Volume 35 · Issue 10 · 2019

With the advancement of target localization, electrode and pulse generator technology and further understanding of the mechanism of disease, deep brain electrical stimulation has become increasingly widespread in its application fields, from the past Parkinson's disease, essential tremor, dystonia, to the treatment of mental diseases, cognitive disorders, epilepsy, consciousness disorders and other diseases. The continuous development of deep brain electrical stimulation technology and application fields is expected to bring hope to more patients with functional diseases.

In 2019, the Guidelines for Clinical Diagnosis and Treatment of Adult Diffuse Glioma-Related Epilepsy, co-written by experts organized by China Anti-Epilepsy Association and the Glioma Professional Committee of Chinese Medical Doctors Association, was published in the journal Cancer Medicine. As the first diagnosis and treatment guideline in the field of glioma-related epilepsy in the world, the publication of this guideline fully reflects the recognition of scientific research and clinical work in related fields in China by international peers. In order to strengthen the in-depth understanding of glioma-related epilepsy among domestic peers, promote the scientific and standardized clinical diagnosis and treatment, and benefit more patients, this article makes a detailed interpretation of the diagnosis and treatment recommendations put forward in the guidelines.

To explore the initial start-up programming and efficacy of deep brain electrical stimulation (DBS) of the hypothalamic fornix (HF) in the treatment of severe Alzheimer′s disease (AD).

A retrospective study was conducted on 9 patients with severe AD who underwent DBS-HF at Department of Neurosurgery, the First Medical Center of Chinese PLA General Hospital from June 2015 to September 2018. Postoperative cranial MRI was performed to determine the electrode position. Four weeks after operation, DBS device was turned on with initial programming set as unipolar stimulation with a frequency of 130 Hz, pulse width 90 μs and voltage of 3 V. The emotion, memory, calculation, language or communication and orientation of the patients were observed based on corresponding function of the brain area where the electrode contacts were located in order to determine the optimal contact and stimulating mode was thus maintained. Outpatient follow-up was conducted for all patients 3 months after the start-up. The follow-up included assessment of the patient′s emotion, memory, calculation, language, communication and orientation evaluated at initial programming. In addition, the patient′s sleep conditions and social skills were documented through consultation with the patient′s families.

Nine patients were successfully operated. No perioperative complications such as intracerebral hemorrhage, abnormal electrode connection or wound infection occurred after operation. The electrodes of 9 patients were accurately implanted into the preset target position. At initial programming, there were no adverse effects reported including psychiatric and behavioral disorders, cardiovascular events and intolerance of stimulation. Among the 9 patients, memory was improved in 2 and mood was improved in 1. No symptom worsening was observed in the patient with severe psychiatric disorder who underwent bipolar stimulation through optimal contacts. Nine patients were followed up for 3 months. Among them, 7 had improved mood, 5 had improved memory, 7 had improved sleep, 6 had improved language ability, 3 had changed social intercourse, and 4 had changed orientation. However, there was no significant change in calculating power of 9 patients.

The preliminary results have suggest that the program-controlled startup scheme with functions of test, calculation, memory, emotion and physiology could be a way to ensure the efficacy of HF-DBS in the treatment of severe AD patients.

To explore the therapeutic effect of bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) in the treatment of refractory Meige syndrome (MS).

A total of 32 patients with MS who underwent STN-DBS at Department of Functional Neurosurgery, Aviation General Hospital of China Medical University from May 2014 to July 2017 were retrospectively enrolled into this study. The Burke-Fahn-Marsden Dystonia Disorder Scale (BFMDRS) was used to assess the improvement of clinical symptoms. The patient′s programmed parameters were documented as well.

All 32 patients were successfully operated. No serious complications such as intracranial hemorrhage, wound infection, allergic reaction or electrical stimulator equipment failure occurred during perioperative period. Ten patients (31.3%) had varying degrees of dyskinesia during postoperative programing, which was improved at a certain level after adjustment of programmed parameters. One patient (3.1%) had psychiatric symptoms after surgery, and the mental symptoms disappeared 3 days after treatment. The postoperative follow-up time was >12 months. The improvement rates (median) of BFMDRS scores at 3, 6, and 12 months after surgery were 76.9%, 81.4%, and 82.8%, respectively. Among them, 18 patients were followed up for >24 months, and the improvement rate (median) was 82.5% at 24 months after surgery. All 32 patients were treated with unipolar stimulation mode, which was changed to double negative stimulation mode in 2 cases due to poor effects. The stimulation voltage was 0.8-3.4 V at 12 months postoperatively, the stimulation pulse width was 50-90 μs, and the stimulation frequency was 100-175 Hz. There was no significant increase or decrease in the programmed parameters of 32 patients between 3 and 12 months post operation.

