Volume 35 · Issue 02 · 2019

Hydrocephalus is a common complication after craniocerebral trauma. Hydrocephalus after craniocerebral trauma has high incidence, complex formation mechanism, serious clinical influence, and obvious intervention effect, so it should be analyzed and studied in detail. Clinicians should be good at identifying and distinguishing the causes of ventricular enlargement by analyzing neurological signs and imaging data, and observing the dynamic characteristics of cerebrospinal fluid circulation, and taking suitable means to deal with normal pressure hydrocephalus in time. Obtaining the characteristic parameters of intracranial pressure fluctuation and volume compensation index related to intracranial pressure to establish the decision-making and prognosis prediction system of hydrocephalus operation indication is one of the future work directions of traumatic hydrocephalus.

Idiopathic normal pressure hydrocephalus is a common disease of the ventricular and cisternal system, mainly affecting the elderly. Ventriculo-peritoneal shunt is a traditional effective treatment for this disease. With the development of neuroendoscopic technology, neuroendoscopic third ventriculostomy has become an emerging treatment for this disease. Based on previous related literature, this paper compares and discusses the clinical treatment effect of ventriculoperitoneal shunt and neuroendoscopic third ventriculostomy for this disease. At the same time, the clinical application effect of various types of valves in ventricular-peritoneal shunt was further discussed, which provided a reference for the choice of clinical treatment of idiopathic normal pressure hydrocephalus.

To reveal the relationship between cerebrospinal fluid pressure(CSFP), regression of amplitude and pressure(RAP) and operative effect of ventriculoperitoneal (VP) shunt on communicating post-traumatic hydrocephalus.

The clinical data of 40 patients with communicating post-traumatic hydrocephalus undergoing VP shunt admitted to Department of Neurosurgical, Renji Hospital, Shanghai Jiaotong University School of Medicine from August 2017 to April 2018 were retrospectively analyzed. The 40 patients were divided into the good prognosis group (1 to 3 degree, n=26) and the poor prognosis group (-2 to 0 degree, n=14) according to Salomon's system of shunt outcome for hydrocephalus at discharge. The cerebrospinal fluid pressure-related parameters were compared between the 2 groups and the relationship between parameters and the surgical effect of VP shunt was analyzed.

Univariate analysis revealed, Patients in poor prognosis group tended to have lower mean CSFP (13.82±4.40 mmHg) and mean RAP [correlation coefficient (R) between AMP amplitude (A) and mean pressure (P), 0.66±0.19] compared to good prognosis group which had mean CSFP (15.12±3.10 mmHg) and mean RAP (0.81±0.13) (both P≤0.001). CSFP dose of good prognosis group under threshold 10 mmHg (D_CSFP10) was higher than that in poor prognosis group [median (inter-quartile range): 84.12 (615.22) mmHg/h vs. 34.72 (91.62) mmHg/h, P<0.05). RAP dose of good prognosis group under threshold 0.60 (D_RAP0.6) was higher than that in poor prognosis group (14.29±6.33 h vs. 4.01±2.01 h, P<0.05). It was suggested by multiple logistic regression that CSFP (OR=2.231, 95%CI: 1.264-3.943, P=0.025) and RAP (OR=19.092, 95%CI: 3.104-162.103, P=0.001) were two risk factors associated with poor outcome in operative effect of VP shunt.

CSFP and RAP are two risk factors associated with poor outcome in patients with communicating post-traumatic hydrocephalus undergoing VP shunt. Both CSFP dose and RAP dose could be used as predicting parameters for effect of post-traumatic hydrocephalus with VP shunt.

To facilitate diagnosis and predict the outcome of shunting surgery in idiopathic normal pressure hydrocephalus (iNPH) and to explore the influence of clinical and neuroimaging factors on cerebrospinal fluid (CSF) tap test response in Han Chinese patients with iNPH.

Forty-three patients with possible clinical diagnosis of iNPH at neurology clinic and neurology inpatient at Department of Peking Union Medical College Hospital, Chinese Academy of Medical Sciences from March 2013 to January 2017 were recruited and underwent CSF tap test. Patients were categorized into CSF tap test responders (24 patients) and non-responders (19 patients) justified by two iNPH professional neurologists. The clinical parameters in those 2 groups including gender, age onset, duration, walking ability, neuropsychological testing result, clinical scores were analyzed. The neuroimaging parameters including Evan's index, callosum corpus angle, sign of disproportion of enlarged subarachnoid space and white matter lesion (WML) Fazekas rating score were also analyzed.

