making electrode plan of stereotactic electroencephalogram (SEEG).

To evaluate the feasibility of a purely endoscopic intradural approach to the suprasellar, petroclival and ventrolateral brainstem regions through a subtemporal keyhole and to assess the value of neuronavigational assistance in the Kawase approach.

Twenty operations through endoscopic intradural subtemporal keyhole approach were performed on 10 cadaveric heads. An intradural Kawase approach and a navigation-assisted intradural Kawase approach were then carried out on a random side of each specimen. Related anatomic structures were observed through endoscopes. Two types of the milled Kawase rhombus ranges and the thicknesses of residual bones were compared.

Through the keyhole endoscopic technique, anatomic structures in the suprasellar, petroclival and ventrolateral brainstem regions were clearly visualized via an intradural subtemporal route. Most structures in the suprasellar region could be observed in the oculomotor nerve-posterior communicating artery space. Using a frameless navigational device, the mean area of milled Kawase rhombus was larger than that in the intradural Kawase approach (276.8±14.6 mm²vs. 244.8±12.6 mm^2,P<0.05), and the thicknesses of residual bones including the superior wall of internal acoustic meatus (1.0±0.2 mmvs. 2.5±0.4 mm), the medial superior wall of cochlear (1.0±0.2 mm vs. 3.0±0.4 mm) and the superior wall of petrous segment of internal carotid artery (1.2±0.2 mm vs. 3.4±0.4 mm) were all thinner than those in the intradural Kawase approach (all P<0.05).

The endoscopic intradural subtemporal keyhole approach could facilitate excellent observation of the suprasellar, petroclival and ventrolateral brainstem regions with less invasiveness. More anatomic exposure and surgical freedom could be achieved via neuronavigational assistance.

To conduct anatomic study of structures and exposure of the posterior third ventricle by simulating superior and inferior transtentorial approach with endoscope and to provide anatomical basis for treatment involving this area with endoscope.

Five formalin-fixed cadaver heads (10 sides) were dissected bilaterally. To observe and measure anatomical structures of the posterior third ventricle by endoscopic infratentorial-supracerebellar (midline or paramedian) approach and occipital-tentorial approach with comparison of exposure using different surgical approaches.

(1) Measurement of anatomical structures: Average number of bridging veins of the cerebellum was 3.6±0.6. The diameter of the vein of Galen was 5.6±0.6 mm. The distance from Habenular commissure to confluence of sinuses was 74.4±6.7 mm and the distance from anterior commissure to confluence of sinuses was 107.2±7.3 mm. (2) Comparison of different surgical approaches: The exposed area of pineal glands was 19.6±2.8 mm^2, which was almost the same to that in operations through infratentorial-supracerebellar (midline or paramedian) approach and occipital-tentorial approach. The average of exposed area in splenium of corpus callosum was 55.2±7.9 mm², 34.7±7.9 mm² and 44.9±5.9 mm² , respectively, and in ipsilateral superior colliculus was 153.8±13.4 mm^2, 177.5±24.0 mm² and 197.6±19.8 mm² , respectively. Both had statistically significant difference (all P<0.05).

Endoscopic superior and inferior transtentorial approach seems feasible and safe for removal of tumors in the posterior third ventricle. Selection of surgical approaches should be based on the tumor type, size, location and its relationship to the surrounding structures.

The 13th Annual Meeting of Neurosurgeons Branch of Chinese Medical Doctors Association, sponsored by Neurosurgeons Branch of Chinese Medical Doctors Association and hosted by Qilu Hospital of Shandong University, Beijing Tiantan Hospital affiliated to Capital Medical University and Beijing Wang Zhongcheng Medical Foundation, was held in Jinan from June 1 to 3, 2018. The meeting was chaired by Professor Zhang Liwei, president of Neurosurgeon Branch of Chinese Medical Doctors Association and vice president of Beijing Tiantan Hospital affiliated to Capital Medical University; Professor Li Xingang, vice president of Neurosurgeon Branch of Chinese Medical Doctors Association and vice chairman of Neurosurgery Branch of Chinese Medical Association, serves as the executive chairman of the conference; Professor Jia Wang, Director General of Neurosurgeon Branch of Chinese Medical Doctors Association, Party Secretary and Deputy Director of Neurosurgery Department of Beijing Tiantan Hospital affiliated to Capital Medical University, and Professor Li Gang, Director of Neurosurgery Department of Qilu Hospital of Shandong University, served as Secretary-General. This meeting is the first annual meeting since the establishment of the fifth committee of the Neurosurgeon Branch of Chinese Medical Doctors Association. Nearly 200 well-known domestic experts and scholars were invited to attend. The conference received a total of 1,163 manuscripts, including 853 speeches. The conference set up 10 sub-venues and held 36 academic forums, with more than 1,000 participants.

