Volume 34 · Issue 10 · 2018

Since the American Heart Association published the "Recommendations for the Management of Intracranial Arteriovenous Malformations" (2001 edition statement) in 2001^[1]Over the past decade, people have gained more knowledge about brain arteriovenous malformations (bAVMs). Therefore, the American Heart Association organized relevant experts to search the literature included in PubMed, Medline and Embase from the 2001 edition of the statement until the end of January 2015, reviewed the existing data, supplemented and revised the 2001 edition of the statement, and issued a new bAVMs treatment statement in 2017-"Management of Intracranial Arteriovenous Malformations" (referred to as the 2017 edition statement)^[2]。 Since 2001, we have accumulated new data on the epidemiology, biology, imaging and treatment of bAVMs, the most notable of which is the publication of the results of the first prospective randomized controlled trial of undisrupted bAVMs (ARUBA; multicenter, non-double-blind trial^[3]。 The 2001 edition statement pointed out that both Grade I and II recommendations need to be supported by the results of randomized controlled studies, but there were no studies that met the requirements at that time, so it was insufficient to provide Grade I and II evidence. Therefore, the results of the ARUBA trial received great attention in the 2017 edition of the statement. The 2017 edition stated that bAVMs was classified into two types, unruptured and ruptured, according to whether the first symptom was intracranial hemorrhage, and was described separately. Combined with the newly published literature at home and abroad, this paper interprets the contents of unruptured bAVMs in the 2017 edition of the statement.

traumatic spinal cord injury (tSCI) is a catastrophic disease that seriously harms young adults. It often leads to severe neurological injury and significant decline in quality of life, and causes a heavy burden on families and society. The main causes of injuries include accidental injuries such as car accidents, high altitude falls, falls, diving and skiing, etc.

To investigate the features and surgical treatment of patients with intracranial hematoma caused by ruptured middle cerebral artery (MCA) aneurysms.

A total of 823 patients with MCA aneurysms were admitted to Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology from January 2013 to January 2017. Among them, 43 patients resulted in only intracranial hematoma without subarachnoid hemorrhage (SAH). Out of 43 patients, temporal lobe hematoma was reported in 25, frontal lobe hematoma in 8 and intracerebral and intraventricular hematomas in 10. Pre-operative angiography was applied in 33 (76.8%) patients. Among the patients without pre-operative angiography, 5 (11.6%) underwent operation because of urgent cerebral hernia and 5 (11.6%) received operation primarily due to their misdiagnosis as hypertensive intracranial hematoma. Microsurgical clipping of intracranial aneurysms was applied in all 43 patients, primary decompressive craniotomy in 8, external ventricular drainage in 4 patients and tracheotomy in 6 patients. The clinical data of these 43 patients were retrospectively analyzed.

The grades of GOS (Glasgow outcome scale) assessed at 2 weeks post operation were Ⅰ in 3 patients, Ⅱ-Ⅲ in 2 and Ⅳ-Ⅴ in 38. Perioperative infarction occurred in 1 (2.3%) case, severer hemiplegia than preoperative conditions in 2 (4.7%) and chronic hydrocephalus in 2 (4.7%). Among 40 patients wdho survived, 4 patients was lost to follow-up, which lasted for 3-48 months, with an average of 26.4±5.6 months. Favorable outcome, based on GOS, was reported in 34 (94.4%, 34/36) cases and poor outcome in 2. Imaging follow-up revealed no aneurysm recurrence.

MCA aneurysmal hematomas without SAH are rare and easy to be misdiagnosed. However, their surgical treatment might lead to relatively good outcomes.

To explore the clinical features and microsurgical treatment strategies of the distal anterior cerebral artery aneurysms (DACAA).

A retrospective cohort study was conducted on 24 patients with DACAA admitted to Department of Neurosurgery, West China Hospital, Sichuan University from March 2013 to June 2014. All cases received clipping surgery. The aneurysm occlusion was assessed by CTA or DSA post operation and the treatment outcome was evaluated using Glasgow outcome scale (GOS) at discharge and modified Rankin scale (mRS) at follow-up.

A total of 33 aneurysms of 24 patients were completely clipped during operation. On the day of operation, postoperative CT revealed complete or partial removal of intracranial hematoma. Complete clipping of aneurysm and patency of parent artery or branch artery were confirmed by CTA or 3D-DSA before discharge. Postoperative complications included hematoma expansion in 1 (4.2%) and transient mental disorder in 1 (4.2%). The GOS assessment at discharge revealed grade V in 20 cases, grade IV in 3 and grade III in 1. The follow-up lasted for 6-12 months. The last follow-up revealed the mRS of 0-1 in 21 cases, 2 in 2 and 6 in 1. There were 95.8% (23/24) of 24 patients who achieved good outcome.

DACAA has a low incidence rate and high surgical risks. Microsurgical clipping could be effective for its treatment.