The univariate analysis showed that compared with CSF tap test negative group, the proportion of males in the positive group was significantly higher (male ∶female 20 ∶4 vs. 9 ∶10, P=0.03), the duration of walking disturbance was longer [M (QR): 30(17) months vs. 12(20) months, P=0.04], Z score of executive function was lower [M(QR): -10.3(25.0) vs. -4.8(11.3), P=0.04], Fasekas score of paraventricular white matter lesions was higher[M (QR): 2.5 (1.0) vs. 1.0 (1.0), P=0.03]. However, those factors had no statistical correlation with the CSF tap test response by multivariate logistic regression analysis(all P>0.05).

Longer disease duration, worse walking ability, worse executive function test performance and prominent white matter lesions might be the impact factors of CSF tap test. Further research of large sample size is needed in the future.

To reveal the value of cerebrospinal fluid (CSF) tap test and continuous monitoring of intracranial pressure in the treatment of idiopathic normal pressure hydrocephalus (iNPH).

Clinical data of 253 patients with iNPH admitted to Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University from January 2013 to June 2018 were retrospectively analyzed. Patients with positive results of tap test underwent shunt operation. One month after 12 hours of continuous CSF pressure monitoring test, patients with negative results of tap test underwent shunt operation. We evaluated the clinical and prognostic value of RAP [correlation coefficient (R) between AMP amplitude (A) and mean pressure (P)] index in the diagnosis and treatment of iNPH.

A total of 189 patients underwent shunt operation out of 253 patients. Among them, 161 patients showed improvement post surgery and 28 patients reported no improvement. The overall surgical rate was 74.7% and the surgical efficiency was 85.2 %. The tap test was positive in 160 patients and 149 patients underwent shunt operation. There were 147 cases with improvement of clinical symptoms after shunting while 2 cases had no improvement. The tap test was negative in 93 cases and 40 accepted 12 hours of continuous CSF pressure monitoring test and shunt operation. Improvement was reported in 12 after shunting and 4 remained unchanged among 16 patients with RAP index>0.6, while 2 were improved after operation and 22 were unchanged out of 24 patients with RAP index≤0.6. The outcome difference between those 2 groups (RAP index >0.6 and RAP index ≤0.6) of patients (χ²=24.350, P<0.01).

The RAP index >0.6 could also be used as an effective supplement of surgical indication for therapeutic effect of shunting in patients with iNPH.It has clinical application value.

To investigate the clinical efficacy of laparoscope-assisted ventricu-loperitoneal(VP) shunt in treatment of idiopathic normal pressure hydrocephalus (iNPH) in elder patients.

From January 2015 to January 2018, a total of 78 elder patients(60 to 89 years old) with iNPH were admitted to Neurosurgery Department of the First Affiliated Hospital of Soochow University. Those patients were retrospectively analyzed and divided into 2 groups with 39 cases in each group: traditional surgical group (control group) and laparoscope-assisted operation group (treatment group). Traditional VP shunt was conducted in the control group and laparoscope-assisted VP shunt in treatment group. We compared the effectiveness in the 2 groups, pre- and postoperative activity of daily living (ADL) scores, classifications of iNPH, Evan's indexes as well as Callosal angles, incidences of postoperative complications.

There were statistically significant differences in average hospitalization time, time of ambulation, average operating hours between the treatment group [(10.5±2.3) d, (3.2±1.3) d, (63.2±10.5) min, respectively] and the control group [(19.8±3.6) d, (6.1±2.1) d, (82.4±11.4) min, respectively] (allP<0.05). ADL scores in treatment group after 3 months and 6 months postoperatively (67.7±1.9, 89.6±2.5, respectively) were significantly higher than those in control group (52.0±1.3, 63.3±2.0, respectively), the classification score of iNPH in the postoperation treatment group (3.8±2.5) was lower than that in control group (6.8±2.8). Patients in the 2 groups were followed up for 3 months and 6 months post surgery. Evan's indexes and Callosal angle values were significantly improved compared with those before surgery. However, there was no statistically significant difference between the 2 groups (P>0.05). The incidence of shunt obstruction, postoperative infection rate, gastrointestinal symptoms, intracranial hypopressure syndrome, abdominal organ injury and cerebral hemorrhage in the treatment group were significantly lower than those in the control group, though these was no statistically significant differences between 2 groups (allP>0.05). The incidence of overall complications was lower in treatment group (33.3%, 13/39) than in control group (89.7%, 35/39) (P<0.001). The total effective rate of treatment group patients (89.7%) was significantly higher than that in control group (69.2%) (P<0.05).

