Volume 35 · Issue 04 · 2019

Sacral cyst is a general term for cystic lesions in the sacral canal, including perineurial cyst, meningeal cyst, meningeal diverticulum, arachnoid cyst and other types. Sacral cyst has a high incidence and is a common clinical disease. Although most sacral cysts have no obvious clinical symptoms, some patients have discomfort that can affect their life and work, which is called symptomatic sacral cysts. At present, there are many controversies about the understanding of sacral cyst, and the treatment is not standardized, so it is urgent to formulate an industry consensus to standardize it. Therefore, the Neurosurgery Branch of Chinese Medical Association organized well-known experts in related fields across the country to jointly write this consensus, hoping to improve the understanding of sacral cyst, standardize the diagnosis and treatment process of this disease, and improve the treatment effect.

Craniopharyngiomas are located in the central core area of the skull base and are surrounded by vital structures, making surgical treatment extremely challenging. Moreover, the operation itself will affect the endocrine and water-electrolyte balance of the patient, further increasing the treatment difficulty of the disease. The traditional surgical method of craniopharyngioma is supratentorial craniotomy and microsurgical resection. In recent years, with the continuous progress of neuroendoscopic technology and equipment, more and more craniopharyngiomas can choose neuroendoscopic nasal surgery and obtain good curative results. For different anatomical locations and types of craniopharyngiomas, how to choose the appropriate surgical approach is still controversial and confusing. This article focuses on which type of craniopharyngioma is suitable for neuroendoscopic nasal surgery, and analyzes its advantages and technical points.

To analyze the risk factors of intracranial infection after endoscopic transnasal skull base surgery in order to guide clinical prevention and treatment.

The clinical data of 1 467 patients who underwent endoscopic transnasal skull base surgery from January 2013 to June 2018 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University was retrospectively analyzed. Postoperative patients were divided into infection group (17 cases) and non-infection group (1 450 cases) according to whether they had intracranial infection or not. Univariate and multivariate logistic regression were used to analyze the risk factors of intracranial infection in patients undergoing endoscopic transnasal skull base surgery.

After surgical treatment, 17 (1.2%) cases developed intracranial infection, including 7 pituitary adenomas, 6 chordomas, 2 craniopharyngiomas, 1 Rathke cleft cyst and 1 cerebrospinal fluid rhinorrhea. The duration of infection was 2-12 days after operation, with an average of 5.0 ± 2.5 days and it was less than 3 days in 1 case, 3-7 days in 13 and more than 7 days in 3. The results of cerebrospinal fluid culture showed that the bacteria were Streptococcus viridis in 5 cases, Klebsiella pneumoniae in 4, Staphylococcus epidermidis in 2, Escherichia coli in 2, Enterobacter aerogenes in 2, Streptococcus parahaemolyticus in 1 and Citrobacter in 1. Univariate and multivariate logistic regression analysis showed that intraoperative cerebrospinal fluid leakage (OR= 3.074, 95% CI: 2.084-4.536, P<0.01), postoperative cerebrospinal fluid leakage(OR = 27.780, 95% CI: 10.266-75.148, P<0.01)and lumbar cistern drainage (OR=192.150, 95% CI: 25.245-1 462.465, P<0.01) were risk factors for intracranial infection, while prophylactic use of antibiotics was the protective factor (OR=0.204, 95% CI: 0.062-0.671, P<0.01).

Avoiding intraoperative cerebrospinal fluid leakage and lumbar cistern drainage, preventing postoperative cerebrospinal fluid leakage and preoperative prophylactic use of antibiotics seem to be important means to reduce the incidence of intracranial infection after endoscopic transnasal skull base surgery.

To explore the effect of removing the bone of the tuberculum sella on the total resection rate of pituitary macroadenomas in endoscopic transsphenoidal surgery.

We retrospectively analyzed the clinical data of 65 patients with pituitary macroadenomas treated with endonasal transsphenoidal surgery at Department of Neurosurgery, the Second Affiliated Hospital of Nanchang University from February 2013 to February 2017. In 28 cases, the tuberculum sella bone was not removed (non-removed group), and in 37 cases the tuberculum sella bone was removed (removal group). All patients were followed up postoperatively and underwent examinations including head/pituitary MRI scan and enhanced scan, hormone levels in patients with functional pituitary adenomas. The total resection rate, clinical symptom remission rate and postoperative complication rate were compared between the two groups.

