Volume 35 · Issue 11 · 2019

The diagnosis and treatment of complex cerebrovascular diseases is a hot and difficult point in the field of neurosurgery. This article discusses the indications of surgical treatment of complicated cerebrovascular diseases, analyzes the advantages and disadvantages of craniotomy and endovascular treatment, and emphasizes the application of combined surgery in complicated cerebrovascular diseases. Compound surgery is based on high-quality images for real-time evaluation, and the "one-stop" treatment model of fusion craniotomy and endovascular treatment can reduce medical risks and save medical costs. This treatment model emphasizes the research and development and application of new surgical technologies and the training of cerebrovascular surgeons, which eventually turns complexity into simplicity, thus continuously narrowing the disease spectrum of complex cerebrovascular diseases and improving the surgical treatment effect of cerebrovascular diseases.

To investigate the role of revascularization in the treatment of complex intracranial aneurysms.

From January 2014 to March 2019, a total of 22 patients with complex intracranial aneurysms were treated with extracranial-intracranial (14 cases) or intracranial-intracranial (8 cases) revascularization at Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine. The treatment methods of intracranial aneurysm included intraoperative isolation, proximal ligation, distal ligation, plastic clamping, encapsulation, intravascular embolism and postoperative embolism. The patency of anastomotic vessels, obliteration of the aneurysms and postoperative complications were observed after operation. Outcomes of patients were evaluated with Glasgow Outcome Scale (GOS).

In this series, 22 cases successfully underwent revascularization. Intraoperative fluorescein angiography or DSA revealed the patency of anastomotic vessels. Postoperative angiographies were performed and patency of anastomotic vessels was confirmed in 18 patients (81.8%) and obliteration of aneurysms was confirmed in 20 patients (90.9%). Five patients (22.7%) developed various degrees of cerebral infarction. One patient was discharged because of poor prognosis and lost to follow-up. The other 21 patients were followed up for 1-59 months. No aneurysm recurred or ruptured during the follow-up period. GOS was Ⅴ in 20 cases and Ⅳ in 1 case.

With the proper selection of individualized revascularization based on the characters of aneurysms and cerebral blood flow requirement, revascularization seems an effective and safe method for the treatment of complex intracranial aneurysms.

To assess postoperative revascularization of adult patients with Moyamoya disease (MMD) operated on with different surgical methods using the technology of MRI territory arterial spin labeling (T-ASL).

The clinical data of 84 adult MMD patients surgically treated at Department of Neurosurgery, Huashan Hospital, Fudan University from June 2018 to December 2018 were reviewed. Seventy patients received superficial temporal artery to middle cerebral artery bypass (STA-MCA bypass) combined with encephalo-duro-myo-synangiosis (EDMS) and were categorized into combined-bypass group. Fourteen patients underwent merely EDMS and categorized into indirect-bypass group. Digital subtraction angiography (DSA) and T-ASL were performed pre- and postoperatively. Matsushima staging system was applied to assess the outcome of revascularization. T-ASL scan used to investigate the revascularization area (RA) and perfusion of deep brain structures by external carotid artery (ECA) on operated side.

The follow-up period of 84 patients ranged from 4 to 8 months (mean: 6.3±1.2 months). There was no difference in baseline data (sex, age, clinical presentations, and pre-surgical spontaneous collaterals), peri-operative complications, postoperative stroke control rate, Matsushima stage (grade A or B) between 2 groups (P>0.05). The volume of RA in combined-bypass group was larger than that in indirect-bypass group (101.5 ± 35.5 mlvs. 45.3 ± 14.2 ml, P<0.01). In the combined group, 81.4% (57/70) of operated ECA could perfuse deep structures such as basal ganglia and thalamus, compared with 2/14 in the control group (P<0.01).

The T-ASL results have suggested that RA of combined bypass seems larger and deeper than that of indirect bypass. T-ASL could an objective and sensitive method to evaluate surgical results of adult MMD in terms of RA volume and spatial distribution.

To investigate the efficiency and influence factors of stereotactic precise aspiration in treatment of primary brainstem hemorrhage.