To develop a method based on pyrosequencing that can be used to accurately and quantitatively detect the IDH1 R132H mutation of gliomas and to evaluate the clinical application of that method.

Thirty cases of formalin-fixed and parrffin-embedded (FFPE) samples of gliomas and clinical database were retrospectively obtained from the Chinese Glioma Genome Atlas (CGGA). There are 15 IDH1 wild type and 15 IDH1 R132H mutant samples. The pyrosequencing results were compared with the findings of immunohistochemistry.

The pyrosequencing results indicated that the percentage of CAT in glioma sample ranged from 10% to 52% in all 30 cases. The percentage of CAT in IDH1 R132H mutant glioma was less than 19%, while the percentage of CAT in IDH1 R132H wildtype glioma was more than 27%. Immunohistochemistry results indicated negative staining in 15 samples and positive staining in the other 15 samples including 8 positive staining and 7 strong positive staining. Further statistical analysis showed that the quantitative IDH1 R132H mutant ratios of pyrosequencing were significantly different between immunohistochemistry-negative and immunohistochemistry-positive glioma FFPE samples, and the former was below 20% (10%-18%), while the latter was above 20% (28%-52%).

The quantitative IDH1 R132H mutant detection method based on pyrosequencing could accurately detect the IDH1 R132H mutant level in FFPE glioma samples, which seems suitable for routine molecular pathological practice.

To analyze the histopathologic subtype "glioblastoma with oligodendroglioma component (GBMO)" based on the integrated diagnosis model by the 2016 WHO (World Health Organization) central nervous system tumor classification (2016 classification).

A total of 54 cases diagnosed as "GBMO" were extracted from the database of Chinese Glioma Genome Atlas(CGGA). Pyrosequencing method was used to detect isocitrate dehydrogenase ( IDH) mutations and fluorescence in situ hybridization (FISH) technique was employed to detect 1p/19q abnormalities. Survival curves were estimated using the Kaplan-Meier method. An integrated diagnosis was established based on the 2016 classification.

Among the 54 patients, the incidence of IDH1 mutation was 37.1% (20/54) and the mutation occurred in 132 (exon 4). IDH2 mutation was not detected in this series. Chromosomal status could be assessed in 40 cases by FISH. The incidence of 1p deletion was 17.5%(7/40), 19p deletion was 20.0%(8/40) and 1p/19q co-deletion was 7.5% (3/40). According to the 2 molecular pathologic features of diffuse glioma by 2016 classification, the 40 patients could be divided into 3 groups: group of IDH wildtype (23 cases), group of IDH mutant and 1p/19q non-codeletion(14 cases), and group of IDH mutation and 1p/19q codeletion(3 cases). There was significantly differences among them in the median survival (P=0.008). The group of IDH mutation and 1p/19q codeletion had the best prognosis (32.3 months). The group of IDH mutant and 1p/19q non-codeletion had the median survival of 24.0 months. The group of IDH wildtype had the worst outcome (14.4 months).

Rather than an independent glioma subtype, the "GBMO" seems to be a combination of several tumor types with various molecular genetic and clinical biological characteristics.

To investigate the effect of adenovirus-mediated interleukin 24 (Ad-IL-24) on proliferation and apoptosis of glioma cells and its mechanism.

We set up Ad-IL-24 group, Ad-GFP group and PBS group. The expression of IL-24 in each group was detected by real-time quantitative PCR (qRT-PCR) and Western blot, and the proliferation activity of 3 groups of U251 cells was detected by MTT assay. Apoptosis of U251 cells was detected by flow cytometry. The expression of Survivin and Bax in U251 cells was detected by qRT-PCR.