All the 65 patients were successfully operated.There was no statistical significance among the age, sex, clinical manifestation, tumor secreting-types, texture and Hardy grade of patients in the two groups(all P>0.05). The gross total resection rate in the removed group[78.4%(29/37)]was higher than that in the non-removed group[50.0%(14/28)](P<0.05). However, the incidence of diabetes insipidus was higher in the former group than in the latter group[73.0%(27/37), 46.4%(13/28),P=0.029]. The postoperative symptom remission rate, cerebrospinal fluid leakage, and new pituitary under-function, were different although, but there were no statistically significant differences.In the non-removed and the removed group, the postoperative symptom remission rate [89.3%(25/28)vs.91.9%(34/37)], cerebrospinal fluid leakage[7.1%(2/28)vs.8.1%(3/37)], and new pituitary dysfunction[3.6%(1/28)vs. 5.4%(2/37)] were not statistically significant(all P>0.05). All cases were followed up for 3 months to 2 years, average 7.8±2.5 months. No tumor recurrence case was found in 43 patients whose tumor were total resection.Among the 22 patients(whose tumors were not total resection), endoscopic endonasal transsphenoidal surgery was re-performed in 5 and 3 patients(in the nonremoved and removed groups respectively) after 0.5-1.0 years. The pituitary function of all patients returned to normal.

Removal of the tuberculum sella bone may be an important for improving the total resection rate of pituitary macroadenomas in endoscopic endonasal transsphenoidal surgery.

To evaluate the efficacy and safety of endoscopic selective posterior/dorsal rhizotomy (SPR) in the treatment of limb spasticity following brain injury in adults.

A total of 88 patients with limb spasticity following brain injury treated with SPR from January 2015 to August 2016 at Department of Neurosurgery, Xinxiang Central Hospital were retrospectively enrolled into this study. Russman-Gage standard and Ashworth standard were used to evaluate the degree of limb spasticity and muscle tension after operation. Surface electromyography (SMG) and evoked potential (EP) were used to measure the sensory and motor nerve conduction velocities of affected limbs 3 weeks after operation. Lower extremity motor function was assessed with the Fugl-Meyer scale in lower extremity (FMA-L) at 3 and 8 weeks after operation. Walking ability was assessed with the Functional ambulation category (FAC) scale, and parameters of patients' stride, stride distance, stride speed and toe deflection angle distance were measured. All patients were followed up clinically after operation. The follow-up included observing the remission of limb spasticity and reviewing the lumbar spine radiographs.

The spasticity of extremities was alleviated in 88 patients after operation. Three weeks after operation, the integrated electromyogram (iEMG) of tibialis anterior muscle in 88 patients was higher than that before operation (1.5±0.2 mV vs. 0.5±0.2 mV, P<0.001), while the gastrocnemius muscle was lower than that before operation (0.7±0.3 mVvs. 1.2±0.2 mV, P<0.001). After detection, latency of cortical somatosensory evoked potential (SEEP) in the dorsomedian part of the head(39.7±3.1 ms) and L₂ (18.5±3.5 ms) was longer than that before operation (34.9 ±3.5 ms, 13.3 ±2.3 ms, both P<0.001). The sensory nerve conduction velocities in head (4.9±1.1 cm/ms) and popliteal region to L₂(4.8±1.3 cm/ms) region were lower than those before operation (6.6±1.4 cm/ms, 6.3±1.5 cm/ms, both P<0.001). At 3-8 weeks post operation, the scores of FMA-L and FAC scales, stride length, stride distance and stride speed of 88 patients were higher than those before operation (allP<0.05), while the deflection angle of toes was lower (P<0.01). The rising trend time of 88 patients ranged from 6.2 to 26.6 months, with an average of 12.2±6.4 months. There were 83 (83/88, 94.3%) patients who had relief of spasticity in lower limbs and 74 (74/79, 93.7%) whose Achilles tendon reflex disappeared. No spinal deformity was found in the reexamination.

The neuroendoscopic SPR treatment for limb spasticity after brain injury could effectively relieve the symptoms of limb spasticity and promote the recovery of motor function. It seems safe and worthy of clinical application and promotion.

To explore the efficacy of neuroendoscopy combined with ventricular irrigation in the treatment of severe intraventricular hemorrhage.