A total of 47 patients with primary brainstem hemorrhage who underwent stereotactic precision aspiration from March 2014 to September 2018 at Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine were enrolled and their clinical data were collected. Surgical approach was chosen according to the location of the pons where the hematoma was located. Meanwhile, patients with postoperative hydrocephalus underwent external ventricular drainage. Intracranial residual hematoma volume was evaluated by CT scan on the first day post operation. Further follow-up at 30 days post surgery by phone or clinic was conducted to confirm the status of all patients. Univariate analysis and logistic regression analysis were performed to investigate the clinical factors associated with survival of patients.(ROC) curvecurve was further drawn to judge its predictive value.

Among 47 patients, no death was reported during the operation. CT scan at day 1 post surgery showed that the average of intracranial residual hematoma volume in 47 patients was (2.7±0.9) ml (0-15.5 ml), and the clearance rate of hematoma was (75.0±24.2)%. In this series, 7 cases died and 40 survived within 30 days. The mortality rate was 14.9%. Univariate analysis revealed that classification of hematoma was the factor influencing postoperative mortality (χ²=13.689, P=0.033), which was confirmed by multiple logistic regression analysis (OR=0.053, 95% CI: 0.744-0.992, P=0.004). Further ROC curve results showed that the sensitivity and specificity of hematoma classification in predicting the prognosis of patients were 85.7% and 82.5%, respectively.

The new classification of brainstem hematoma is suitable for surgical planning and beneficial for prediction of the 30-day mortality.

To summarize the short-term therapeutic effect and safety of flow diverter (FD) in the treatment of small unruptured intracranial aneurysms.

From April 2014 to March 2019, clinical data were collected from 110 patients with 145 small (diameter < 10 mm) unruptured intracranial aneurysms who were admitted to Department of Neurosurgery, People′s Hospital of Zhengzhou University. Among those, 133 aneurysms were treated with FD alone and 12 aneurysms were treated with FD combined with coiling. Radiological outcomes were assessed based on the Raymond grading. Clinical outcomes were assessed based on the modified Rankin scale score (mRS).

A total of 121 FD were used for 145 aneurysms. The successful rate of stent implantation was 99% (120/121). For 17 FD, balloon dilatation or massage were performed for better cell opening and wall apposition. There were no hemorrhagic complications. Ischemic complications occurred in 5 cases (4.5%). At 6 months post surgery, DSA results showed that Raymond grade Ⅰ embolism rate was 67.6% (50/74). Asymptomatic stenosis of parent artery was found in 2 cases. The 6-month follow-up results showed the mRS score of 0 in 101 cases, 1 in 4 cases, 2 in 3 cases, and 4 in 1 case and 5 in 1 case.

Treatment of small unruptured intracranial aneurysms with FD is associated with high success rate and safety. The 6-month follow-up results seem satisfactory and the long-term treatment results still need further follow-up.

To explore the efficacy and safety of microsurgical treatment of choroidal artery aneurysm (AChAA).

A retrospective analysis was conducted on the clinical data of 94 patients with AChAA admitted to Department of Neurosurgery, Affiliated Hospital of Qingdao University from December 1997 to December 2018. Among them, 90 patients underwent aneurysm clipping with the Yasargil pterional approach, and 4 patients underwent modified pterional approach for decompressive craniectomy. After surgery, all patients were followed up clinically to assess the outcomes based on the Glasgow outcome scale(GOS) system.

A total of 120 aneurysms were successfully clipped in 94 patients. Three patients developed cerebral hemorrhage after operation, including 1 case of epidural hematoma on the contralateral side of the lesion, 1 case of ipsilateral frontal lobe hematoma, and 1 case of contralateral basal ganglia hemorrhage. Seven patients developed cerebral infarction, including 1 case of large-scale cerebral infarction and 6 cases of basal ganglia infarction with paralysis. One case suffered from pulmonary embolism 3 days after operation. Three cases developed hydrocephalus and returned to independent life after ventriculoperitoneal shunting. The follow-up time in 94 patients was 6 to 120 months. Of the 94 patients, 84 (89.4%) were GOS Ⅳ, 3 (3.2%) were grade Ⅲ, 2 (2.1%) were grade Ⅱ, and 5 (5.3%) were grade Ⅰ.

Open microsurgical clipping remains important treatment for AChA aneurysms, for which sufficient understanding of microanatomy of the AchA combined with skilled microsurgical clipping techniques would help achieve satisfactory clinical outcomes.