STN-DBS seems safe and effective for patients with drug-resistant MS. Postoperative programming is relatively easy with parameters varying in a small scope.

To explore the feasibility of using electrophysiology to locate STN targets in the treatment of Parkinson′s disease (PD) by deep brain stimulation (DBS) with bispectral index (BIS) monitoring under general anesthesia.

The data of 22 PD patients treated by bilateral STN-DBS at Department of Neurosurgery, the First Hospital of China Medical University from September 2017 to May 2019 were retrospectively analyzed. All patients completed surgery with BIS monitoring under general anesthesia. All STN nuclei were located based on microelectrode recording (MER). Postoperative MRI was fused with preoperative MRI to evaluate the accuracy of electrode implantation.

The discharge in the sensory-motor area of STN were recorded by MER in all 44 sides during asleep DBS. Microelectrodes were implanted and STN electrophysiological signals were recorded for 40 sides when BIS value was maintained above 70. For the other 4 sides when BIS value was maintained between 30 and 60, and the discharge frequency and amplitude were only about 50% of those when BIS value was maintained above 70. The electrophysiological length of STN was 3.5-7.5(5.2±0.9) mm on the right side and 3.5-7.5(5.5±1.0)mm on the left side, respectively. After intracranial electrode was implanted and when BIS value ≥80, 18 patients could complete the stimulation test for clinical symptoms and side effects, and 4 patients could only complete the test for motor side effects. Postoperative MRI showed that all electrode targets were located in STN nucleus, and the radial error was (1.10±0.45)mm on the right side and (1.24±0.56)mm on the left side. No intracranial hemorrhage, infection or other complications occurred.

During the surgery of asleep STN-DBS, clear and typical STN discharge could be recorded in MER with BIS (≥70) monitoring. The target localization seems accurate.

Deep brain electrical stimulation (DBS) is currently internationally recognized as the best treatment for refractory Parkinson's disease (PD). The precision of electrode implantation is the key to ensure the efficacy of DBS. Minimally invasive treatment of all procedures during operation plays an important role in improving the accuracy of electrode implantation and reducing postoperative complications. In this paper, 257 patients (512 sides) with PD were treated with DBS in the subthalamic nucleus, and a more minimally invasive method was used in the treatment of dura mater and arachnoid. A small amount of asymptomatic cortical hemorrhage occurred in 1 case and a large amount of intracranial pneumatosis in 3 cases. There was no obvious shift in the optimal contacts of the electrodes.

To evaluate the accuracy and safety of electrode implantation of deep brain stimulation (DBS) with visual registration-based robot assistance.

The clinical data of 15 patients with Parkinson′s disease (PD) admitted to Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from October 2018 to June 2019 were retrospectively analyzed. All those patients underwent DBS assisted with neurosurgical robot (Remebot system). The distance deviations of implanted electrodes in the lateral direction (x-axis) and longitudinal direction (y-axis) were documented according to postoperative CT fused with preoperative imaging of surgical plan. Postoperative complications were documented as well.

A total of 30 DBS electrodes were successfully implanted in 15 patients. Twenty-six electrodes were implanted into the subthalamic nucleus and 4 into the globus pallidus internus. The x-axis distance deviation between the tip of electrode and planned target ranged from 0.10 mm to 1.34 mm, and the average distance deviation was 0.60±0.33 mm. The y-axis distance deviation ranged from 0.02 mm to 0.83 mm, and the average distance deviation was 0.45±0.24 mm. There were no electrode-related bleeding events, intracranial infection or surgical incision non-healing.

DBS with assistance of neurosurgical robot seems to be associated with relatively little deviation in electrode implantation and no surgery-related complications.

To compare the therapeutic effects of subthalamic nucleus (STN) and globus pallidus internus (GPi) deep brain stimulation (DBS) on Parkinson′s disease (PD) with levodopa-induced dyskinesia (LID), and to explore the possible underlying mechanism.