A retrospective study was conducted on 145 cases of severe intraventricular hemorrhage admitted to Department of Neurosurgery at Harrison International Peace Hospital Affiliated to Hebei Medical University from January 2015 to November 2017. Among them, 65 cases were treated by neuroendoscopy combined with ventricular irrigation (neuroendoscope group) and 80 were treated with external ventricular drainage (drilling drainage group). The hospital stay length, recovery time of cerebrospinal fluid, intracranial infection rate, hematoma clearance and rebleeding rate at 6h post operation were compared between the 2 groups. After 6 months of follow-up, the occurrence of hydrocephalus was assessed according to CT examination and the patient's outcome was assessed according to the activity of daily living (ADL) score. The Bsrsel index≥90% indicated that the patient had a good outcome.

Compared with the drilling drainage group, the recovery time of cerebrospinal fluid after neuroendoscopy was shortened (3.9±0.9 min vs. 4.6±1.1 min, P=0.034), the clearance rate of hematoma was significantly higher [23.1%(15/65) vs. 2.5%(2/80), P<0.001]. There was no significant difference between the two groups in hospital stay length, the incidence of intracranial infection and rebleeding rate after operation (allP > 0.05). After 6 months, the rate of good outcome in the neuroendoscopy group was better than in the drilling drainage group [50.8%(33/65) vs. 28.8%(23/80), P=0.001]. The occurrence rate of hydrocephalus [4.6%(3/65) vs. 16.3%(13/80)] and mortality rate [4.6%(3/65) vs. 15.0%(12/80)] were lower than those in the drilling drainage group(both P<0.05).

Neuroendoscopy combined with ventricular irrigation could effectively improve clinical efficacy, reduce complications and improve the outcome of severe ventricular hemorrhage, which might be worthy of clinical promotion.

To explore the scope, feasibility and indications of extended neuroendoscopic endonasal approach to reveal the region of cranial-cervical junction.

Ten (20 sides) intact frozen adult cadaveric heads were used to simulate the extended neuroendoscopic endonasal approach to remove the anterior tubercle of atlas, part of the atlas anterior arch, odontoid and part of the slope. In the cranial-cervical junction area, we observed the exposed range and measured the distance from the nostril to the anterior tubercle of atlas, the height and width of the anterior arch of the atlas, the distance of bilateral medial margin of occipital condyle, the distance of bilateral medial margin of the foramen lacerum, the vertical distance from the occipital condyle to the homolateral foramen lacerum, and the height, anteroposterior diameter and transverse diameter of the odontoid.

The exposed range of the extended neuroendoscopic endonasal approach was as follows: when the lesion was located at the foramen magnum, the medial margin of the occipital condyle was the boundary of both sides, the root of the odontoid was the lower boundary, and the lower edge of the occipital bone was the upper boundary. When the lesion was located at the region of cranial-cervical junction, the upper edge of the foramen lacerum on both sides was the upper boundary, and the foramen lacerum and the outer edge of the occipital condyle were the boundaries of both sides of the bone window. By measurement, the distance from the nostril to the anterior tubercle of atlas was 8.9-9.7 cm, with an average of 9.3±0.3 cm. The height of the anterior arch of the atlas was 2.3-3.0 cm, with an average of 2.7±0.3 cm; the width was 1.5-2.0 cm, with an average of 1.8±0.2 cm; the distance of bilateral medial margin of occipital condyle was 1.5-2.0 cm, with an average of 1.8±0.2 cm; the distance of bilateral medial margin of the foramen lacerum was 2.1-2.9 cm, with an average of 2.4 ±0.3 cm; the vertical distance from the occipital condyle to the homolateral foramen lacerum was 1.6-2.2 cm, with an average of 1.9±0.3 cm; the height of the odontoid was 0.9-1.3 cm, with an average of 1.1±0.2 cm, its length was 0.8-1.3 cm, with an average of 1.1±0.2 cm; the transverse diameter of the dentate was 0.9-1.2 cm, with an average of 1.0±0.1 cm.The maximum exposed area of cranio-cervical junction was 6.4-9.8 cm^2, with an average of 8.6±1.6 cm².

The extended neuroendoscopic endonasal approach with removal of the anterior tubercle of atlas and part of the atlas anterior arch could effectively reveal the cranial-cervical junction area which is suitable for the treatment of odontoid deformity, skull base depression and atlantoaxial joint dislocation as well as resection of epidural tumors in the cranial-cervical junction and ventral and ventral midline tumors.