Compared with the traditional VP shunt, laparoscope-assisted VP Shunt used for treatment of iNPH of elderly patients has significant curative effect, and the location of the catheter is accurate which could effectively prevent the total occurrence of postoperative complications and improve the clinical symptoms and outcome of elderly patients to certain degrees.

To investigate the clinical outcomes of patients with idiopathic normal pressure hydrocephalus (iNPH) treated with lumboperitoneal shunt (LPS).

In this 4-year study (December 2013 to December 2017), we retrospectively analyzed 31 adult patients (age>18 y) with iNPH who underwent preoperative evaluation using HLPS (Huaxi LPS preoperative evaluation scale) at Department of Neurosurgery, West China Hospital, Sichuan University. The improvement of symptoms and imaging following LPS, including Keifer's hydrocephalus score (KHS), Evans index, score of mini-mental state examination (MMSE), complications, shunt revision rate, and quality of life including modified Rankin scale (mRS) and function independent measurement (FIM), were synchronously investigated.

Compared to preoperative conditions, patients had lower KHS (10.06±5.69 vs. 6.06±4.41, P=0.003) and Evans index (0.35±0.05 vs. 0.27±0.05, P=0.001) at 5 days post LPS. The results of MMSE showed that 9 (29.0%) patients were normal while 15 (48.4%) had mild dementia, 5 (16.1%) had moderate dementia and 2 (6.5%) had severe dementia. At 5 days post LPS, 12 (38.7%) patients were normal while 17 (54.8%) had mild dementia and 2 (6.5%) had severe dementia. Statistical analysis suggested that preoperative and postoperative MMSE scores were significantly different (Z=-3.466, P=0.001). The overall incidence of complications was 35.5%. Six (19.4%) patients had over-drainage, 5(16.1%) reported infection, 3 (9.7%) reported inadequate drainage, and 1 (3.2%) developed abdominal symptoms. The median follow-up duration was 9 (1- 48) months. The follow-up indicated that the overall rate of shunt failure was 19.4% and the median of mRS and FIM were 1 (0-5) and 93.5 (23-126), respectively.

Patients who underwent evaluation before LPS using HLPS could have favorable clinical outcomes with low failure rate.

To investigate the long-term efficacy and safety of ventriculoperitoneal (VP) shunt in the treatment of idiopathic normal pressure hydrocephalus (iNPH).

The data of 27 patients diagnosed with iNPH admitted to Department of Functional Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of medicine from April 2014 to April 2016 were retrospectively analyzed. All those patients underwent VP shunt surgery, postoperative follow-up according to the questionnaire, Krauss rating scale (Krauss improved index ≥0.5 was considered as significant) and modified Rankin Scale (mRS) for clinical curative effect was analyzed.

A total of 27 patients were followed up from 2 to 22 months(median: 9.6 months) after operation. Twenty-two (81.5%) patients showed improvement in gait, cognition or urine control, while 17 (63.0%) showed improvement in Krauss index ≥0.5. Two patients were lost to follow-up and 25 were followed up for 26 to 46 months, with an average of 36.0±8.3 months. Gait, cognition or urine control was improved in 17 (68.0%) cases and Krauss improvement index ≥0.5 accounted for 15(60.0%)cases. The mRS scores at the first and last postoperative follow-up were 1(0-4) and 1(0-5) respectively with no statistically significant difference (P=0.486). Compared with preoperative mRS score 2(1-5), the difference were statistically significant (both P<0.05). Krauss improvement index at the first and last postoperative follow-up were 0.7(0-1) and 0.5(0-1) respectively, and the difference was not statistically significant (P=0.301). Postoperative complications occurred in 6 (22.2%, 6/27) cases, including chronic subdural hematoma (1 case), headache (1 case), shunt blockage (1 case), epilepsy (1 case) and abdominal incision pain (2 cases).

VP shunt for patients with iNPH is safe and the long-term postoperative efficacy seems similar to short-term efficacy.

To explore the clinical outcome and complications of ventriculoperitoneal (VP) shunt for secondary normal pressure hydrocephalus.