A total of 27 PD patients with LID treated with STN and GPi-DBS from August 2015 to October 2017 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University were retrospectively enrolled. Among them, 14 underwent STN-DBS and 13 underwent GPi-DBS. Patients were evaluated preoperatively and every 6, 12, 18 months after surgery. The primary outcome was assessed based on the Unified Dyskinesia Rating Scale (UDysRS). The secondary outcome was investigated according to the Unified Parkinson Disease Rating Scale part Ⅲ (UPDRS-Ⅲ), levodopa equivalent dose (LED), stimulation parameters and side effects.

Both STN-DBS and GPi-DBS group showed significant improvement in LID, while GPi-DBS exerted higher LID improvement (F=15.326, P<0.05). The improvement of LID at the 18 month follow-up was 68.2%±33.9% and 96.5%±5.9%, respectively for STN and GPi-DBS. However, there was no significant difference between the two targets in terms of UPDRS-Ⅲ improvement (F=0.050, P>0.05). The improvement of UPDRS-Ⅲ at the 18 month follow-up was 44.7%±20.0% and 45.7%±17.1%, respectively for STN and GPi-DBS. The LED reduction rate was higher in STN-DBS group (F=4.693, P<0.05). The LED reduction rate at the 18 month follow-up was[M(P₂₅, P₇₅)] 44.8(26.7, 80.2)%and 14.0(0, 41.3)%, respectively for STN and GPi-DBS.The stimulation voltage and pulse width of the GPi-DBS group were higher than those of the STN-DBS group (F values were 4.435 and 21.415 respectively, P<0.05). In the STN-DBS group, there were 5 cases of stimulation induced dyskinesia (SID), 1 case of electrode fracture, and 1 case of incision infection.There were 1 case of SID and 1 case of bradykinesia in the GPi-DBS group.

Both STN and GPi-DBS could improve dyskinesia. Compared with STN-DBS, GPi-DBS seems to have a stronger effect on improvement of LID. The anti-dyskinesia effect of STN-DBS may be related to drug reduction and adjustment of stimulation sites, while GPi-DBS might exert a direct anti-dyskinesia effect.

To evaluate the long-term efficacy of deep brain stimulation (DBS) for the treatment of primary generalized dystonia (PGD) and to analyze the factors influencing the clinical outcome.

We retrospectively analyzed the data of 21 patients with PGD who underwent DBS from December 2004 to April 2013 at Department of Neurosurgery, Tangdu Hospital, Air Force Medical University. DBS targeting the subthalamic nucleus (STN-DBS) was applied in 11 patients, and DBS targeting the globus pallidus internus (GPi-DBS) was performed in 10 patients. The severity of dystonia was assessed using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). Multiple linear regression analysis was used to explore the factors affecting clinical outcomes.

The follow-up period ranged from 5 years to 11 years, and the median time was 6.5 years. The average improvement rate of BFMDRS movement scores was 65.7%±13.9% and the median improvement rate of disability scores was 54.5 %[IQR (interquartile range): 17.0%] in the 21 patients with PGD at the last follow-up. The mean/median improvement rates of movement score and disability score in STN-DBS group were 64.4%±15.8% and 57.1%(IQR: 20.2%) respectively, and those in GPi-DBS group were 67.1%±12.2% and 52.8%(IQR: 18.0%) respectively. There was no significant difference in the average improvement rate of BFMDRS movement score or disability score between STN-DBS and GPi-DBS group (both P>0.05). Multiple linear regression analysis showed that only the course of disease had a significant effect on clinical outcome, which was negatively correlated with the results (t=-7.082, P<0.001). The remaining variables including gender, age of onset, age of surgery, DBS target and preoperative movement score had no effect on clinical efficacy (allP>0.05).

DBS treatment of PGD is effective. Both GPi and STN can be used as alternative therapeutic targets and their efficacies seem similar. Patients with shorter disease duration may achieve better clinical outcomes.

To investigate the therapeutic effect of deep brain stimulation (DBS) in patients with chronic consciousness disorder (DOC) and its influencing factors.

Twenty-four DOC patients admitted to Department of Neurosurgery, the Seventh Medical Center of PLA General Hospital from July 2011 to December 2018 were retrospectively enrolled into this study. All patients were treated with DBS targeting unilateral central nucleus-parafascicular nucleus complex. CT or MRI was performed post operation to determine the electrode position. All patients were clinically followed up post operation. The follow-up included physical examination of the nervous system, assessment of modified coma recovery scale (CRS-R) score and extended Glasgow outcome score (GOS-E). According to the clinical symptoms and assessment scores of the patients, the therapeutic effects were evaluated and categorized into effective and ineffective. Furthermore, univariate and multivariate logistic regression analyses were used to explore the risk factors affecting the efficacy of patients.