Forty-four patients with chronic subdural hematoma (CSDH) treated with soft neuroendoscopy combined with field drying technique (DFT) and 31 patients with CSDH treated with soft neuroendoscopy alone were retrospectively enrolled. The operative time, hematoma clearance rate, drainage tube indwelling time, hospital stay, modified Rankin scale score on postoperative day 1 and at discharge, complications and postoperative recurrence rate of the two groups were compared and analyzed. The results showed that compared with soft neuroendoscopy alone, soft neuroendoscopy combined with DFT in the treatment of CSDH can significantly shorten the operation time and reduce the incidence of postoperative subdural effusion.

Rathke cyst is a common cystic lesion in the sellar region. The main symptoms of symptomatic Rathke cyst are headache, vision loss and pituitary function decrease. Surgical treatment is an effective means to improve the symptoms, and its surgical goal is to totally remove the cyst as much as possible without damaging the nerve function; The incidence of cyst recurrence and complications was different with different surgical methods and intraoperative management. The advantages of neuroendoscopy such as close observation and multi-angle treatment are helpful for the removal of cyst contents, and partial resection of cyst wall is a desirable method to reduce pituitary injury.

To discuss the clinical characteristics and prognostic factors of gliosarcomas.

A total of 188 patients with primary gliosarcomas who underwent surgical treatment from January 2008 to January 2018 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University were retrospectively analyzed.The incidence of gliosarcoma among the gliosarcoma and glioblastoma was 5.15% (188/3 647). The clinical features were summarized and influencing factors of outcomes including progression-free survival (PFS), overall survival (OS) and tumor recurrence and metastasis were investigated.Univariate Log-rank analysis and multivariate Cox regression analysis were used to analyze the factors.

Among the 188 patients, gross total resection was achieved in 143 patients, sub-total resection in 37 and partial resection in 8. After surgery, 169 patients received radiotherapy and chemotherapy, 13 received radiotherapy only and 6 did not undergo radiotherapy or chemotherapy. The median follow-up period was 15 months (range: 3-28 months). The median OS was 15 months(range: 4-28 months), and the median PFS was 8 months(range: 3-18 months). Log-rank univariate analysis showed that age, extent of tumor resection and postoperative radiotherapy and chemotherapy were influencing factors for OS and PFS (all P<0.05). The OS and PFS had no correlation with gender, preoperative Karnofsky performance scale (KPS) or MGMT methylation (allP>0.05). Univariate and multivariate Cox regression analysis showed that age, extent of tumor resection and postoperative radiotherapy and chemotherapy affected the OS and PFS of the patients (allP<0.05).

Gliosarcoma is rare and its prognosis seems poor. The age < 60 and maximum tumor resection combined with postoperative adjuvant radiotherapy and chemotherapy could prolong the survival of patients.

To evaluate the safety and efficacy of transarterial embolization of dural arteriovenous malformation (DAVF) using transvenous Copernic RC balloon protection.

Fifteen patients with DAVF (6 from Departments of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University and 9 from Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University) embolized using transvenous balloon protection between March 2014 and November 2017 were included retrospectively. Fourteen patients had single fistula in which 11 were located at transverse-sigmoid sinus (TSS) and 3 were located at superior sagittal sinus (SSS). One patient had multiple fistulas located at SSS and tentorium. Two patients presented with Cognard type I fistula, 7 with Cognard type Ⅱa, 1 with Cognard type Ⅱb and 5 with Cognard type Ⅱa+ b. Ten patients were treated for the first time and 5 were re-treated. The clinical and angiographic data were collected and the cure rate, complications and clinical outcome were analyzed.

In the 10 patients treated for the first time, complete occlusion was achieved in 8 patients, near-complete occlusion in 1 and partial occlusion in 1. In the 5 patients re-treated, complete occlusion was achieved in 1, near-complete occlusion in 2 and partial occlusion in 2. All the involved sinuses were patent after embolization. Three patients suffered from severe complications including 1 with epidural hemorrhage, 1 with cerebellar hemorrhage and 1 with cerebellar infarction. All patients were followed up for 5 to 48 months(median: 19 months). Seven patients′ symptoms disappeared at follow-up, 7 patients were improved including 2 with postinterventional hemorrhage. One patient with cerebellar infarction deteriorated. The angiography follow-up was achieved in 8 cases for 4 to 24 months(median: 7 months). There was no recurrence in 6 patients with complete occlusion. One patient with near-complete occlusion and 1 with partial occlusion were stable.