To explore the risk factors affecting the rupture of intracranial aneurysms (IA).

A retrospective analysis was conducted on 486 patients with IA admitted to Department of Neurological Intervention, Beijing Tiantan Hospital Affiliated to Capital Medical University and 95 IA patients admitted to Department of Neurosurgery of Beijing Luhe Hospital Affiliated to Capital Medical University from January to December of 2016. According to the presence/absence of rupture, those patients were divided into ruptured group (n=120) and unruptured group (n=461). Univariate analysis and multivariate logistic regression analysis were used to analyze the risk of IA rupture.

Univariate and multivariate logistic regression analysis showed that hypertension (OR=1.778, 95% CI: 1.101-2.870, P=0.019) and the location of aneurysm (anterior communicating: OR=15.808, 95% CI: 7.284-34.309, P<0.001; posterior communicating:OR=11.437, 95% CI: 5.303-24.665, P<0.001), maximum diameter (OR=2.045, 95% CI: 1.144-3.657, P=0.016) and shape (OR=1.705, 95% CI: 1.030-2.825, P=0.038) are independent risk factors for IA rupture, while hyperlipidemia was a protective factor (OR=0.212, 95% CI: 0.073-0.615, P=0.004) and could reduce the risk of rupture of IA. The risk of rupture in patients with smoking <20/d and smoking ≥20/d was 3.290 and 3.460 times that of non-smokers, respectively, indicating that the risk of IA rupture was elevated with the increase of number of cigarettes smoked per day ( P<0.05). There was no significant difference in the risk of aneurysm rupture between patients with smoking cessation and non-smokers (OR=0.654, 95% CI: 0.179-2.388, P=0.520).

Smoking is an independent risk factor for rupture of IA and smoking cessation does not increase the risk of rupture of IA. Hypertension, located at ACoA (anterior communicating artery) and PCoA (posterior communicating artery), aneurysm diameter of ≥7 mm and irregular shape could increase the rupture risk of IA while hyperlipidemia could reduce the risk of IA rupture.

To evaluate the tendency of circle of Willis variation and hemodynamic alteration for the purpose of identifying predictors of single intracranial aneurysm (IA) formation.

A retrospective study was conducted on 223 patients with DSA-confirmed single IA (IA group) admitted to Neurosurgery Department of Zhujiang Hospital, Southern Medical Hospital and 118 patients without IA (control group) from November 2010 to November 2011. The 3D-DSA images were carefully evaluated to confirm the variation of circle of Willis by vascular structural abnormity in those 2 groups. TCCD (transcranial color Doppler) was performed to measure the hemodynamic parameters. Multivariate predictors of IA formation were analyzed by using univariate analysis and multivariate logistic regression.

The incidence of variation of circle of Willis in IA group was higher than that in control group [78.0% (174/223) vs. 11.9% (14/118), P<0.001]. Besides, the incidence of variation of anterior circle of Willis in IA group was higher than that of variation of posterior circle of Willis [63.8% (111/174)vs. 36.2% (63/174)]. The incidence of variation of anterior circle of Willis in IA group was more in the left side than the right [46.0% (80/174) vs. 17.8% (31/174)]. Both WSS (arterial wall shear stress) and CWT (circumferential wall tension) in IA group were higher than those in control group (WSS: 8.7±2.7 dyne/cm²vs. 7.9±1.6 dyne/cm^2,P=0.007; CWT: 3.8±1.1 dyne/cm²vs. 3.5±1.0 dyne/cm^2,P=0.014]. Univariate and multivariate analysis showed that the female gender (OR=1.970, 95%CI: 1.010-3.870, P=0.048), hypertension (grade Ⅱ) (OR=2.830, 95%CI: 1.160-86.880, P=0.022), variation of circle of Willis (OR=29.680, 95%CI: 10.280-85.680, P<0.001) and WSS (OR=1.530, 95%CI: 1.140-2.070, P=0.005) were independent risk factors of IA formation.

The variation of circle of Willis predominantly occurs in IA patient. The incidence rate of variation of anterior circle of Willis seems higher than that of variation of posterior circle of Willis. The female gender, hypertension (grade Ⅱ), variation of circle of Willis and WSS are independent risk factors of IA formation.

Endovascular embolization has become one of the main methods for the treatment of intracranial aneurysms, and has achieved good results^[1,2]。 However, when the branch artery is closely related to the aneurysm, even from the neck or body side wall of the aneurysm, the branch artery needs to be preserved during the embolization process, which is a difficult problem in aneurysm embolization^[3,4]。 From January 2014 to January 2017, 6 patients with ruptured intracranial aneurysms involving branch arteries were embolized by coil support technique in the Department of Neurointervention, Beijing Chaoyang Hospital affiliated to Capital Medical University, with satisfactory results. The results are reported retrospectively below.