To investigate the strategy and effect of microsurgical treatment of basilar artery bifurcation aneurysms with different surgical approaches.

We retrospectively reviewed the clinical data of 43 patients with basilar artery bifurcation aneurysms who underwent microsurgical clipping at Department of Neurosurgery, the Second Xiangya Hospital, Central South University from April 2011 to April 2018. Of all 43 cases, 32 cases had ruptured basilar aneurysms and 11 cases had unruptured basilar aneurysms. According to the different morphological and anatomical locations of aneurysms, 17 cases underwent infraorbital approach, 26 cases underwent transsyvian approach (including the transorbirozygomatic approach, the 'half-half’ approach which combined the subtemporal approach with pterion approach and the simple pterion approach) to conduct microsurgical clipping. Intraoperative monitoring was performed using the combination of multiple technologies. Clinical and imaging follow-up was conducted over 6 months post surgery.

Of all 43 cases with basilar artery bifurcation aneurysms, 38 cases were completely clipped, 4 cases were partially clipped, and 1 case was wrapped. There were 2 cases (4.7%) of hemiplegia after operation, 1 case (2.3%) of coma, 14 cases (32.6%) of oculomotor nerve palsy and no death during perioperative period. Thirty-seven patients (86.4%) were followed up for 25.0±10.1 months (range: 6 months to 4 years). Among them, 35 patients underwent radiographic review without aneurysm residual and 1 patient with partial clipping was treated with second-stage interventional embolization. In 1 case with wrapped aneurysm, the significantly enlargement of aneurysm was not observed in the follow-up image. Of 14 cases with oculomotor nerve palsy after operations, 11 were followed up and 8 of them improved significantly afterwards. Glasgow′s outcome scale(GOS) showed that grade V was reported in 34, grade IV in 1 case, grade III in 1 case, grade II in 0 and grade I in 1 case who died from severe pulmonary infection at 42 days post operation.

The superior treatment of the basilar artery bifurcation aneurysm could be achieved through subtemporal and transsyvian approach. Preoperative evaluation of anatomical and morphological characteristics of aneurysm seems important for the choice of surgical approach. The application of various assistive techniques during surgery is an important part of ensuring the safety of surgery.

To investigate the safety and efficacy of carotid endarterectomy (CEA) and carotid artery stenting (CAS) for the treatment of internal carotid artery stenosis.

This study retrospectively analyzed 136 patients who underwent surgical treatment of internal carotid artery stenosis at the First Affiliated Hospital of Soochow University from July 2017 to December 2018. Among those, 78 underwent CEA (CEA group) at Department of Neurosurgery and the other 58 underwent CAS (CAS group) at Department of Interventional Radiology. General data, time of surgery, postoperative complications, postoperative hospital stay, hospitalization cost, and incidence of postoperative restenosis were compared between the 2 groups.

There was no difference in the age, gender, lesion side, preoperative comorbidity, preoperative complication or preoperative internal carotid artery stenosis rate between 2 groups (all P>0.05). There was no significant difference in operation time, postoperative complications or the incidence of postoperative restenosis between 2 groups (allP>0.05). The follow-up period was 3 to 21 months. The postoperative hospital stay in CEA group was shorter than that in CAS group (6.5±2.3 dvs. 8.3±1.4 d, P<0.01), and the hospitalization cost in CEA group was lower than that in CAS group (57±10 thousand yuansvs. 103±18 thousand yuans, P<0.01).

For patients with internal carotid artery stenosis, both CEA and CAS seem safe and effective. In terms of hospital length-of-stay and economic factors, CEA has certain advantages over CAS.

To investigate the diagnosis and treatment of dural arteriovenous fistulas (DAVFs) of anterior skull base.

The clinical data of 26 patients with DAVFs of anterior skull base admitted to Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University from January 2011 to January 2019 were studied retrospectively. All the patients underwent operation through subfrontal approach. We focused on their clinical manifestations, imaging features and surgical methods. The therapeutic effects were evaluated by digital subtraction angiography (DSA) after operation and during follow-up.

The fistulas of all 26 patients were successfully closed. Anosmia was reported in 2 cases and no other serious complications occurred. The complete obliteration of DAVFs was confirmed by postoperative DSA, and no recurrence was observed at follow-up ranging from 3 months to 9 years.