The transvenous balloon assisted technique seems helpful to preserve the patency of dural sinus and improve the occlusion rate during the embolization of DAVF. However, it might have risks of hemorrhage and infarction and should be used carefully.

To investigate the effectiveness and safety of cervical selective posterior rhizotomy(SPR) and replacement laminoplasty (RL) for children with spastic cerebral palsy (SCP) in upper limbs.

A retrospective study was conducted on 47 children cases of SCP in upper limbs enrolled into Department of Functional Neurosurgery, Beijing Children′s Hospital, Capital Medical University from June 2015 to May 2017. Twenty-one cases among them underwent SPR+ RL by using ultrasonic bone-cutting knife combined with rehabilitation (surgery-rehabilitation group) and the rest 26 cases received merely rehabilitation (rehabilitation group). Three-dimensional CT of cervical vertebra was re-examined for imaging evaluation. The modified Melbourne assessment (MMA) of unilateral upper limb function and modified Ashworth scale (MAS) were used for clinical evaluation.

At the follow-up after 8 months of treatment, the spasticity and motor function of upper limbs in all cases were improved, and no one was going with serious postoperative complications including instability of cervical vertebra. The means of scale scores before treatment and after 8-month treatment in rehabilitation group were as follows: MMA: 0.54±0.19 vs. 0.66±0.19 (t=2.28, P=0.03) and MAS: 5.48±0.65 vs. 4.92±0.56 (t=-3.33, P<0.01). Those in surgery-rehabilitation group were MMA: 0.58±0.17vs. 0.84±0.15 (t=5.26, P<0.01) and MAS: 5.61±0.73vs. 4.07±0.51 (t=-7.92, P<0.01). Between the 2 groups, the difference in MMA or MAS scale score was not statistically significant prior to treatment(bothP>0.05), while it was statistically significant after 8-month treatment (MMA:t=3.54, P<0.01; MAS:t=-5.38, P<0.01). The bone fusion rate in surgery-rehabilitation group was C₅: 76.2% (16 cases), C₆: 85.7% (18 cases), C₇: 90.5% (19 cases) and T₁: 81.0% (17 cases). The bone fusion rate of C₅-T₁ was 83.3%.

Using ultrasound bone-cutting knife in laminectomy followed by RL could optimize the operation process, increase the bone fusion rate in vertebral reduction and reduce the risk of cervical instability postoperatively. SPR+ RL combined with rehabilitation therapy seems more effective than merely rehabilitation therapy for SCP children in upper limbs.

To evaluate the safety and efficacy of fornix deep brain stimulation(DBS) for patients with severe Alzheimer's disease(AD).

A retrospective analysis was conducted on 7 patients with severe AD who underwent fornix DBS from April 2015 to March 2018 at Department of neurosurgery, First Medical Center of Chinese PLA General Hospital. Those severe AD cases were enrolled to evaluate the accuracy of electrode implantation, the patient's safety at early and late postoperative stages, efficacy of fornix DBS including mood, memory, visuospatial ability and sleep.

The fornix was accurately targeted with electrode implantation in all cases. The operation duration was 6.0-8.5 hours (mean: 7.0±1.0 h). The hospitalization length was 12-32 days (mean: 26.0±7.3 d). There was no perioperative complications such as intracranial hematoma, cerebral infarction, malfunction of DBS or wound infection. At early DBS-on stage, there were no psychiatric or sleep disorders, swallowing difficulty, cardiovascular events or intolerance of stimulation. The follow-up time of 7 patients ranged from 1.5 to 34.0 months (mean: 13.9±3.9 months). At early stage of post-DBS (< 6 months), the patient's mood was improved in 7 patients, memory was improved in 1, visuospatial ability was better in 1, and sleep was better in 4. At long-term follow-up, 1 patient was confined to bed because of prolapse of the anus and another patient had poor self-care ability and could not eat independently.

Fornix DBS, which is a safe procedure, could partially improve the cognitive performances of patients with severe AD at early stage. Further investigations are needed for study of long-term effect.

To investigate the relationship of chronic occlusion site of internal carotid artery (ICA) to the outcome of recanalization.