Anterior communicating artery aneurysms are common intracranial aneurysms, accounting for 1/4 of all intracranial aneurysms^[1]。 Rupture and bleeding of anterior communicating artery aneurysm can lead to dysfunction of corresponding blood supply area, and promote adhesion and spasm of surrounding blood vessels, which not only seriously affects the life safety of patients, but also limits the treatment of craniotomy^[1]。 Endovascular stent-assisted embolization has greatly improved the safety and effectiveness of coil embolization of anterior communicating artery aneurysms. This study retrospectively analyzed the clinical data of 34 patients with anterior communicating artery aneurysm treated with LVIS stent-assisted embolization, and evaluated its safety and efficacy by analyzing the degree of embolization, efficacy, complications and recurrence.

To investigate clinical factors of recurrence of unruptured paraclinoid aneurysms following endovascular embolization at follow-up.

A total of 89 consecutive patients with 104 paraclinoid aneurysms admitted into Department of Interventional Radiology, Huashan Hospital Affiliated to Fudan University between March 2011 and August 2016 were enrolled retrospectively in this study. Patients were treated with stent-assisted coiling (SAC) or simple coiling (SC). Digital subtraction angiography (DSA) was conducted immediately post operation and modified Rankin scale score (mRS) was evaluated before discharge. Rotation DSA was included to observe whether the aneurysm recurred and whether the coil had become compacted at follow-up. Univariate and multivariate Cox regression were further used to analyze the clinical factors influencing aneurysm recurrence.

For 89 patients (104 aneurysms), SAC was applied for 73 aneurysms and SC for 31. Operational success rate was 100.0%. There were 16 (18.0%) cases of asymptomatic thrombosis and 2 (2.2%) cases of acute postoperative stent thrombosis complications. There were no symptoms of new neurological deficits following timely treatment. Five patients with diplopia and 1 with blurred vision recovered to normal post surgery. For immediate postoperative DSA results, 61 (58.7%) were graded as Raymond Ⅰ, 18 (17.3%) as Ⅱ, 13 (12.5%) as Ⅲa and 12 (11.5%) as Ⅲb. The mRS score was 0-2 in 75 cases and 3-4 in 14. The follow-up period was 3-43 months, with an average of 10.2±3.1 months. During the follow-up, 14 (13.5%) showed recurrence with local coil compaction. The mRS score was 0-2 in 83 cases and 3-4 in 6. Univariate Cox regression analysis revealed that the aneurysm size, daughter sac, size ratio (SR) were risk factors for aneurysm recurrence (all P<0.05). Multivariate Cox regression analysis results showed that SR value (HR=1.674, 95% CI: 1.109-2.526, P=0.014) was an independent risk factor for aneurysm recurrence.

Aneurysm size, daughter sac and SR tend to be related to a relatively high recurrence post treatment. Among those, the SR is an independent risk factor for recurrence of aneurysm.

To explore the management of global cerebral swelling and hyperperfusion in patients following cerebral aneurysm surgery.

A retrospective study was conducted on 30 patients who developed global cerebral edema post operation of intracranial aneurysm and admitted to Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University from October 2011 to October 2017. The patients’ medical records, laboratory data and outcome follow-up results were analyzed.

The GCS (Glasgow coma scale) scores were significantly increased from 9.0±1.2 to 13.7±1.5 after the treatment of withdrawal of anti-vasospasm drugs combined with dehydration therapy (P<0.01). During global cerebral edema, the global cerebral blood flow (CBF) increased 4.72(7.28) ml·100 g^-1·min^-1, the global cerebral blood volume (CBV) increased 0.36(0.74) ml/100 g, the mean transit time (MTT) increased 2.52(2.34) s, the maximum velocity of MCA (Vmax) increased 50.35(66.99)cm/s, the mean velocity of MCA (Vmean) increased 26.43(46.19)cm/s compared with pre-surgical data (all P<0.01). For outcome assessment, GOS grade V was reported in 22 cases, IV in 4 and III in 4 at discharge.

Cerebrovascular hyperperfusion leads to global cerebral swelling following intracranial aneurysm surgery, which needs to be differentiated from cerebral vasospasm. Withdrawal of anti-vasospasm drugs combined with dehydration therapy could alleviate global cerebral edema and improve the patient’s neurological deficits.

To investigate the differences in the diagnosis and treatment between iatrogenic intracranial pseudoaneurysms (II-PSAN) and traumatic intracranial pseudoaneurysms (TI-PSAN).