The clinical data of 202 patients with secondary normal pressure hydrocephalus treated with VP shunt at Department of Neurosurgery, the No. 101 Hospital of PLA from January 2012 to November 2016 were retrospectively analyzed. The surgical effect and complications were summarized. The clinical outcome was analyzed using the Black Grading Scale.

Among 202 patients, the ventricles of 185 (91.6%) cases were narrowed after VP shunt. One week post operation, poor outcomes were reported in 7(3.5%) cases, out of which 2 (1.0%) showed hemorrhage, 2 (1.0%) had intracranial infection and 3 (1.5%) had blocked splitter and underwent shunt again. The mean follow-up duration was 11.2±12.6 months and ranged from 3 to 60 months. During the follow-up, seizures occurred in 23 (11.4%) patients. There were 29 (14.4%) patients who developed shunt-related complications. Among them, 3 (1.5%) had the trapped fourth ventricle, 3 (1.5%) reported intracranial infection, 16 (7.9%) had subdural effusion, 7 (3.5%) had blocked splitter and underwent revision surgery. Five cases died of cardiorespiratory system disorder. Finally, 79.7% (161/202) patients achieved favorable clinical outcome (Black cure rate ≥30%). Multivariate logistic regression analysis showed that lower Glasgow Coma Scale (OR=0.600, 95%CI: 0.501-0.719, P<0.001), no obvious change of consciousness (OR=0.206, 95% CI: 0.086-0.495, P<0.001) and previous history of hypertension (OR=2.690, 95% CI: 1.134-6.378, P=0.025) were risk factors associated with poor outcome.

VP shunt is suggested to be a safe and efficacious way to treat secondary normal pressure hydrocephalus. Proper selection of surgical candidates could be helpful for favorable outcome.

To analyze the effect of craniotomy area on the development of normal pressure hydrocephalus after decompressive craniotomy.

The clinical data of 34 patients with traumatic brain injury who underwent unilateral craniotomy from January 2012 to April 2018 at Department of Neurosurgery, Tangdu Hospital, Airforce Military Medical University were retrospectively analyzed. The effects of multiple factors on hydrocephalus, including the gender, age, Glasgow coma scale before craniotomy, open injury, extent of midline shift on CT before craniectomy, duration of operation, intracranial pressure after craniotomy, cerebrospinal fluid infection and craniotomy area were analyzed.

Univariate analysis showed that the age (P=0.016), preoperative Glasgow coma scale (P=0.018), craniotomy area (P<0.001) were all associated with hydrocephalus. However, the gender, open injury, extent of midline shift on CT before craniectomy, duration of operation, intracranial pressure after craniotomy, cerebrospinal fluid infection were not influencing factors of postoperative hydrocephalus(allP>0.05). It was also suggested by multiple logistic regression that craniotomy area (OR=1.138, 95% CI: 1.005-1.288, P=0.042) was an independent risk factor for hydrocephalus.

After decompressive craniotomy, the skull defect area may increase the risk of hydrocephalus.

To evaluate the predicting value of disturbance coefficient (DC) of noninvasive brain edema monitoring in patients with secondary hydrocephalus after traumatic brain injury.

Non-invasive brain edema monitoring technology was used clinically to perform dynamic monitor of 84 patients with traumatic brain injury admitted to Department of Neurosurgery, Nanfang Hospital, Southern Medical University from December 2016 to January 2018. Among them, 17 had hydrocephalus (hydrocephalus group) and 67 did not (control group). The patient’s age, gender, Glasgow coma scale at admission, brain CT status, DC and hydrocephalus situation were compared between the 2 groups.

Hydrocephalus occurred in 17 patients and 8 of them had normal pressure hydrocephalus. The median DC of patients with hydrocephalus was decreased by 35.2(25.7-48.1) and that of patients with no hydrocephalus was decreased by 8.3(5.2-11.1). The difference was statistically significant (P=0.008). The DC decrease of more than 18.0 (sensitivity: 92.5%; specificity: 88.2%) indicated the occurrence of hydrocephalus.

The decrease of DC in non-invasive brain edema monitoring could be used to predict the occurrence of early hydrocephalus. Higher continuous decrease of DC was related to greater probability of occurrence of intracranial hydrocephalus.

To evaluate the efficacy and safety of dorsal root entry zone (DREZ) ablation surgery in the treatment of lower limb pain after thoracolumbar fracture, and to analyze the underlying mechanism of lower limb pain.