The patients with chronic symptomatic occlusion of ICA who were treated by endovascular revascularization or hybrid surgery at Cerebrovascular Division of Interventional Therapy Center, Henan Provincial People's Hospital from May 2015 to May 2017 were retrospectively reviewed. According to the location of ICA occlusion, the patients were divided into 2 types: Type Ⅰ occlusion and Type Ⅱ occlusion. Type Ⅰ occlusion was located from cervical segment to the cavernous segment and below, whereas Type Ⅱ occlusion was originated from cervical segment to the clinoidal segment and beyond.Comparison was conducted on the rates of technical success and re-occlusion after operation between Type Ⅰ occlusion and Type Ⅱ occlusion.

Forty-five patients with chronic symptomatic ICA occlusion had a total technical success rate of 91.1% (41/45). The technical success rate was 100.0% (25/25) in Type Ⅰ occlusion and 80.0% (16/20) in Type Ⅱ occlusion, and the difference was statistically significant (χ²=5.040, P=0.025). Among the 41 patients who were successfully recanalized, 40 acquired clinical follow-up with a median of 12 months(range: 4-36 months). The rate of re-occlusion was 0% (0/25) in Type Ⅰ occlusion and 26.7% (4/15) in Type Ⅱ occlusion with statistical difference (χ²=8.821, P=0.003).

Patients with Type Ⅰ occlusion seem to have high technical success rate and low re-occlusion rate, which can be treated to improve the outcome. Type Ⅱ occlusive patients have relatively low technical success rate whereas high re-occlusion rate, which should be comprehensively evaluated before operation.

To conduct preliminary study on the assessment role of bitangent angle in atlantoaxial dislocation.

A total of 66 case of non-traumatic atlantoaxial dislocation underwent operation at Department of Neurosurgery and Orthopedics, Zhengzhou First People′s Hospital from March 2010 to April 2015 and were classified into illness group. During the same study period, a total of 336 patients with cerebrovascular disease underwent head-neck CT angiography (CTA) examination and were categorized into normal group. The bitangent angle in the 2 groups were measured in CT image, and the difference of bitangent angles between 2 groups was analyzed. The Nurick score was used as evaluation tool for severity of clinical symptoms and was used for correlation analysis with the bitangent angle.

The bitangent angle range in normal group was 121.1-176.9°, with an average of 152.2±8.9°. In the illness group, the bitangent angle range prior to operation was 72.3-134.9°, with an average of 102.4±20.1°. The bitangent angle range post operation was 69.6-167.2°, with an average of 131.9±23.9°. There was significant difference between 2 groups both preoperatively and postoperatively concerning bitangent angle (P<0.01) and also between preoperative and postoperative conditions (P<0.01). In the illness group, the difference in Nurick score between preoperation and postoperation was significant (P=0.015). Based on Spearman correlation analysis, the bitangent angle and Nurick score had negative correlation before the operation (r=-0.79, P<0.01), while the correlation was attenuated obviously after the operation (r=-0.51, P<0.01).

The preliminary results have suggested that the bitangent angle is decreased in patients with atlantoaxial dislocation, which might be correlated with clinical symptoms.

To explore the application value of combined monitoring of somatosensory evoked potential (SEP) and transcranial Doppler ultrasound (TCD) in carotid endarterectomy (CEA).

We retrospectively enrolled 50 patients with carotid stenosis who underwent CEA at Department of Neurosurgery, Chengde Central Hospital from January 2015 to January 2018. SEP and TCD were used in combination to record changes in N20 amplitude of SEP and blood flow velocity in the middle cerebral artery (MCA) by TCD monitoring. Whether or not to perform a bypass procedure was decided based on the monitoring results which was also used to judge whether the open carotid artery developed restenosis and assess the high brain perfusion. The data of the two monitoring methods were recorded during the operation and comparative analysis was performed.

Intraoperative SEP monitoring results showed that 2 cases met the standard of bypass and then underwent intraoperative transferring. TCD monitoring showed that 8 cases reached the standard of bypass and included the above-mentioned 2 cases. The difference in the rate of conversion to standard was statistically significant using SEP (4.0%, 2/50) and TCD (16.0%, 8/50) (χ²=4.000, P=0.046). In those 2 patients whose monitoring results showed that they did not meet the standard of bypass, after opening blocked carotid artery in the operation, TCD monitoring showed severe restenosis or reocclusion, and the thrombus was opened again during the operation. However, there was no positive findings in SEP monitoring during this process. In 2 case with open-blocking carotid artery, whose data in both monitoring showed that they did not meet the standard of bypass, high perfusion was revealed by TCD, and no positive findings were found in SEP monitoring. There was no cerebral infarction, cerebral hemorrhage, hyperperfusion or death in 50 patients within 30 days after CEA. CT angiography results showed no carotid stenosis in this series.