In this retrospective study, 11 patients with intracranial PSAN admitted to the Department of Neurosurgery of Huashan Hospital Affiliated to Fudan University between January 2013 and December 2017 were enrolled. Among those 11 cases, TI-PSAN was diagnosed in 9 cases and II-PSAN in 2. In the 9 TI-PSAN cases, there were 11 PSAN including 7 undergoing embolization treatment (PSAN and parent artery), 2 receiving revascularization (stent and Guglielmi detachable coil placement in 1 and double stents placement in 1), 1 undergoing surgery and the other 1 receiving no treatment. For the 2 cases with II-PSAN, 1 received embolotherapy and 1 received revascularization using LVIS stent and GDC. At the follow-up, the DSA, CTA or MRI was performed to evaluate the recurrence and residue of PSAN and assess the outcomes by using the modified Rankin score (mRS).

Among the 13 PSAN of 11 patients, 12 showed satisfactory outcomes after surgery. One TI-PSAN patient died from intracranial hemorrhage at 1 day post surgery and no postoperative hemorrhage was reported in the other 10 cases. The 10 cases were followed up for 1-36 months, with an average of 13 months. Among them, 6 received DSA in the follow-up and the other 4 received CTA or MRA in the follow-up. Among 8 cases with TI-PSAN, no revascularization or recurrence of PSAN was reported in the 6 cases undergoing embolization and the vascular compensation was satisfactory. In the other 2 cases undergoing revascularization, 1 showed no residual or recurrent PSAN and 1 showed residue in the aneurysm neck. In the 2 II-PSAN cases, there was no residual or recurrent PSAN. Eight TI-PSAN cases showed the mRS score of 0-2 and 2 cases with II-PSAN showed the mRS score of 0. The outcomes were all good.

Unlike TI-PSAN, the symptoms of II-PSAN are not typical. Thus, much attention should be paid to the diagnosis of II-PSAN. For the II-PSAN patients or TI-PSAN patients with mild vascular injury and good integrity, vascular reconstruction is preferred. For PSAN patients with poor vascular integrity and compliance to reconstruction, occlusion of PSAN combined with vascular bypass surgery should be considered in advance.

To investigate the safety and efficacy of embolization assisted with varying stent release methods in the treatment of intracranial wide-neck bifurcation aneurysms (WNBA).

A retrospective analysis was conducted on 62 patients with WNBA treated with varying stent release methods at Department of Neuro-intervention, the First Affiliated Hospital of Zhengzhou University from May 2012 to May 2017. Among them, 14 patients were treated with "waffle cone" technique, 29 with double stents in "Y" configuration, 1 with double stents in "X" configuration and 18 with LVIS "Barrel" technique.

Except 1 case that failed to be treated with "Y" configuration, the others underwent successful operations. According to the Raymond classification, the immediate procedural outcome was Class I in 30 (48.4%) patients, Class II in 21 (33.9%) and Class Ⅲ in 11 (17.7%). Perioperative ischemic complications occurred in 6 (9.68%) cases including intraoperative thrombosis in 2 cases and acute ischemic complications post operation in 4. Postoperative thalamic hemorrhage was reported in 1 (1.6%) case. Clinical follow-up lasted for 5-57 months, with an average of 11.9±1.7 months. For 59 cases, the mRS (modified Rankin scale) score was 0-1 in 55 (93.2%) cases, 2-3 in 2 (3.4%) and 4-5 in 5 (3.4%). Angiographic follow-up at 3-36 months in 33 cases showed that aneurysms were completely occluded in 18 (54.6%), improved in 5 (15.2%) and remained stable in 9 (27.3%). There was 1 (3.0%) case with aneurysm recanalization that needed retreatment.

The technical feasibility and safety of embolization assisted with varying stent release methods could be accepted for treatment of intracranial WNBA. However, further studies are needed for evaluation of its long-term efficacy.

To summarize the epileptogenic localizations, pathological findings and long-term surgical outcomes of patients with refractory epilepsy at a single center during past 15 years.

A total of 2 424 patients who underwent epilepsy surgeries at Department of Functional Neurosurgery between April 2001 and December 2016 were included in this retrospective study. The traits of epileptogenic localization were analyzed. Outcomes of all patients who were followed up longer than 1 year post surgeries were studied in two stages, and the rate of seizure free was calculated.