DSA seems to be an effective method for the diagnosis of anterior skull base DAVFs, for which microsurgical closure of fistulas is the effective treatment. Sufficient preoperative imaging evaluation, skilled microsurgical techniques, exact closure of fistulas are keynotes for the success of operation.

In recent years, transradial artery puncture cerebral angiography has been widely used in clinical practice. This study retrospectively analyzed the clinical data of 2 314 patients who underwent whole brain angiography, including 1 085 transradial puncture and 1 229 transfemoral puncture. The results showed that compared with the transfemoral approach, patients undergoing trans-radial puncture cerebral angiography had shorter postoperative hospital stay and fewer overall complications, making it one of the alternative vascular routes for cerebral angiography examination.

To analyze the atypical clinical manifestations and clinical prognosis of pediatric diffuse intrinsic pontine glioma (DIPG).

A total of 27 patients with complete clinical data of DIPG undergoing clinical treatment at Neurosurgery Department of Beijing Tiantan Hospital, Capital Medical University from November 2015 to November 2017 were retrospectively enrolled into this study. All patients were divided into 2 groups according to the presence of atypical manifestations: atypical clinical manifestation group (17 cases) and the control group (10 cases). Among the 27 cases, 16 patients underwent stereotactic biopsy or open cranial biopsy, and the other 11 patients underwent tumor excision through craniotomy. All the children were followed up clinically or by telephone after operation to study the clinical outcomes. Comparative analysis was conducted on those clinical data. Prognosis was compared between the 2 groups through Kaplan-Meier survival analysis.

Among the 27 cases, 20 were pathologically identified as high grade gliomas (including 4 cases of diffuse midline glioma, 6 cases of glioblastoma, 6 cases of anaplastic oligoastrocytoma, 4 cases of anaplastic astrocytoma) and 7 as low grade glioma (including 4 cases of oligoastrocytoma and 3 cases of astrocytoma). One child suffered from pneumonia and finally recovered postoperatively. No statistically significant difference (all P>0.05) was identified between 2 groups in the age, gender, clinical manifestation (including cranial nerve palsy, long tract dysfunction and cerebellum signs), clinical imaging features (including lesion enhancement, supratentorial ventricle enlargement and brachium pontis involvement), clinical treatment or pathology. Kaplan-Meier survival analysis showed that patients with atypical clinical manifestation had significantly higher cumulative survival rate than those in the control group (P=0.045).

Atypical clinical manifestation could be identified in some pediatric DIPG patients, which might be predictive of a better prognosis.

To study the outcomes of the revision surgeries correcting electrode malposition in deep brain stimulation (DBS) for Parkinson’s disease (PD).

A total of 18 PD patients were enrolled who underwent lead revision surgeries due to subthalamic nucleus (STN) DBS lead malposition at Neuromodulation Center, Department of Neurosurgery, Tsinghua University Yuquan Hospital between September 2013 and May 2018. Changes in UPDRS-III scores on and off medication were analyzed at 1 month and 6 months postoperatively compared to those before surgery. MR images were also collected to analyze the lead location change.

Among the 18 patients, 14 had bilateral lead revision and 4 had unilateral revision. A total of 32 leads were revised, among which 25 were reimplanted and the other 7 were repositioned without reimplantation. Off medication, the average UPDRS-Ⅲ scores before and 1 month and 6 months after surgery were 44.0±10.5, 22.4±7.4 and 25.3±7.7 respectively. On medication, those were 27.3±9.1, 16.7±8.7 and 20.3±8.3 respectively. The analysis of variance and comparisons between groups showed that the on and off medication scores were significantly reduced after the revision surgery (P<0.05). The off medication score at 6 months was averagely improved by (40.7±4.7)%(5.9-79.5%). The average distance between pre-implantation and post-implantation lead locations on the plane 3.5 mm below AC (anterior commissure)-PC (posterior commissure) was (2.8±1.0) mm(1.2-4.5 mm). No adverse events such as hemorrhage or infection were observed after surgery.

Lead revision surgery could safely and effectively remedy the suboptimal outcomes due to electrode malposition in STN-DBS for PD patients.