All 24 operations were successful. After reexamination of CT or MRI, the electrodes of all patients were implanted into the preset target position. DBS was turned on at 7 days post surgery in the 24 patients who received unipolar electrical stimulation with the voltage of (3.3±1.2)V (1.0-4.0 V), frequency of 100 Hz and pulse width of 120 μs. At 1-year follow-up, the outcomes of 24 patients were effective in 10 patients, improved in 13 and death in 1. The overall effective rate was 41.7% (10/24). Univariate analysis showed that the age, CRS-R score and recommendation criteria for surgery were influencing factors of the patient′s outcome (all P<0.05). Further multivariate logistic regression analysis showed that recommendation criteria for surgery was the independent risk factor affecting the outcome of patients(OR=4.333, 95%CI: 1.207-519.697, P=0.037).

DBS seems effective in the treatment of DOC and could be used as one of the feasible schemes for DOC treatment. recommendation criteria for surgery is the independent risk factor affecting the outcome of DOC patients.

To evaluate the safety of branch arteries covered by Tubridge flow diverters (TFDs) in the treatment of intracranial aneurysms.

The clinical and angiographic data of 79 patients harboring 79 aneurysms treated with TFD from the Parent Artery Reconstruction for Large or Giant Cerebral Aneurysms Using Tubridge (PARAT) trials were retrospectively collected and analyzed, in which 12 nationwide centers participated from December 2012 to May 2014. Digital subtraction angiography (DSA) was performed to evaluate immediate treatment results and coverage of branch vessels. For aneurysms treated by TFDs and coils, immediate results were classified according to Raymond Grade System, and for aneurysms treated by TFDs only, immediate results were evaluated according to stagnation of contrast. Angiographic follow-up was preformed conventionally after treatment with TFDs at 3 months using magnetic resonance angiography (MRA)and 6 months using DSA.

A total of 91 TFD were delivered and implanted successfully in the 79 lesions. Fifty-eight aneurysms were treated by TFDs and coils, and Raymond Ⅰwas achieved in 2 lesions (3.4%), Raymond Ⅱ in 5 lesions (8.6%) and Raymond Ⅲ in 51 lesions (87.9%). For 21 aneurysms treated by TFDs alone, stagnation of contrast was observed in 15 lesions (71.4%). One hundred and ten branch arteries were covered by TFDs. MRA was available in 52 patients at 3 months, and 31 lesions (59.6%) were completed cured, 16 lesions (30.8%) were improved and 5 lesions (9.6%) remained stable. DSA data were available in 73 patients at 6 months. Among them, 55 (75.3%) were completed cured, 14 (19.2%) were improved, 2 (2.7%) remained stable and 2 (2.7%) developed recurrence. The total rate of effective treatment (completely cured and improved) was 94.5% (69/73). Branch artery occlusion was observed in 3 cases, including 1 anterior choroidal artery, 1 anterior cerebral artery and 1 ophthalmic artery, without permanent neurologic deficits. The occlusion rate of branch arteries was 2.9% (3/104).

Branch arteries covered by Tubridge flow diverter in treatment of intracranial aneurysms seem relatively safe and further clinical follow-up is needed.

To explore the predictive values of different methods measuring the distance between lesion and eloquent cortex (LED) in surgery-related functional deficit (SFD) in intracranial arteriovenous malformations (iAVMs).

This study retrospectively reviewed and followed up the patients who underwent microsurgical resection of iAVMs at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January to December 2017. Based on the difference (≥1) between the mRS (modified Rankin scale) at 3 months after surgery and that prior to surgery, 17 patients were categorized into the SFD group and 79 into non-SFD group. The eloquent cortex was firstly recognized according to the Spetzler-Martin(S-M)standard. Based on the presurgical T1-weight, T2-weight, time-of-flight, functional and diffuse tensor imaging MR, the LED and modified LED (MLED) were measured. Multivariate logistic analysis was performed to investigate the independent risk factors related to SFD at 3 months post surgery. The ROC (receiver operating characteristic) curve analysis was performed to explore the predicting values of different measuring methods in SFD.