Among all 2 424 patients, 1 299 (53.6%) had obvious lesions on MRI. There were 1 007 (41.5%) patients who underwent intracranial electrode placement and 65.5% of those had no definite lesions on MRI. There were 1 030 (42.5%) cases who were diagnosed as temporal lobe epilepsy (TLE) and 1 394 (57.5%) diagnosed as extratemporal lobe epilepsy (ETLE). The common pathological types included focal cortical dysplasia (37.5%, 909), mesial temporal sclerosis (17.7%, 429), ulegyria (15.7%, 381) and low grade tumor (9.2%, 223). There was a double pathological change in 303 (12.5%) patients. A total of 1 424 (59.0%) patients were followed up for more than 1 year post surgery. At the first stage of follow-up (April 2001 to July 2012), 846 patients completed follow-up lasting at least 1 year. The seizure-free rate was 64.7% (547/846) at 1 year, 52.5% (241/459) at 3 years and 49.6% (119/240) at 5 years post surgery. For the patients with TLE, the seizure-free rate was 57.9% (210/363) at 1 year, 57.8% (108/187) at 3 years and 56.3% (58/103) at 5 years post surgery. For the patients with ETLE, the seizure-free rate was 59.4% (287/483) at 1 year, 47.8% (130/272) at 3 years and 46.7% (64/137) at 5 years post operation. At the second stage of follow-up (August 2012 to September 2015), 578 patients completed follow-up lasting at least 1 year. The seizure-free rate was 64.7% (374/578) at 1 year and 57.3% (133/232) at 3 years post surgery. For the patients with TLE, the seizure-free rate was 71.4% (187/262) at 1 year and 66.4% (64/95) at 3 years post operation. For patients with ETLE, the seizure-free rate was 59.5% (188/316) and 51.1% (70/137) at 1 year and 3 years post operation respectively. However, the difference in the seizure free rate was significant only at the first year post surgery in the patients with TLE between the 2 stages (57.9% vs. 71.4%, P=0.001), and there was no significant difference afterwards.

Long-term intracranial recording seems to be indispensable for identification of epileptogenic focus for some patients. Although surgical efficacy might decrease to some extent with extension of postoperative time, surgical treatment is beneficial and postoperative outcome is relatively stable for patients with either temporal or extratemporal epilepsy.

To investigate the clinical data and origin of pineal meningiomas, and to discuss the definite meaning of the term "velum interpositum meningioma" .

From January 2005 to December 2016, 21 cases of pineal region meningiomas underwent operations at Department of Neurosurgery, Nanfang Hospital, Southern Medical University and were enrolled into this retrospective study. Analysis was conducted on the clinical characteristics, imaging findings and surgical video data of those patients who were divided into 2 groups according to literature: falcotentorial meningioma group and velum interpositum meningioma group. Comparison was conducted between the 2 groups.

Among 12 cases of falcotentorial meningiomas, 4 cases were originated from cerebral falx, 4 from cerebellar tentorium and 4 from straight sinus. Among 9 cases of velum interpositum meningiomas, 7 were originated from the cerebral arachnoidal envelope, 1 from the posterior cerebral vein and 1 from pineal surface. Postoperative pathological examination confirmed the diagnosis of meningioma in all cases. Among those, total resection was achieved in 16 cases and subtotal resection in 5. There were 3 cases of vertical movement limitation of the eyes, 7 cases of isotropic hemianopia, 1 case of hemiplegia, and 1 case of death.

The falcotentorial meningioma and primary pineal meningioma might be more appropriate for classification of origins of pineal meningiomas. The term "velum interpositum meningioma" may not be able to accurately reflect the origin of meningioma in the pineal gland region. During resection of pineal gland meningiomas, the protection of large veins and collateral circulation is of much significance.

To summarize the diagnostic efficiency, application value and safety of CereTom 8-layer mobile CT in neurosurgery.

This study retrospectively analyzed the number of cases, number of examinations, location and mode of CereTom's 8-layer mobile CT head bedside scan from August 2010 to July 2017 at Affiliated Bayi Brain Hospital, PLA Army General Hospital. We analyzed the characteristics of brain disorders, diagnostic efficiency and radiation doses.

(1) Number and pattern of mobile CT examinations: A total of 78, 771 head scans were performed in 49, 068 patients including 44, 433 at outpatient emergency rooms, 4, 549 at ICU (intensive care unit) and 86 at operating rooms. Those consisted of 48, 905 plain scans and 163 enhanced scans, some of which were for 115 cases of intracranial aneurysms with three-dimensional CT angiography. (2) Types of disorders: There were 13, 516 cases of craniocerebral injury and 21, 665 cases of cerebrovascular disorders (including 10, 594 cases of cerebral infarction, 5, 045 cases of cerebral hemorrhage, 6, 026 cases of subarachnoid hemorrhage), 2, 450 cases of brain tumor, 115 cases of intracranial aneurysm, 1, 795 cases of others such as trigeminal neuralgia, hemifacial spasm and skull base depression. There were 37, 160(75.73%) patients with mild to moderate disorders and 11, 908 patients (24.27%) with severe conditions. (3) Diagnostic efficiency: The total positive rate of mobile CT scan was 80.35% (39, 426/49, 068) and positive rate of mobile CT examination at ICU and operating room was 100%. (4) Radiation dose: The volumetric dose index of mobile CT was (76.03±1.54) mGy, the absorbed dose was (8.26±0.50) mSv, and the radiation dose was (82.54±3.13) mGy, which were significantly higher than those of large fixed CT [(63.52±3.72)mGy, (5.46±0.72)mSv, (71.09±2.98)mGy, respectively, P<0.05)]. However, the radiation dose values of mobile CT were within the scope of international radiation standards.