To investigate the clinical features and surgical outcomes of posterior cingulate epilepsy (PCE) confirmed by stereotacticelectroencephalogram (SEEG).

Eleven patients of PCE were retrospectively enrolled into this study who were identified by SEEG at Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University from June 2014 to August 2018. Among them, 9 underwent epileptogenic zonectomy involving post cingulate gyrus and 2 underwent SEEG-guided radiofrequency thermocoagulation of epileptogenic zone. Retrospective analysis was conducted on the patients′ clinical symptomological characteristics, electroencephalograms, and ictal SEEG. The Engel scale was used to evaluate the surgical outcomes.

Among the 11 patients, preoperative scalp-EEG showed epileptiform discharges in the posterior temporal-parietal-occipital areas in 7 cases, anterior-middle temporal areas in 2, and no epileptiform discharge in 2 cases. Two patients showed simple partial motor seizures spreading to frontal and parietal areas on SEEG. Nine patients showed dialeptic and automotor seizures spreading to medial temporal areas on SEEG. The mean followed-up time after surgery was 13-48(29±12)months. Among the 9 patients undergoing resection of posterior cingulate gyrus, Engel Ⅰa was achieved in 7 cases, Ⅰc in 1 and Ⅱ in 1 case. Out of the 2 patients undergoing SEEG-guided radiofrequency thermocoagulation, 1 had 50% reduction of seizure frequency (Engel Ⅱ) and the other had 25% seizure reduction (Engel Ⅲ). For the 2 patients with posterior cingulate lesions, the seizure originated from the head of contralateral hippocampus and spread to ipsilateral hippocampus and posterior cingulate lesion. One out of the 2 patients was seizure free after resection of posterior cingulate gyrus.

The interictal discharges on scalp-EEG of PCE are often localized in posterior regional. The seizure semiology varies due to different spread networks among PCE patients verified by SEEG. SEEG could improve postoperative seizure-free rates in patients with PCE. The symptomatic and epileptogenic zones may be two different areas.

To investigate the efficacy and influencing factors of spinal cord stimulation (SCS) in the treatment of patients with chronic disorders of consciousness (DOC) after brain injury.

The clinical data of 110 patients with chronic DOC after brain injury were analyzed retrospectively who were admitted to Department of Neurosurgery, the Seventh Medical Center of Chinese PLA General Hospital from August 2011 to December 2017. CT scan of the cervical spine was performed to show the location of the electrode implanted. All patients underwent clinical follow-up at 3 and 6 months after surgery. The follow-up included neurological physical examination and assessment based on modified coma recovery scale-revised (CRS-R). According to the patient's clinical symptom outcome and CRS-R scores, the surgical outcomes were evaluated and divided into effective and ineffective. Univariate and multivariate logistic regression analysis were used to explore risk factors affecting the patient′s outcomes.

Cervical CT was performed after operation. The electrodes of 110 patients were implanted at cervical spinal epidural C₂-C₄ level. Stimulation parameters in 110 patients included the frequency of 5 Hz or 70 Hz, pulse width of 210 μs, voltage of 1-5 V, daily device-on time of 8-12 h, stimulation mode of 15-min stimulation with 15-min interval. At 6 months post surgery in this series of 110 patients, 38 cases were effective (good in 24 and improved in 14), 72 were ineffective (ineffective in 67 and death in 5), and the overall effective rate was 34.5% (38/110). Univariate analysis showed that age, duration of disease, CRS-R score, and preoperative surgical recommendation criterion were clinical factors affecting the patient′s outcome (all P < 0.05). Further multivariate logistic regression analysis showed that preoperative evaluation recommendation criterion was an independent risk factor affecting the patient′s outcome ( OR=8.179, 95% CI: 2.171-30.816, P=0.002). CRS high score was an independent protective factor affecting the patient’s outcome (OR=0.304, 95% CI: 0.095-0.978, P=0.046).

SCS is effective in the treatment of DOC and can be used as one of the feasible treatments for DOC. The preoperative evaluation recommendation criterion is an independent risk factor for the efficacy of patients with DOC.

To analyze the influencing factors of cognitive impairment after moderate traumatic brain injury and to develop prognostic models for cognitive impairment after moderate traumatic brain injury.