Multivariate logistic analysis based on 96 patients demonstrated that the S-M grading (OR=3.10), MLED (OR=0.66) and nidus type (diffuse and compact, OR=0.12) were independent risk factors for SFD (all P<0.05). For all iAVMs, both MLED and LED had good predictive value in SFD, and the AUC (area under a curve) values were 0.843 and 0.830 respectively (bothP<0.05), while the S-M grading(AUC: 516,P=0.804) did not have predictive value. For compact iAVMs, LED (AUC=0.784) and MLED (AUC=0.726) could effectively predict the risk of SFD(all P<0.05). For diffuse iAVMs, MLED (AUC=0.833) could predict the risk of SFD (P=0.003), whereas LED (AUC=0.583, P=0.665) had poor predicting value.

The distance between iAVM and eloquent cortex seems to be an important factor to predict the surgical outcome. For compact iAVM, both LED and MLED have good predicting values, while only MLED shows predicting value for diffuse iAVM.

To investigate the safety and efficacy of microsurgery in the treatment of subtentorial cavernous malformations (CMs) in children.

From June 2015 to June 2018, 12 patients (14 lesions) with pathologically proven subtentorial CMs at Department of Neurosurgery, the Children′s Hospital, Zhejiang University School of Medicine, were retrospectively enrolled into this study. The lesions were located in the brainstem in 4 cases and cerebellum in 8 cases (2 of them have 2 lesions in each). The brainstem lesions were examined by diffusion tensor imaging before operation. The safety and effectiveness of the operation were evaluated based on imaging examination, improvement of nervous system symptoms and modified Rankin scale (mRS).

Of the 14 lesions, 13 were totally resected and 1 was followed up. During hospitalization, 9 of 12 cases with preoperative symptoms were improved, 2 cases kept preoperative symptoms and 1 case died. No new neurological deficits occurred. Eleven cases were followed up for 3 to 34 months. No re-bleeding or recurrence was found in the primary site of the lesion. The mRS scores were 0 in 9 cases, 1 in 1 and 2 in 1.

Under the premise of safety, surgical treatment of children′s subtentorial CMs is effective.

To investigate the correlation between the parameters of intracranial pressure (ICP) wave and global cerebral edema for providing basis of early prediction and intervention for global cerebral edema after operation in patients with aneurysmal subarachnoid hemorrhage (aSAH).

A total of 80 patients with aSAH admitted to Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University from May 2017 to December 2017 were retrospectively enrolled. The parameters of ICP wave and clinical data of 80 patients within 3 days after intracranial aneurysm clipping were collected and analyzed. The aSAH patients were divided into the global cerebral endema (GCE) group (n=13) and NO-GCE group (n=67)to compare the clinical data and parameters of ICP wave. The multivariate logistic regression analysis was used to determine the risk factors that might lead to GCE. According to receiver operating characteristic (ROC) curve, diagnostic threshold values for GCE were evaluated and sensitivity and specificity were calculated for optimal thresholds to investigate the predictive value of parameters of intracranial pressure wave for postoperative GCE.

The difference of mFisher(modified Fisher) grading, mean ICP wave amplitude (MWA) and R-symbol of correlation between amplitude and pressure (RAP) were significant between NO-GCE group and GCE group (P value: 0.012, 0.005, 0.001, respectively). The result of multivariate logistic regression analysis showed that mFisher grading (OR=8.896, 95%CI: 1.678-47.165, P=0.010), RAP (OR=2.130, 95%CI: 1.155-3.931, P=0.016) were independent risk factors of postoperative GCE. The optimal threshold values of MWA and RAP were 3.853 and 0.480 respectively, which had high diagnostic value in prediction of GCE. The relevant sensitivity and specificity were 84.6% and 70.1% for MWA and 92.3% and 74.6% for RAP.

The mFisher grading, MWA and RAP might be related to postoperative GCE in patients with aSAH.The mFisher grading and RAP are independent risk factors of postoperative GCE in patients with aSAH. Monitoring of MWA and RAP could help identify the early occurrence of GCE.

To explore the predictive values of island signs and blend signs on non-contrast CT in early hematoma enlargement of spontaneous intracerebral hemorrhage (sICH).

A total of 84 patients with sICH were admitted to Department of Neurosurgery, Wenjiang District People′s Hospital of Chengdu from January 2015 to December 2017 and consecutively enrolled into this study. The time from onset to the first CT examination was ≤6 h, and the second CT examination time was ≤24 h. According to the results of those 2 examinations, the patients were divided into the early hematoma enlargement group (35 cases) and the hematoma non-enlargement group (49 cases). The effects of CT island signs and blend signs on early hematoma enlargement and their diagnostic efficacy for early hematoma enlargement were analyzed.