From October 2011 to December 2016, a total of 20 patients with lower limb pain after thoracolumbar fracture were treated with DREZ ablation in the spinal cord segment corresponding to the dermatome of the pain territory at Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University. The relationship between the segments of the spinal cord injury, sensory level, and area of pain was analyzed retrospectively. The efficacy (overall VAS score improvement more than 50%, no more analgesics needed) and safety of the operation were evaluated according to the postoperative pain relief and complications.

The segments of spine injuries were T₁₂-L_3,and the pain territory was distributed at T₁₁-S_2,which lied 2-6 segments higher than that of the injured spinal cord segment. Spinal cord and nerve root were severely injured at the fractured vertebra level. The corresponding spinal cord segments of the pain territory dermatome were moderately atrophied and in 12 cases the corresponding nerve roots were avulsed from the spinal cord. Eighteen patients was pain free right after the operation, 2 cases with pain relieve rate less than 50%. 1 case developed pain recurrence after 3 months. The effective rate on time interval with immediate, 3months and 1 year after operation was 18/20, 17/20, 17/20 respectively. Seven patients had developed transient stabbing pain within the upper boundary of the ablated segment. Two patients who underwent unilateral DREZ lesion developed irritant pain in the contralateral lower extremity area after the operation.

Chronic neuropathic pain of the lower limb due to thoracolumbar fracture seems more likely to be caused by nerve root injury instead of spinal cord injury. DREZ ablation is safe and effective for those patterns of pain.

To investigate the clinical value of intraoperative magnetic resonance imaging (iMRI) in endoscopic transsphenoidal surgery for recurrent pituitary adenomas.

A retrospective analysis was conducted on 29 cases of surgically treated patients with recurrent pituitary adenomas at Neurosurgery Department of the First Medical Center of Chinese PLA Greneral Hospital from February 2009 to February 2015. All patients underwent surgical resection of tumor with intraoperative magnetic resonance imaging. The parameters evaluated included the extent of tumor resection, scanning frequency and timing, relief of symptoms and signs, follow-up results and complications.

Among 24 patients with possible totally resection according to the Knosp grading, 16 showed total tumor resection through the first intraoperative scanning and the second intraoperative scanning revealed another 4 cases achieving total resection after extended resection. After more than 3 times of extended resection, intraoperative scanning revealed 2 patients with total resection and the remaining 2 patients had residual tumor tissues. The number of intraoperative scanning was 1.6±0.8 times per case and the average scanning duration was 45.9±19.3 minutes. The total time for surgery was 157.2±55.6 minutes. The postoperative headache remission ratio was 11/13 and the visual dysfunction remission ratio was 12/15. Postoperative pituitary insufficiency occurred in 2 cases, olfactory disorder in 1 case, temporary diabetes insipidation in 7 cases and cerebrospinal fluid leakage in 2 cases. Twenty-nine patients were followed up for 3 to 67 months, with an average of 46.6±19.4 months. There were 2 patients with tumor recurrence among the 22 patients with total tumor resection.

For recurrent pituitary adenomas, iMRI-assisted endoscopic resection seems to be a safe and effective treatment which has high rate of total resection and less postoperative complications.

To investigate the feasibility, safety and efficacy of endovascular recanalization of symptomatic subacute and chronic occlusion of large intracranial artery.

During the period from October 2015 to September 2017, 11 patients with symptomatic subacute and chronic occlusion of large intracranial artery were treated with endovascular recanalization at Department of Interventional Radiology of Shanghai Tongji Hospital, Tongji University School of Medicine. We retrospectively analyzed the patients' clinical and imaging data to evaluate the rate of perioperative complications and follow-up results.

Recanalization was successful in 10 of 11 patients and incomplete recanalization (2a based on Thrombolysis in Cerebral Infarction classification) was achieved in 1. Intraoperative complications occurred in 8 cases and included peripheral vascular embolism in 7 (1 symptomatic and 6 asymptomatic cases). One case was complicated with artery dissection and intracerebral hemorrhage associated with embolectomy occurred in another case. One patient was lost to follow-up and 10 patients received angiography and clinical follow-up for 3-12 months. The results of angiography follow-up showed that the stenosis artery segment of patient with incomplete recanalization was blocked again at 3 months. Of the 9 patients with complete recanalization, 1 patient developed in-stent restenosis at 12 months and suffered transient ischemic attack (TIA). The other 8 patients had no hemodynamic restenosis and no recurrence of TIA or stroke. The mRS (modified Rankin scale) score at 3-month follow-up was 0-1 in 9 patients and 4 in 1.