A prospective study was performed on 104 patients with moderate traumatic brain injury at Department of Neurosurgery, the Third Xiangya Hospital, Central South University from November 2016 to February 2018. The cognitive function at 3 months after injury was assessed using the Montreal cognitive assessment (MoCA) score. The impact of various lesions on cognitive function was analyzed using univariate and multivariate logistic regression. Prognostic models was established based on logistic regression analysis results. The validation sampling was used to compute the accuracy, sensitivity and specificity of the prognostic models.

Logistic regression analysis revealed that age (OR=1.118, 95%CI: 1.000-1.250, P=0.049), education (OR=0.202, 95%CI: 0.041-0.988, P=0.045), Glasgow coma scale (GCS) score (OR=2.582, 95%CI: 1.242-5.369, P=0.011) and injury cause (OR=0.429, 95%CI: 0.201-0.915, P=0.029) were independent risk factors of cognitive impairment after moderate traumatic brain injury. The prognostic model based on the risk factors of admission had favorable performance (P>0.05 for partial chi square test, 0.902 for area under curve). The accuracy of the prognostic model was 88.6%. The sensitivity and specificity were 55.6% and 100.0% respectively.

Age, education, GCS score and injury cause are influencing factors of cognitive impairment after moderate traumatic brain injury, based on which the established model could be used to timely and accurately predict the prognosis of cognitive impairment after moderate traumatic brain injury.

To investigate the effect of microprobe vascular Doppler (MVD) on the operation of skull base lesions.

From September 2017 to September 2018, 13 patients with skull base lesions at Neurosurgery Department of the first Affiliated Hospital of Soochow University were retrospectively analyzed. The 13 cases included 6 cases of meningioma in Sellar region, 2 cases of meningioma in petroclival region, 3 cases of pituitary adenoma of Knosp Ⅲ-Ⅳ grade, 1 case of chordoma in Sellar clival region, and 1 case of invasive growth of granulation tissue in intraorbital, skull base, sphenoid and ethmoid sinus after Aspergillus infection. The surgical methods included neuroendoscopic transnasal approach and microsurgical resection under craniotomy microscope. MVD was applied in all operations of this series. Medical imaging examination and follow-up were performed after operation.

Among the 13 patients, total resection of meningioma in Sellar region was performed in 6 cases and subtotal resection in 2, total resection of Knosp grade Ⅲ-Ⅳ pituitary adenoma was conducted in 2 and subtotal resection in 1. Total resection was performed in 1 case of invasive growth of granulation tissue in intraorbital, skull base, sphenoid and ethmoid sinus after Aspergillus infection and 1 case of chordoma in Sellar base clival region. Uncorrected left eye vision was reported in the patient with Aspergillus infection post surgery. Postoperative symptoms of the other patients were improved. The prolactin level of 1 patient with prolactin adenoma was more than 204 ng/ml before operation. At 2 months post operation, the prolactin level was 105.66 ng/ml after oral bromocriptine combined with radiotherapy. The last reexamination was 11.3 ng/ml without hypophysis dysfunction. Six patients had varying degrees of electrolyte disorder after operation. Four patients had fever after operation and all returned to normal before discharge from hospital after treatment. All patients were followed up for (16.1±3.3) months(10-22 months), and there was no recurrence in imaging examination.

With the aid of MVD during the surgical resection of invasive growth lesions and large space occupying lesions in the skull base, the important blood vessels invaded, wrapped, pushed and displaced by the lesions can be monitored in real time, which might help avoid the disastrous consequences during and after operation and reduce the risk of surgery.

Cryptococcal meningitis neoformans is one of the common opportunistic infections of AIDS. The main clinical manifestations are intracranial hypertension, meningeal irritation and cranial nerve damage caused by intracranial hypertension, which is one of the main causes of death. Timely and effective control of intracranial hypertension is the key to reduce the early mortality rate of patients. In this study, 44 patients with intracranial hypertension caused by AIDS complicated with cryptococcal meningitis neoformans were operated, of which 16 patients underwent ventriculoperitoneal shunt and 28 patients underwent lumbar cistern-peritoneal shunt. The symptoms of 42 cases improved significantly after operation, and 2 cases died during perioperative period; Four patients died of other opportunistic infections 15-28 months after operation after 3-36 months of follow-up; Two cases underwent secondary surgery for intracranial hypertension.