Non-contrast CT scan showed that 60.0% (21/35) in the early hematoma enlargement group had island sign, and 71.4% (25/35) had blend sign. Compared with 14.3% (7/49) and 24.5% (12/49) in non-enlargement group, those differences were statistically significant (both P<0.01). Multivariate logistic regression analysis revealed that both island sign (OR=12.720, 95% CI: 3.501-46.218, P<0.01) and blend sign (OR=10.793, 95% CI: 3.172-36.727, P=0.01) were independent predictors of early hematoma enlargement. The sensitivity, specificity, positive predictive value, negative predictive value and Youden index of island sign for early hematoma enlargement were 60.0%, 85.7%, 75.0%, 75.0% and 45.7% respectively. The sensitivity, specificity, positive predictive value, negative predictive value and Youden index of blend sign for early hematoma enlargement were 71.4%, 75.5%, 67.6%, 78.7% and 46.9% respectively. The sensitivity, specificity, positive predictive value, negative predictive value and Youden index of island sign combined with blend sign for early hematoma enlargement were 91.4%, 63.3%, 64.0%, 91.2% and 54.7% respectively.

Island sign and blend sign are independent predictors of early enlargement of hematoma. The diagnostic performance with the combination of island sign and blend sign seems higher than the that of either single indicator.

This study investigated the efficacy of neuroendoscopic third ventriculostomy (ETV) combined with lumbar cistern drainage in the treatment of hydrocephalus after subarachnoid hemorrhage. The clinical data of 57 patients with hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) admitted to the Department of Neurosurgery of Hebei Provincial People's Hospital from October 2012 to October 2015 were retrospectively analyzed. 31 cases (observation group) were treated with ETV combined with postoperative lumbar cistern drainage, while 26 cases (control group) were treated with ETV only. The overall effective rates of the observation group and the control group at 3 months postoperatively were 90.3% (28/31) and 69.2% (18/26), respectively; At 1-year follow-up, the overall effective rates of the two groups were 87.1% (27/31) and 61.5% (16/26), respectively. The differences of efficacy between the two groups at 3 months and 1 year after surgery were statistically significant (bothP<0.05)。 For hydrocephalus after aSAH, compared with ETV alone, ETV combined with lumbar cistern drainage can significantly improve the effective rate, and the effect is good 1 year after operation.

To investigate the diagnosis and treatment of intracranial hemangioblastomas (HBs) with special imaging findings in order to improve the clinical diagnostic level of this disease.

The clinical data of 8 patients with HBs who had atypical imaging findings admitted to Department of Neurosurgery, Huashan Hospital, Fudan University from May 2014 to April 2018 were retrospectively analyzed. Eight patients underwent CT and MRI, 7 of which underwent magnetic resonance spectroscopy (MRS) and 3 underwent positron emission tomography (PET)-CT. One case was diagnosed as Von Hippel-Lindau (VHL)-HB before surgery due to multiple lesions and the other 7 were misdiagnosed as other intracranial tumors. Eight patients with intracranial HB underwent microsurgery.

All 8 cases showed atypical imaging findings. Four cases of cystic HBs presented the partial enhanced cystic wall or enhanced ring lesion without the nodules. The other 4 cases of substantial HBs showed severe peritumoral edema surrounding the lesions. Eight tumors were completely resected by microsurgery and HBs were confirmed by the postoperative pathology. The severe edema in 4 patients completely disappeared after dehydration therapy. Seven patients underwent VHL gene test, and 3 were found to be VHL-HB (including the patient with multiple lesions), which were recruited in the management of VHL disease. Postoperative follow-up duration was 32±17.6 months (3-50 months).

Those intracranial HBs with atypical imaging findings are very rare and misdiagnosis is common based on preoperative MRI results. MRS, PET-CT and other examinations might have supporting value for the diagnosis of HB and its definite diagnosis relies on pathological examination. Microsurgical resection is the main treatment for HB.

To explore the precision, efficiency and safety of robot-assisted stereoencephalography (SEEG) electrode implantation applied in epilepsy surgery.