For patients with symptomatic subacute and chronic occlusion of large intracranial artery, on the premise of strict screening cases, mechanical recanalization is technically feasible and could improve the patient' symptoms in short term and reduce the recurrence rate of stroke. Its long-term effect, however, needs to be confirmed by longer follow-up.

To investigate the mild traumatic brain injury (mTBI) using diffusion tensor imaging (DTI)in MRI and the serum neuron specific enolase (NSE) and S100B protein expression changes.

A total of 84 patients with mild injury and 70 age and sex matched normal volunteers as controls were prospectively admitted to Department of Neurosurgery, Tianjin First Center Hospital between October 2013 and January 2016. All participants underwent Rivermead post-concussion symptoms questionnaire (RPQ) within 7 days of laboratory examination and evaluation. Among them, all patients with mTBI and 50 normal volunteers were included in this study to undergo MRI scanning, including susceptibility weighted imaging (SWI) and diffusion tensor imaging (DTI), within 7 days to compare the imaging characteristics. The patients were divided into 2 groups depending on SWI appearances. The mTBI group 1 consisted of those with positive findings in SWI and the mTBI group 2 consisted of the other patients. The differences in RPQ scores and DTI data, including fractional anisotropy (FA) and apparent diffusion coefficient (ADC), was analyzed between those 2 groups. The expression levels of serum NSE and S100B protein in the 34 patients with mTBI and 20 normal volunteers.

Among the 84 patients, there were 31 patients with abnormal SWI at admission and 53 patients with normal SWI, and their median RPQ scores were 17 (1-31) and 15 (22-27) respectively. There was no significant difference between the 2 groups (P=0.116). At 6 months post discharge, 20 cases in abnormal SWI group and 33 cases in normal SWI group were followed up, and their RPQ scores were 6 (1-15) and 3 (1-11) respectively(P=0.177). DTI analysis showed that there were 32 abnormal FA areas in SWI abnormal group and 7 in SWI normal group. In addition, there were 34 ADC abnormal areas in SWI abnormal group and 7 in SWI normal group. Those differences were statistically significant (P=0.001, P<0.001). Serum NSE levels were 10.01±2.82 μg/L, 30.51±12.32 and 12.35±3.67 μg/L, S100B protein levels were 0.17±0.06 μg/L, 0.52±0.26 μg/L and 0.19 ±0.01 μg/L in healthy control group, abnormal SWI group and normal SWI group, respectively. There were significant differences in NSE and S100B protein levels among the 3 groups (P=0.006, P=0.025), while there was no significant difference between the healthy control group and the normal SWI group (all P>0.05).

The combined detection of serum NSE and S100B protein by cranial DTI may have important clinical value and significance in accurate diagnosis and treatment of acute mTBI.

To investigate the clinical outcomes and prognosis of carotid endarterectomy (CEA) for moderate to severe carotid stenosis.

The clinical data of 78 patients with moderate or severe carotid stenosis treated with CEA from March 2015 to December 2017 at Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University (18 cases) and Department of Neurosurgery, General Hospital of Tianjin Medical University (60 cases) were retrospectively analyzed. There were 72 cases of symptomatic stenosis, 6 cases of asymptomatic stenosis. Among them, there were 66 cases of unilateral stenosis and 12 cases of bilateral stenosis. All patients were treated with standard CEA. There were 72 cases of unilateral CEA and 6 cases of bilateral CEA. A total of 84 CEA operations were performed.

All operations were performed successfully. The clamping duration was 18.0 to 52.0 minutes, with an average of 28.0±4.2 minutes. During perioperative period, there were 3 new cases of cerebral infarction, including 1 case of massive cerebral infarction and 1 case of transient ischemic attack. The incidence of cerebral ischemic events was 4.8% (4/84). No intracranial hemorrhage or death occurred after operation. All patients were followed up for 6.0 to 38.0 months, with an average of 18.0±3.2 months. There were 4 (4.8%) cases of restenosis (stenosis degree ≥50%) after operation, including 2 cases of cerebral infarction, 1 case of transient ischemic attack and 1 asymptomatic case.