The combined monitoring of SEP and TCD seems to have a high clinical value in CEA. The former may be more advantageous in making choice of intraoperative bypass. The latter may be more valuable in detection of severe restenosis or recurrent hyperperfusion after opening the carotid artery.

To identify the abnormal metabolic pathway of pituitary oncocytoma based on Mass spectrum.

In this study, all 25 tumor samples were obtained following trans-sphenoidal surgery performed at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University. All 18 healthy pituitary glands were used as controls and obtained from donors who died from accidents. Proteomics analysis was used to analyze the differentiated expressed proteins between between pituitary oncocytoma and normal pituitary glands by nano liquid chromatography tandem mass spectrometry (nanoLC-MS/MS). Metabolomics analysis were performed to analyze the differentiated metabolites between pituitary oncocytoma and normal pituitary glands. The bioinformatics methods were used for analyzing the abnormal metabolic pathways related to pituitary oncocytoma. The expression of c-Myc was validated by western-blot method among pituitary oncocytoma and normal pituitary glands.

Proteomics analysis showed that a total of 598 proteins were significantly different expression between pituitary oncocytoma and normal pituitary glands (all P<0.05). Metabolomics analysis displayed 95 metabolites with significant differences between pituitary oncocytoma and normal pituitary glands (allP<0.05). Ten of the most obvious enrichment pathways were shown by the Integrated Molecular Pathway Level Analysis of differentially expressed proteins and metabolites, including metabolism, immune System, innate immune system, metabolism of proteins, neutrophil degranulation, post-translational protein modification, vesicle-mediated transport, membrane trafficking, hemostasis and EGFR1 pathway. Ten of the most obvious enrichment pathways were shown by gene set enrichment analysis of differentially expressed proteins, including HALLMARK_OXIDATIVE_PHOSPHORYLATION, HALLMARK_MYC_TARGETS_V1, HALLMARK_FATTY_ACID_METABOLISM, HALLMARK_ ADIPOGENESIS, HALLMARK_MTORC1_SIGNALING, HALLMARK_EPITHELIAL_ MESENCHYMAL_TRANSITION, HALLMARK_HYPOXIA HALLMARK_GLYCOLYSIS, HALLMARK_XENOBIOTIC_METABOLISM, HALLMARK_HEME_METABOLISM. The expression of c-Myc(1.58) was significantly higher in pituitary oncocytoma than that in normal pituitary (0.56)(P<0.05).

The abnormal metabolic pathway has been identified in pituitary oncocytoma and the expression of c-Myc is higher in pituitary oncocytoma compared to normal pituitary glands.

To detect the expression of let-7b and STAT3 during epileptogenesis and to explore the effect of let-7b on activation of hippocampal glial cell by targeting STAT3 using a rat model of temporal lobe epilepsy.

A rat model of status epilepticus was induced by intra-amygdala kainic acid(KA) injection (n=40). Sham-operated controls received equal-volume intraperitoneal saline injection (n=10). The adeno-associated virus vector was used to construct the let-7b overexpression rats. The expression of let-7b was examined by qPCR. The dual luciferase reporter assay was used to confirm the relationship between let-7b and STAT3. Astrocyte and microglia activation were assessed by immunofluorescence. Expression of proinflammatory cytokines and components of the Janus kinase (JAK)/signal transducer and activator of transcription (STAT) signaling pathways were evaluated with Western blot.

Let-7b was decreased (both P<0.01) while its target gene STAT3 was increased (bothP<0.001) in the latent period of epilepsy (at 3 d and 7 d post KA injection) compared with sham-operated controls rats. The dual luciferase reporter assay demonstrated that let-7b inhibited the expression of STAT3 (P<0.05). The immunofluorescence analysis showed that let-7b overexpression inhibited the activation of astrocytes and microglia and the release of inflammatory factors in CA3 subfield of the hippocampus of epileptic rats (bothP<0.01). Western blot analysis showed that let-7b overexpression inhibited the expression of p-Stat3 and its downstream effector c-Myc(bothP<0.001) and the release of inflammatory factors (IL-1β, IL-6 and TNF-α)(allP<0.01).