The volume of mobile CT is small, which is convenient for bedside scan. Its imaging quality is stable with high diagnostic efficiency as well as safety and reliability.

To summarize the imaging findings, treatment and prognosis of pituitary adenoma associated with intracranial aneurysm.

From July 2014 to June 2017, 4 patients (3 females and 1 male) with pituitary macroadenoma associated with intracranial aneurysm were admitted to Neurosurgery Department of the Second Affiliated Hospital of Zhejiang University School of Medicine. Among them, 1 patient had bilateral ophthalmic artery aneurysms and 2 cases had right ophthalmic artery aneurysms. All those 3 cases underwent endovascular treatment of intracranial aneurysms followed by transsphenoidal surgery for pituitary adenomas. The other 1 patient with anterior communicating artery aneurysm underwent successful clipping of aneurysm after removal of pituitary adenoma.

Of the 4 patients with pituitary adenoma and intracranial aneurysm, 3 underwent endovascular embolization of the aneurysm followed by endoscopic transsphenoidal pituitary adenoma resection. MRI showed no recurrence after resection. Digital subtraction angiography (DSA) was performed and revealed that the aneurysm had no recurrence and a good prognosis. One patient with anterior communicating artery aneurysm, although undergoing aneurysm clipping and pituitary adenoma resection, eventually gave up treatment due to pulmonary infection, resulting in a poor prognosis.

For patients with pituitary adenoma with high risk factors, it is recommended to perform magnetic resonance angiography (MRA) and/or DSA before surgery. MRI T1 and T2 weighted sequences showing flow shadow is an important factor for pituitary adenoma with intracranial aneurysms. For patients with pituitary adenomas with intracranial aneurysms, one or two stages of surgery should be performed according to the presence or absence of aneurysm, and a relatively good prognosis can be obtained.

To investigate the significance of atrophy of the trigeminal nerve (cistern portion) in the diagnosis of primary trigeminal neuralgia.

We retrospectively analyzed 59 PTN (primary trigeminal neuralgia) patients (experimental group) and 25 patients with hemifacial spasms (control group) admitted to Department of Neurosurgery, the Affiliated Hospital of Qingdao University from February 2014 to January 2016. The MRI data were used to measure and compare the volumes and CSAs of bilateral trigeminal nerves (cistern portions) in coronal plane. We investigated the relationship of trigeminal nerve atrophy to the type of offending vessels, neurovascular compression regions and extent.

The mean volume of the trigeminal nerve on the affected side (63.3±14.5 mm³) was significantly less than that on the contralateral side (74.4±16.5 mm³) or in the control group (73.2±13.8 mm³) (all P<0.05). Similarly, the mean CSA of the trigeminal nerve on the affected side (3.8±1.1 mm²) was significantly smaller than that on the contralateral side(4.6±1.3 mm²) or in the control group(4.9±1.1 mm²)(all P<0.05). The differences of trigeminal nerves in their volumes (14.5%±3.8 %) and CSAs (11.0%±2.8 %) between the two sides in the PTN group were greater than those in the control group (volume: 3.7%±1.2%, CSA: 2.9%±0.7%) (P<0.001). The CSA difference between the two sides was significantly greater in the arterial compression group (11.9%±4.3%) than venous compression group (4.8%±1.9%) (P=0.016), and greater in the degree III and II compression groups than degree I compression group (P=0.022).

Trigeminal nerve (cistern portion) atrophy might be associated with PTN and have certain value for the diagnosis of PTN.

neurofibromatosis 2 (NF2) is an autosomal dominant disease caused by mutations in the NF2 gene, and its incidence is about 1 in 25 000^[1]。 NF2 can be manifested as bilateral vestibular schwannoma, subcutaneous schwannoma, cataract, meningioma, intraspinal schwannoma, etc^[2,3]。 Studies have shown that 45% ~75% of NF2 patients are accompanied by multiple intraspinal schwannomas. When the tumor enlarges, compressing the surrounding tissues can cause pain, limb sensory or motor disorders, urine and fecal incontinence and other symptoms, which affect the quality of life of NF2 patients^[4,5,6]。 Surgical treatment is the main treatment for intraspinal schwannoma in NF2 patients at present. At present, the research mainly focuses on the treatment of bilateral vestibular schwannoma caused by NF2, and there are few reports on the treatment of intraspinal schwannoma caused by NF2. This article retrospectively analyzed 37 patients with intraspinal NF2 admitted to the Department of Neurosurgery of Beijing Tiantan Hospital affiliated to Capital Medical University from June 2004 to December 2015, and discussed their clinical symptoms, treatment methods and efficacy, which are summarized and reported below.