To explore the localization and protection of the parapharyngeal segment of the internal carotid artery, and to provide anatomical data for clinical surgery.

Five adult cranial specimens (10 sides) were dissected by simulating the preauricular sub-temporal fossa approaches under microscope and the endoscopic endonasal transclival approaches, and the relevant data were measured by vernier calipers.

Microscopically, the parapharyngeal internal carotid artery was located between the levator veli palatini anteriorly and the stylopharyngeal muscle posteriorly. The distance between the two muscles was 14.7±0.4 mm (14.2-15.3 mm). From the endoscopic perspective, the parapharyngeal segment of internal carotid artery was located behind the levator veli palatini muscle, and the distance from its attachment to the anterior border of the carotid canal was 5.1±0.2 mm (4.9-5.5 mm). The parapharyngeal internal carotid artery was located in the sheath of the carotid artery with sympathetic nerve attached on its surface. The posterior group nerves descended behind the sheath of the artery. The hypoglossopharyngeal nerve and hypoglossal nerve crossed the internal carotid artery in the posterior part of the styloid muscle groups and moved forward. There was a constant stylopharyngeal fascia on the surface of the carotid sheath, which extended to the fascia on the surface of the long cephalic muscle in front of the carotid sheath. The parapharyngeal internal carotid artery gradually approached the midline from the external orifice of the carotid artery. At the level of the carotid canal, the level of pharyngeal tubercle, and the level of the atlantooccipital junction, the distances from the anterior border of the parapharyngeal segment of the internal artery to the middle line of the clivus were 23.2±2.5 mm (20.6-25.8 mm), 19.3±1.1 mm (17.9-20.7 mm) and 15.5±1.3 mm (14.1-16.9 mm) respectively.

The levator veli palatini muscle could act as the landmark of the parapharyngeal segment of internal carotid artery. The stylopharyngeal fascia and the fascia of the longus capitis major are anatomical barriers to protect parapharyngeal segment of internal carotid artery under the endoscopic endonasal approach.

To investigate the effect of sesquiterpene lactone derivative (ACT001) on the neurosphere formation and stemness maintenance of U87-MG glioma stem cells.

Bioinformatics was used to analyze the relationship between STAT3 mRNA and different grades of human glioma as well as the overall survival in 1 477 glioma patients in CGGA, TCGA, and GEO (GSE4290, GSE16011) databases. Magnetic activated cell sorting method was used to obtain CD133-positive U87-MG cells. The effect of ACT001 on the survival viability of U87-MG GSCs was detected via Cell Counting Kit-8 (CCK-8). The effect of ACT001 on the ability of neurosphere formation was observed by single-cell neurosphere formation assay. Immunofluorescence staining was used to measure the effect of ACT001 on stem cells markers (CD133、CD44 and Nestin) in neurospheres of U87-MG GSCs. The expressions of STAT3, p-STAT3, CD44 and CD133 were detected using western blot after treatment of ACT001.

Bioinformatics analysis showed that as the grades of glioma increased, the expression of STAT3 mRNA also increased (all P<0.05). Patients in the group with high-level of STAT3 exhibited worse prognosis (allP<0.01). The expression of STAT3 was higher under the conditions of the neurosphering culture and stem-like cell culture (P<0.05). CCK-8 results showed that with the increase of the ACT001 concentration, the inhibition rate of U87-MG GSCs gradually increased. The results of the single-cell neurosphere formation assay showed that with the increase of the ACT001 drug concentration, the number and volume of neurospheres in each group were gradually decreased, and the difference was significant (P<0.01). The results of immunofluorescence staining showed that the expressions of CD133, CD44 and Nestin in GSCs were decreased compared with those in the control group. The protein expressions of stem cells markers (CD44 and CD133) were gradually decreased in the ACT001 drug groups (allP<0.01). There was no significant difference in STAT3 protein expression with the increase of ACT001 drug concentration (allP>0.05), while the protein expression of p-STAT3 was decreased through assessment by Western blot (allP<0.01).

ACT001 could suppress the neurosphere formation ability and reduce the stemness maintenance in U87-MG glioma stem cells by inhibiting STAT3 signaling pathway.

To explore the molecular mechanism through which miR-32 affects the proliferation and invasion of glioma cells by targeting KLF4.