Let-7b could lead to suppression of glial cell activation and proliferation of the hippocampus of epileptic rats by targeting STAT3.

The incidence of cranio-orbital penetrating injuries is low, and most of them are metal foreign body puncture injuries. Among them, vegetative foreign body cranio-orbital penetrating injury is more rare. A patient with giant vegetative foreign body cranio-orbital penetrating injury was admitted to the Department of Neurosurgery of the Second Xiangya Hospital of Central South University. After surgical treatment, the curative effect was satisfactory.

CT myelography was performed in a patient with low intracranial pressure caused by spontaneous cerebrospinal fluid leakage, and the discovered cerebrospinal fluid leakage was surgically repaired. After the repair, the clinical symptoms of the patients were relieved, the intracranial pressure returned to normal 3 days after operation, and the patients had no symptoms of hypotension after 1 month follow-up. For such cases, the location of cerebrospinal fluid leakage can be defined by CT myelography, and surgery is an effective treatment for spontaneous high cervical cerebrospinal fluid leakage.

Ultra-refractory status epilepticus (SRSE) is when status epilepticus continues for more than 24 h after the use of anesthetic drugs, or the seizure has been terminated, and the seizure reappears when the dose of anesthetic drugs is reduced or discontinued. SRSE is a critical neurological disease that seriously threatens the life of patients. It has a high morbidity, mortality and disability rate. This paper reports two cases of SRSE treated by emergency surgery. All patients achieved good clinical results after surgery.

Craniopharyngioma is a common congenital tumor in the cranium. Although it is benign in histology, it often invades important nerve structures such as pituitary stem, optic path and hypothalamus, which seriously affects the quality of life of patients. At present, the pathogenesis of craniopharyngioma is still unclear, but with the advancement of molecular biology technology, its basic research is deepening. In this paper, the research progress of craniopharyngioma was described from the aspects of signaling pathway, gene mutation and animal model.

Common complications after microvascular decompression (MVD) of hemifacial spasm include hearing impairment, facial paralysis, vertigo, cerebrospinal fluid leakage, posterior cranial nerve injury, etc. Among them, facial paralysis is one of the main complications. Although it has been previously reported that the prognosis of facial paralysis after MVD is good, clinical cure is generally achieved with or without treatment, including low-dose hormonal or antiviral therapy. However, the research on the etiology, course and clinical characteristics of facial paralysis after MVD is helpful to deepen the understanding of the nature of facial spasm and the understanding of the mechanism of MVD, and on this basis, further improve the effectiveness and safety of MVD.

Microvascular decompression (MVD) has been widely recognized and popularized as the only way to cure hemifacial spasm (HFS) etiologically. However, in some patients, the symptoms of HFS gradually disappear after a period of time, which is called delayed cure. In-depth research and understanding of delayed cure will help surgeons to reasonably predict the prognosis of patients, especially for patients who have failed after surgery to determine the timing of reoperation is of great significance. This article reviews the research progress of delayed cure after MVD in patients with HFS.

Anterior clinoid meningioma refers to a meningioma that originates from the dura mater on the surface of the anterior clinoid process and grows intracranially or extends into the optic canal. The tumor is closely related to cavernous sinus, internal carotid artery, optic nerve, optic chiasm and other structures, so the microsurgical treatment of anterior clinoid meningioma is still a major problem in the field of neurosurgery. With the continuous development of skull base neurosurgical techniques, the microsurgical treatment of anterior clinoid meningioma is constantly improving. This article reviews the recent progress in microsurgical treatment of anterior clinoid meningioma.

Papillary glial neuronal tumor (PGNT) is a mixed neuroglioma associated with epilepsy. It was classified as an independent pathological type in the 2016 World Health Organization (WHO) classification of central nervous system tumors, which belongs to WHO grade I. PGNT has the growth characteristics of benign tumors, with epilepsy as the main symptom in clinical practice and no gender difference. If there is no pathological evidence, preoperative diagnosis is difficult. The prognosis of patients with total tumor resection is good. PGNT is very rare, and it is rarely reported in domestic and foreign literatures. In this paper, the progress of PGNT in pathological characteristics, imaging characteristics, clinical manifestations, treatment and prognosis were reviewed.