dural arteriovenous fistulae (DAVF) are complex lesions in cerebrovascular diseases. Because the cavernous sinus involves large intracranial vessels and multiple groups of cranial nerves, the treatment of DAVF in the cavernous sinus area is particularly difficult. With the continuous progress of endovascular therapy techniques and materials, the therapeutic effect of DAVF in cavernous sinus region has been greatly improved^[1,2,3]。 Although conventional endovascular treatment of DAVF in cavernous sinus can improve the clinical symptoms of most patients, it is easy to lead to recurrence due to the impossibility of complete embolization and the establishment of collateral circulation. The Brain Center of the Affiliated Hospital of Armed Police Logistics College has achieved good clinical results in the treatment of DAVF in the cavernous sinus area through superior ophthalmic vein approach since 1993. However, this approach needs to expose the superior ophthalmic vein. If the superior ophthalmic vein is thin and difficult to intubate, it will occasionally lead to rupture of the superior ophthalmic vein, and the postoperative wound is prone to edema and there is a risk of infection. Since 2007, the Brain Center of the Affiliated Hospital of Armed Police Logistics College has used the inferior petrosal sinus (IPS) approach to treat 37 cases of DAVF in the cavernous sinus area, and achieved good therapeutic results. The retrospective analysis is as follows.

With the aging of our population and the improvement of people's living conditions, cardiovascular and cerebrovascular diseases have replaced tumors as the first cause of death in our country, and their mortality rate is 4~5 times higher than that in European and American countries^[1]。 The incidence, disability and mortality of stroke are extremely high. Early detection of high-risk stroke groups, early intervention treatment and standardized management are of great significance to reduce or delay the occurrence of stroke^[2]。 The Brain Hospital of Liaocheng People's Hospital, as a stroke screening base and a carotid endarterectomy (CEA) training base, undertakes the screening of people over 40 years old in Liaocheng, Shandong Province. The screening results are summarized and analyzed as follows.

To analyze the expression and function of cell division cycle-associated 7-like protein (CDCA7L) in gliomas and to investigate the biological processes and signal pathway involved in glioma cells by CDCA7L.

The clinical data and CDCA7L expression information of 309 glioma patients were collected retrospectively from the CGGA mRNA sequencing data. TCGA mRNA sequencing was used as validation sets. Kaplan-Meier method and log-rank test were used to estimate the role of CDCA7L in the prognosis of patients. Gene ontology (GO) and KEGG pathway analysis were used to obtain biological processes and signal pathway involved in CDCA7L expression. Transwell chamber assay was used to detect the effect of knockdown of CDCA7L protein on migration of glioma cell lines. Flow cytometry was used to analyze the effect of knockdown of CDCA7L protein on glioma cell line apoptosis.

CDCA7L was significantly upregulated along with tumor grades progress of glioma [0.053 (0.051), 0.083 (0.078)and 0.133 (0.152), respectively from WHO Ⅱ to Ⅳ, all P<0.05]. The expression of CDCA7L was higher in IDH wild-type gliomas [0.123 (0.165)and 0.068 (0.068),P<0.001]. Survival analysis revealed that high expression of CDCA7L indicated a poor survival outcome (P<0.001). Knockdown of CDCA7L inhibited glioma cell migration and promoted apoptotic (allP<0.01).

CDCA7L may be associated with the biological processes and signal pathway of glioma such as cell cycle, cell division, DNA replication, DNA repair and chromosome segregation. CDCA7L could promote the development of glioma and thus be used as a prognostic indicator and a potential therapeutic target.

hemangiopericytoma (HPC) is a rare tumor of vascular origin, which occurs mainly in adults and children<10%^[1]。 Because of its low incidence, difficult preoperative diagnosis, abundant blood supply, and difficult surgical treatment, the treatment of HPC is extremely challenging. At present, there is no unified treatment standard in the world. A neonatal congenital frontal HPC was treated in the Department of Neurosurgery of Yangzhou University Affiliated Hospital in October 2012, and the prognosis was good. The report is now as follows.