CEA is an effective treatment for moderate to severe carotid stenosis. Standardized perioperative management and operative procedures could help to reduce postoperative complications and achieve good clinical results.

The clinical outcome of 9 patients with acute basilar artery occlusion (ABAO) treated with the Solitaire mechanical thrombectomy device was retrospectively analyzed. Of the 9 cases, 8 cases were successfully recanalized immediately after surgery. During hospitalization, a total of 2 patients died. Two cases suffered from large cerebellar infarction complicated by supratentorial hydrocephalus, of which one recovered and one died during hospitalization due to symptomatic cerebral hemorrhage. The embolus was detached to the distal arteriole in one case and the vertebral artery was dissected in one case. Among the 7 surviving patients, the modified Rankin scale (mRS) at 90 days after surgery showed a good prognosis (0-3 points for mRS) in 4 cases and a poor prognosis (4-5 points for mRS) in 3 cases. Solitaire thrombectomy is safe and effective in treating patients with ABAO who meet the surgical indications.

Dural (spinal) arteriovenous fistula is a rare cerebrovascular disease, and its exact etiology has not been defined. Three-dimensional digital subtraction angiography (3D-DSA) is currently recognized as the gold standard for the diagnosis of intracranial vascular diseases, but it lacks comprehensive recognition of multiple supply arteries, multiple fistulas and relative spatial positions between fistulas. The fusion of 3D images of each blood vessel of arteriovenous fistula with multiple arterial blood supply can not only intuitively understand the vascular structure of the lesion and the distribution of fistula space, but also optimize the surgical treatment plan. 3 cases of dural arteriovenous fistula and 1 case of atlanto-occipital dural arteriovenous fistula were reported in this paper. 4 cases had 2 or more blood vessels from different sides participating in blood supply. Satisfactory fusion images were obtained by 3D-DSA vascular fusion technology, which clearly showed the vascular architecture of complex dural (spinal) arteriovenous fistula, and was used to guide clinical treatment.

To investigate the application value of combined surgery in the treatment of spinal dural arteriovenous fistula by hemilaminar approach. Eight patients with dural arteriovenous fistula diagnosed by spinal cord MRI and angiography were positioned by intraoperative angiography in the composite operating room, and the fistula was surgically clipped by hemilaminar approach. Intraoperative angiography confirmed the disappearance of fistula and abnormal drainage vein in 8 patients; Postoperative MRI of the spinal cord showed that the empty shadow of the blood vessel flow around the spinal cord disappeared. Combined surgery is safe, minimally invasive and effective for the treatment of spinal dural arteriovenous fistula through hemilaminar approach.

To establish neural tube defect mouse model induced by folate antagonist methotrexate (MTX) under low folate diet, and to demonstrate folate deficiency acting as a sensitizing agent leading to neural tube defects.

C57BL/6J female mice were divided into 3 groups. Normal feeding group was fed with normal SPF diet. Low folate diet group was given special low folate food. Low folate and MTX group was injected intraperitoneally with MTX (1.00 mg/kg, 1.25 mg/kg, 1.50 mg/kg, 2.50 mg/kg, 3.50 mg/kg, 4.50 mg/kg, respectively) at E7.5 and dissected at E10.5 to E13.5. The other 2 groups were injected with equal volume of normal saline. The embryo phenotype was observed and the number of normal and deformed fetuses were counted. Fetal brain to hip lengths were measured. Embryos and placentae were weighted.

In low folate diet group, developmental retardation was observed without mouse embryonic abnormality of neural tube defects (NTDs). The MTX dose of 1.50 mg/kg might led to the highest deformity rate of 36.5% in low folate diet plus MTX group and the phenotype of NTDs was mainly spina bifida.

Methotrexate with low folate diet could be used to establish the mouse model of NTDs.

To investigate the efficacy and safety of the microvascular decompression (MVD) for glossopharyngeal neuralgia (GN).

A systematic review was performed to retrieve relevant literatures up to February 2018 through PubMed, Embase and Web of Science database. The relevant literatures were screened according to the inclusion and exclusion criteria. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used to conduct a quality evaluation for the included literatures. The relevant data were extracted to evaluate the immediate complete remission rate post operation, long-term remission, proportion of occurrence on the left side, proportion of posterior inferior cerebellar artery (PICA) as offending vessel, proportion of a single vessel as offending vessel, operational mortality and complications. Meta-analysis was conducted by using the meta package of R software.