A retrospective analysis was conducted on 23 patients of refractory epilepsy who were admitted to Beijing Institute of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University from February 2018 to June 2018 and underwent robot-assisted SEEG electrode implantation ('robot’ group). A total of 25 refractory epilepsy patients admitted from October 2017 to January 2018 underwent CRW stereotactic apparatus-guided SEEG implantation and served as control ('CRW’ group). Continuous thin-slice CT was conducted post operation in each case, based on which the distance between the actual and planned target of each electrode trajectory was measured and set as operational deviation.Operational duration for each electrode implantation and incidences of postoperative complications were documented. The parameters as above were compared between the 2 groups.

In the 'robot’ group, a total of 179SEEG electrodes with 2 642 contacts were implanted in this series (23 cases), with the median of 8 (5-10) electrodes with 120 (76-136)contacts in each patient.In the 'CRW’ group, 25 patients underwent implantation of 172 electrodes with 2 520 contacts, with the median of 7 (6-9)electrodes with 100 (60-128) contacts in each patient.The operational deviation of each electrode was 1.4 (0.4-9.3) mm ('robot’ group) and 1.4 (0-4.6) mm ('CRW’ group), respectively, which had no statistical difference ( P>0.05). Compared with 'CRW’ group, the 'robot’ group had significantly shorter operational duration[8(5.9-12.8) minvs. 14.7 (10.3-18.5) min, P<0.01] for each electrode implantation. In the 'robot’ group, there were 2 cases (8.7%) of asymptomatic intracranial hemorrhage. No cases of infection or other complications were observed. In the 'CRW’ group, there were 1 case (4.0%) of intracerebral hemorrhage causing contralateral paralysis, 1 case (4.0%) of asymptomatic hemorrhage and no cases of other complications.

Robot-assisted technique seems to be able to remarkedly increase the efficiency of SEEG electrode implantation with relatively good precision and safety, which could thus be recommended for clinical use and promotion.

To analyze the correlation on the prominent germline or somatic mutations at chromosome 22 of the sporadic patients with spinal schwannomatosis.

From May to November 2015, 9 serial patients with multiple spinal cord tumors underwent open surgery at Neurosurgical Department, the Third Hospital of Peking University. All spinal cord tumors in the 9 patients were removed by operation. The multiple spinal cord tumors were located at lumbar segments in 4 patients, at cervical segments in 4, and at thoracolumbar segments in 1. The samples of tumor and blood were preserved during operation. In order to determine the SNP (single nucleotide polymorphism), SNV (single nucleotide variants) and CNV (copy number variations) of 9 patients, whole-exome targeted enrichment and sequencing were performed on tumor and blood DNA after operation.

The open surgery was successful performed in 9 patients. Among 9 patients, histological staining showed neurofibromatosis type I (NF1) in 3 cases, ganglioneuroma in 1, ependymoma in 1, and schwannomatosis in 4 (1 case with comorbidity of bilateral acoustic tumors). Among 9 sporadic cases, gene mutation was detected in a large region of chromosome 22 only in 4 cases with spinal schwannomatosis. Among 4 cases, the germline mutation was identified in 2 cases, and somatic mutation in 2 cases. Splice-donor neurofibromatosis type 2 (NF2) germline high frequency mutation (T→C) was identified in the No.1 patient. Frame-shift leucine-zipper-like transcriptional regulator 1 (LZTR1) germline high frequency mutation (G→GT) was identified in the No. 2 patient. Frameshift NF2 somatic mutation (CGA→C) was identified in the No. 3 patient. Stop-gained NF2 somatic mutation was identified in the No. 4 patient. Among 4 cases, chromosome fibrillin 3 (FBN3) intermediate frequency missense mutation was simultaneously found in chromosome 19 in 2 cases, out of which 1 was somatic mutation and the other was germ line mutation.

The preliminary results have suggested that most of the genes with high frequency mutations in spinal schwannomatosis are on chromosome 22.

To explore the efficacy of vagus nerve stimulation (VNS) for the treatment of drug resistant epilepsy.

The clinical data of 110 patients with drug resistant epilepsy who underwent VNS at Department of Neurosurgery, Provincial Hospital Affiliated to Anhui Medical University (the First Affiliated Hospital of University of Science and Technology of China) from February 2014 to March 2018 were analyzed retrospectively. The frequency and severity of seizures were followed up by outpatient review, and the efficacy was analyzed according to the McHugh seizure outcome classifications.