PatientMale, 37 years old. The main reason was "20 years of defecation and urination disorders after suffering from Guillain-Barre syndrome (GBS)". The patient was diagnosed with GBS 20 years ago due to weakness of both lower limbs and urinary incontinence, and was given drug treatment, and the symptoms of weakness of both lower limbs were slightly improved. The patient has urinary incontinence, urinating about every 10 minutes, and sleeping enuresis at night; Constipation, about once every 7 days. The patient complained of abnormal sensation below the knee joint in both lower limbs, weakness in both toes and ankles, and forward leaning when walking. Poor sexual function. Admission physical examination: anal relaxation, anal reflex disappearance, dull pain stimulation around the anus about 20 cm, bilateral ankle muscle strength grade IV, bilateral toe muscle strength grade III. Bilateral knee tendon reflexes were slightly hyperactive, Achilles tendon reflexes were obtuse, and bilateral Babinski sign was positive. B-ultrasound of urinary system: the morphology of both kidneys, ureters and bladder was normal, and the residual urine volume of bladder after urination was 24 ml. Urodynamic findings: slightly dull sensation of the bladder, hyperactivity of the detrusor muscle, and decreased bladder compliance. Admission diagnosis: sequela of GBS-neurogenic bladder, refractory constipation. Neuromodulation was performed according to standard procedures^[1,2]。 Via left S₃The electrode was inserted into the sacral plexus and connected with the extracorporeal temporary sacral nerve modulator. The treatment for 2 weeks was satisfactory. The permanent sacral neuromodulator Intersim II (Medtronic, USA) was then installed (Figure 1)。 Stimulation parameters: frequency 14 Hz, pulse width 220 μ s, voltage 2 V. The patient had normal urination and defecation at 7 days after surgery, without urinary incontinence, enuresis or constipation. After 1 year follow-up, the patient had normal urine and defecation. Since 3 months after surgery, there was occasional enuresis during night sleep, but it could be avoided by restricting drinking and eating 4 hours before bedtime. B-ultrasound revealed that the ureter and bladder of both kidneys were normal and the residual urine volume was 0.

Ischemic stroke has a high incidence rate. In the United States, for example, 800,000 strokes occur every year, of which 610,000 are new strokes, and ischemic stroke accounts for 87%^[1]。 Large vessel occlusion (referring to the internal carotid artery, the main middle cerebral artery, the basilar artery and the intracranial vertebral artery) occupies a high proportion of ischemic stroke. An imaging evaluation of 2 152 patients with acute ischemic stroke performed by magnetic resonance angiography (MRA) or CT angiography (CTA) found that arterial occlusion was present in 1 043 patients (48.5%), including a total of 860 (40.0%) large vessel occlusions^[2]。 Occlusion of large vessels is closely related to the poor prognosis of stroke (modified Rankin scale score 3-6), and the poor prognosis rate of occlusion of large vessels without successful recanalization is as high as 91%-95%^[3]。 Intravenous thrombolysis is inefficient for recanalization of large vessel occlusion, and thrombus with a diameter of more than 8 mm can hardly be dissolved by tissue plasminogen activator (tPA) (<1%)^[4]。 In recent years, several large randomized controlled studies have confirmed the effectiveness of endovascular treatment for acute anterior circulation large vessel occlusion. Compared with intravenous thrombolysis alone, it has achieved higher recanalization rate and lower disability and fatality rate, and has become one of the main treatment modalities for acute ischemic stroke^[5,6]。 However, recanalization surgery is different from traditional surgery, and its recanalization time is crucial for surgical outcome. Early recovery of cerebral blood flow is the key to prevent permanent brain tissue damage. Recanalization time is closely related to prognosis. Rapid recanalization technology is of great significance for stroke patients undergoing endovascular therapy.

Glioma is the most common intracranial primary central nervous system tumor. It originates from glial cells, is invasive and highly heterogeneous, lacks a histological boundary that can be recognized by naked eye, and brings challenges to surgical treatment, pathological grading and prognostic evaluation^[1]。 Traditional neuroimaging (such as CT, MRI and other structural imaging) can provide information on anatomical location, size, shape and other information of tumor, and find indirect signs such as edema, hemorrhage and necrosis around tumor^[2]It plays a certain role in the diagnosis and differential diagnosis of glioma, but is insufficient in the classification, prognosis assessment and delineation of tumor scope. Positron emission tomography (PET) can provide metabolic information of lesions and explore the abnormalities of cellular molecules during tumor formation. Combined with traditional neuroimaging methods, it has certain advantages in early diagnosis, early treatment and delineation of tumor scope^[2,3]。

Glioma is the most common primary tumor of the central nervous system, with an incidence rate of more than 50% of intracranial tumors. The prognosis of patients with high-grade glioma is poor. Taking glioblastoma multiforme (GBM) as an example, the median survival of patients with adjuvant radiotherapy and chemotherapy after surgery is about 15 months^[1]While the median survival of low-grade gliomas is 4 to 15 years^[2,3]。 Traditional clinicopathological classification based on histological features, combined with immunohistochemical detection of relevant proteins, ultrastructure, etc. is no longer sufficient to explain the large differences in survival of patients with low-grade glioma. The latest research shows that low-grade gliomas also have different biological manifestations, some of which are indolent and progressing slowly; Another part rapidly progresses to GBM, while differences in differentiation depend on specific gene mutations^[4]。 In 2016, the new World Health Organization (WHO) classification of central nervous system (CNS) tumors introduced molecular parameters, changing the old principles mainly based on histogenesis and microscopic diagnosis. This article will briefly describe glioma genotyping and its guiding significance for prognosis evaluation and treatment, as well as the research progress of glioma marker genes.