A total of 12 studies involving 665 patients were enrolled. The mean STROBE score of the included literatures was 16. The immediate complete remission after operation was achieved in 553 of 665 patients and the corresponding rate was 91% (95% CI: 83%-96%, I²=82%). The long-term remission was achieved in 298 of 335 patients and the corresponding rate was 87% (95% CI: 80%-93%, I²=64%). The symptoms of 387 in 665 patients were located on the left and the proportion of occurrence on the left side was 59% (95% CI: 52%-67%, I²=67%). The PICA was found to be the offending vessel in 292 of 408 patients and the corresponding proportion was 72% (95% CI: 68%-76%, I²=0). A single vessel was found to be the offending vessel in 336 of 408 patients and the corresponding proportion was 84% (95% CI: 77%-93%, I²=82%). The funnel plot and Egger linear regression demonstrated no publication bias. The cumulative meta-analysis suggested that the rate of remission did not change with a fixed trend with the date of the publication. Sensitivity analysis and subgroup analysis provided similar results.

The results of our meta-analysis suggested that MVD is an effective and safe modality of treatment for GN with high immediate postoperative complete remission rate, high long-term complete remission rate and low relapse rate. The surgical complications of MVD are few and slight, which is worth getting promoted.

Dural arteriovenous fistula (DAVF) is an abnormal vascular communication between intracranial and extracranial arteries and reflux veins and sagittal, transverse, sigmoid and cavernous sinuses. It is one of the intracranial vascular malformations, but anterior skull base DAVF is rare. Because there are no venous sinuses in the anterior skull base, DAVF in this site is drained to the superior sagittal sinus through the cerebral cortical vein, which is often accompanied by aneurysm-like dilatation, but aneurysm-like dilatation is more rare. Rare aneurysms of the middle cranial fossa are similar to the characteristics of middle cerebral artery aneurysms. They often have more bleeding and severe clinical symptoms, so surgery is the first choice of treatment. The surgical method is similar to the surgical method of common middle cerebral artery aneurysm, and the early surgical effect is better. Two cases of rare aneurysms in the middle cranial fossa floor were reported. The aneurysms were successfully clipped by craniotomy, and satisfactory clinical results were obtained after operation.

Ependymoma is a class of benign tumors that originate in the ventricular wall or spinal canal and can occur in both the pediatric and adult population. 90% of these pediatric ependymomas occur intracranially and 2/3 occur in the posterior cranial fossa. Until today, surgery combined with radiotherapy is still the standard treatment for this disease, but 45% of patients have a poor prognosis, and new treatment strategies and methods are still needed. With the development of molecular biology, many studies on the occurrence and development mechanism of ependymoma have been carried out. It has been confirmed that ependymoma has completely different molecular types, and there are obvious differences in biological and clinical characteristics between different subtypes. With the further clarification of the molecular mechanism, the research results will also provide an important basis for the establishment of a precision medical model for ependymoma, the determination of new therapeutic targets, and the judgment of patient prognosis. This article reviews the recent advances in molecular biology of ependymoma.

Postoperative cerebellar mutism syndrome (POPCMS) in children is a common postoperative complication of posterior fossa tumors in children, including a series of clinical manifestations characterized by delayed mutism. The previous literature has not reached agreement on the description and diagnostic criteria of this syndrome, and there are many hypotheses about its specific pathogenesis. Through literature review, this paper summarizes the current research status of POPCMS in clinical manifestations, pathogenesis, related risk factors and treatment, aiming to improve the diagnosis and treatment level of POPCMS and the understanding of cerebellar speech, cognition, emotion and other advanced neurological functions.

Disorders of consciousness are serious and persistent complications caused by injury to the brainstem ascending reticular activation system or cerebral cortex, and long-term disorders of consciousness place a heavy burden on society and families. Therefore, it is of economic and social significance to promote awakening treatment for patients with consciousness disorders to restore their functions. Electrical stimulation of vagus nerve is a regulation technique in which a coil electrode is placed on the cervical vagus nerve through neurosurgery, and the vagus nerve is automatically stimulated by a stimulator to achieve the therapeutic purpose. At present, there have been case reports on the treatment of vagus nerve stimulation to promote awakening, which bring hope for the rehabilitation treatment of patients with consciousness disorders. This article reviews the current status, possible mechanisms and future prospects of clinical research in the treatment of vagus nerve stimulation to promote wakefulness.