The results of McHugh grade of 110 patients were as follows: grade ⅠA in 10 cases, grade ⅠB in 6, grade ⅡA in 25, grade ⅡB in 7, grade ⅢA in 30, grade ⅢB in 8, grade Ⅳ in 1 and grade Ⅴ in 20, and 3 patients were lost to follow-up. There was significant difference in seizure frequency between preoperative and postoperative conditions (P<0.001). None of the factors including the patient′s age, sex, type of seizure and course of disease would be associated with the difference above (allP>0.05). In terms of seizure types, there were significant difference in the distribution of the McHugh classifications between patients with seizures of unclassified onset, focal onset and generalized onset (allP<0.05). The frequency of seizures decreased gradually with prolonged VNS stimulation time(P<0.05).

VNS could significantly reduce the frequency of seizure. VNS has a better effect on seizures with focal onset and generalized onset, while it has a poor effect on seizure types that cannot be classified. With the increase of stimulation time, the therapeutic effect of VNS is gradually improved. However, the age, sex or duration of disease is not related to the effect of VNS.

This study retrospectively analyzed the clinical data of 4 children with frontal synostosis admitted to the Department of Neurosurgery, Children's Hospital affiliated to Nanjing Medical University from April 2017 to March 2018. All the children were diagnosed by plain CT scan and three-dimensional reconstruction. All 4 cases were treated with frontal-orbital bridge advancement and biparietal bone flap instead of frontal bone flap. The surgical procedure was smooth, and no postoperative complications occurred. Four children were followed up for 9 to 20 months. The postoperative appearance improved satisfactorily, and the frontal angle and cranial cavity volume increased significantly.

Patients with severe craniocerebral injury (sTBI) are prone to cerebral ischemia, cerebral infarction and other brain injuries after operation. If early diagnosis can effectively prevent the occurrence of cerebral infarction. It is reported in the literature that both CT perfusion imaging (CTP) of the head and neuron-specific enolase (NSE) in serum can show the extent and severity of ischemia in patients. This study prospectively enrolled 23 patients with sTBI admitted to the Department of Neurosurgery of North Jiangsu People's Hospital from October 20016 to January 2019, and all patients were treated with craniectomy and decompression and craniotomy for hematoma evacuation. Postoperatively, patients were divided into cerebral infarction group (16 cases) and non-cerebral infarction group (7 cases) according to whether cerebral infarction occurred. Further univariate analysis showed that the preoperative Glasgow coma score, the related parameters of postoperative CTP and serum NSE were the clinical factors affecting the postoperative cerebral infarction. Therefore, it is preliminary speculated that CTP and NSE may have predictive value for judging whether cerebral infarction occurs in patients with sTBI after operation.

Epidermoid cysts of the cavernous sinus are rare intracranial tumors. The Department of Neurosurgery of Ganzhou People's Hospital treated two patients with epidermoid cysts of the cavernous sinus from October 2017 to June 2018. Tumor resection through the anterior subtemporal petrous approach was performed with intraoperative neuronavigation assistance and intraoperative neuroelectrophysiological monitoring. Postoperative MRI showed total tumor resection, and the preoperative cranial nerve-related symptoms of the patients were alleviated without new neurological dysfunction.

Internal carotid artery vesicular aneurysm (BBA) is a rare intracranial vascular lesion. Compared with intracranial sac aneurysm, it has high mortality and poor prognosis. Because BBA tumor wall is thin, the base is wide, and part of the tumor neck is unclear, which makes clinicians face great challenges. At present, the surgical treatment of BBA mainly includes craniotomy, endovascular treatment and craniotomy combined with endovascular treatment, but there is no optimal treatment plan at present. Many literatures have reported that endovascular treatment is superior to craniotomy. Moreover, the development of endovascular therapy has advanced by leaps and bounds, which has greatly improved the efficacy and prognosis of BBA patients. This article will review the surgical treatment of internal carotid artery BBA.

Surgery is an effective treatment for refractory temporal lobe epilepsy. Besides traditional resection surgery, minimally invasive surgery and neuromodulation treatment have been paid more and more attention. Traditional resection surgery can control the seizure of most patients with temporal lobe epilepsy, but some patients still have postoperative epilepsy recurrence, the cause of which is not completely clear. Epileptic seizure symptomatology, electrophysiological characteristics and imaging indexes are all helpful to evaluate the surgical prognosis. This article reviews its research progress, and discusses the advantages and disadvantages of different surgical methods, so as to provide help for deeply understanding the surgical treatment of temporal lobe epilepsy and optimizing the treatment plan.