(1) In group PBS and group Ad-GFP, U251 cells adhered well and grew well. The number of adherent growth in group Ad-IL-24 was significantly reduced and the infection efficiency in group Ad-IL-24 and Ad-GFP was above 95%. (2) The results of qRT-PCR and Western blot showed that the expression levels of IL-24 in PBS group and Ad-GFP group were significantly lower than those in Ad-IL-24 group (all P<0.05). (3) U251 cells infected with 100 MOI Ad-IL-24 for 48 h significantly inhibited the growth of U251 cells and the inhibitory effect was significantly higher than that in PBS and Ad-GFP groups (bothP<0.05) and presented certain time dependence (P<0.05). (4) The U251 cells were infected with 100 MOI Ad-IL-24 for 48 h. Flow cytometry results showed that the rate of cell apoptosis in Ad-IL-24 group was 39.2%±4.2%, which was significantly higher than that of PBS group and Ad-GFP group (2.5%±1.0% and 4.9%±2.3%, respectively, bothP<0.05). (5) The expression level of Survivin in Ad-IL-24 group was significantly lower than that in PBS group and Ad-GFP group (bothP<0.05). The expression level of Bax was significantly higher in Ad-IL-24 group than in PBS group and Ad-GFP group (bothP<0.05).

Ad-IL-24 expression could significantly inhibit the growth of U251 cells and induce apoptosis. It is speculated that the mechanism of action may be down-regulating the expression of apoptosis-inhibiting gene Survivin and up-regulating the expression of apoptosis-promoting gene Bax.

Pituitary adenoma is one of the common benign tumors in the cranium, accounting for the third place among intracranial tumors. The harm of pituitary adenoma is mainly endocrine dysfunction and compression of surrounding normal tissues causing symptoms. At present, multidisciplinary and comprehensive treatment strategies are mostly adopted for pituitary adenomas, but surgical resection is still considered to be the most effective treatment for pituitary adenomas that cause symptoms. The commonly used surgical method is microscopic or endoscopic transnasal sphenoidal sinus tumor resection. Because the tumor is adjacent to important structures such as internal carotid artery and optic nerve, the texture of pituitary adenoma is an important factor affecting the difficulty of surgery and the resection rate of tumor. With the development of imaging technology, preoperative MRI has provided some help for the judgment of tumor texture during operation. However, the current research conclusions on the effect of preoperative MRI examination to predict intraoperative tumor texture are inconsistent, and there is no conclusion on which sequence to apply to predict tumor texture. This article reviews the research progress of preoperative MRI in predicting the texture of intraoperative pituitary adenomas.

traumatic brain injury (TBI) is a kind of severe trauma caused by external force acting on the head. The mortality rate is 4% ~7%, and the mortality rate of severe brain injury is higher, reaching 50% ~60%. TBI can be divided into two categories: closed injury and open injury. The secondary symptoms caused by TBI, such as intracranial hypertension, brain ischemia and hypoxia, brain energy metabolism disorder, etc., are common causes of death and disability^[1]。 Monitoring the dynamic progression of secondary brain injury by nervous system monitoring technology is of great significance to guide the evaluation and treatment of TBI patients. At present, common brain metabolism monitoring techniques include diffusion-weighted magnetic resonance imaging, CT perfusion imaging, etc^[2]。 However, these imaging tests cannot dynamically monitor the metabolic changes of brain tissue in real time, so they cannot detect and intervene in the occurrence of secondary brain injury in time. In the early 1990s, microdialysis technology, as a tool to dynamically monitor the microenvironment and cell metabolism of brain capillaries, began to be applied to neurointensive care. In the past 10 years, many clinical studies using microdialysis technology have better explained the pathogenic mechanism of secondary brain injury, such as cerebral edema, energy metabolism disorder, neuroinflammatory reaction, etc., and improved new treatment methods and the effect of new drugs on the body. It is used at the bedside in combination with instruments to monitor intracranial pressure and brain tissue oxygen partial pressure of TBI patients, and can be used to guide individualized intensive care treatment of TBI patients^[3]。

Intracranial aneurysm is a common cerebrovascular disease of unknown etiology, manifested by localized dilatation of arteries, which is one of the main causes of subarachnoid hemorrhage. At present, it is believed that genetic factors, hemodynamic abnormalities and vascular risk factors are involved in the formation of intracranial aneurysms. The pathological changes mainly included absence of internal elastic layer, degradation of extracellular matrix (ECM), ectopic smooth muscle cells, etc^[1]。 It is well known that the phenotypic regulation of vascular smooth muscle cell (VSMC) plays an important role in the occurrence and development of peripheral vascular diseases, hypertension, and angioproliferative diseases^[2]。 Nakajima et al.^[3]Phenotypic transformation of VSMC in human aneurysm walls was found and predicted to be related to the development and rupture of intracranial aneurysms. In this paper, the research progress on the role of VSMC phenotype regulation in the occurrence and development of intracranial aneurysms in recent years is reviewed.