The expression of miR-32 in glial cell lines (HA) and glioma cell lines (U87, U373MG, U251) was detected by real-time quantitative PCR (RT-qPCR). The effects of miR-32 on U87 glioma cell lines were detected by cell proliferation (MTT), cell invasion and scratch assay. Afterwards, the target gene of miR-32 was found by the Target Scan Human 7.1 online detection system and verified by the dual luciferase reporter assay. After successful verification, the RT-qPCR and Western blot (WB) assay were used to determine the regulation of target gene KLF4 mRNA by miR-32, and the effects of target gene KLF4 on glioma cell lines were detected by MTT, cell invasion and scratch assay. Finally, rescue experiments were used to explore how miR-32 regulated the target gene KLF4 and thus affected the proliferation and invasion of glioma.

The results of RT-qPCR showed that the expression levels of miR-32 in U87, U373MG and U251 cells were significantly higher than those in HA cells (all P<0.01). Compared with the group transfected with miRNA-NC, the miR-32 expression level, proliferation, invasion and migration ability of U87 cells were significantly up-regulated in the group transfected with miR-32 mimic (allP<0.05). The expression levels of miR-32, proliferation, invasion and migration were significantly down-regulated in the group transfected with miR-32 inhibitor (allP<0.05). The bioinformatics and dual luciferase reporter results showed that KLF4 was a target gene of miR-32, and when miR-32 was overexpressed, the cell luciferase activity was significantly decreased, and the expression of KLF4 was down-regulated. When miR-32 was silenced, the luciferase activity was significantly increased, and the expression of KLF4 was up-regulated. The expression of KLF4 in U87, U373MG and U251 cells was significantly lower than that in HA cell lines (allP<0.01). The proliferation, invasion and migration of glioma cell lines were inhibited when KLF4 was highly expressed. The rescue experiments showed that KLF4 silencing reversed the down-regulation of proliferation and invasion of glioma cell induced by miR-32 silencing. Overexpression of KLF4 reversed the promotion of proliferation and invasion of glioma cells induced by miR-32 overexpression.

miR-32 promoted proliferation and invasion of glioma cells by inhibiting the expression of its target gene KLF4.

The location, morphology and vascular architecture of intracranial arteriovenous malformations have high variability, which has an important influence on the prognosis of surgery. Adequate preoperative assessment of intracranial arteriovenous malformations is an essential link to reduce perioperative risk and improve neurological prognosis. This paper summarizes the current situation and development direction of various types of assessment tools.

Craniopharyngioma is a common congenital benign tumor of epidermal origin in the cranium, which mostly grows suprasellar and intrasellar in children and adults. Because of the adjacency to important complex structures, the operation is difficult. There are many theories about the formation and pathogenesis of craniopharyngioma, but the exact mechanism has not been fully elucidated. Recent studies have shown mutations in the CTNNB1 gene in enamel craniopharyngioma and the BRAF gene in papillary craniopharyngioma, which lay the relevant molecular mechanism in the pathogenesis of craniopharyngioma. In this paper, the research progress on the molecular biological mechanism of craniopharyngioma is reviewed.

Ependymoma is a neoplasm of the central nervous system that originates from the neuroepithelium and can be seen almost anywhere in the central nervous system, mostly in children. Previous methods of classification according to histopathological characteristics have limited clinical utility. With the continuous development of genomics technology, the understanding of this disease is also deepening. The emergence of new classification methods provides a more reliable basis for the treatment and prognosis evaluation of ependymoma. Because the low sensitivity of ependymoma to adjuvant therapy is one of the important reasons for poor prognosis of patients, people have begun to focus on exploring the treatment mode of ependymoma in recent years. Therefore, this article reviews the research progress of genetic changes and diagnosis and treatment strategies of pediatric ependymoma in recent years.

Immunotherapy is one of the most important methods for the treatment of malignant tumors at present. In recent years, chimeric antigen receptor (CAR) T cell technology has made great progress in basic research and clinical trials of glioma. Its main feature is that T cells carrying receptors specific for recognizing tumor antigens are obtained by genetic engineering technology and endowed with targeted killing activity. With the deepening of translational medicine research, new CAR-based immunotherapy strategies may bring new hope to glioma patients.