Volume 35 · Issue 12 · 2019

Vagus nerve stimulation (VNS) has been approved in China for more than 18 years, with a total of about 3,000 cases. However, there are no multicenter prospective clinical reports and segmented research data in China at present. The reason is that many neurosurgeons and neuropediatricians in China still lack sufficient knowledge of the applicable population, prognostic indicators and exact curative effect of VNS. Due to the broad indications of VNS, it is difficult to draw a definitive conclusion based on the results of existing domestic single-center retrospective small-sample clinical studies. Therefore, it is necessary to give higher-level evidence from the perspective of evidence-based medicine, based on foreign bulk clinical research data, to guide clinical practice, and give suggestions on the related issues of VNS treatment that clinicians are concerned about.

To explore the feasibility and efficacy of deep brain stimulation (DBS) in the treatment of generalized dystonia in children.

A retrospective study was designed to investigate the clinical data of 12 children with generalized dystonia. All of them were treated with DBS at Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences from August 2015 to July 2018. Genetic etiology testing showed that 5 cases were type DYT-1, 1 case was type DYT-6, and 6 cases were idiopathic generalized dystonia. All children underwent head susceptibility-weighted imaging (SWI) to locate the target before surgery. The clinical efficacy of the children was assessed using the Burke-Fahn-Marsden dystonia rating scale (BFMDRS). In addition, 12 adult patients with generalized dystonia with matched gender, genotype were selected from our database. We compared and analyzed the difference in anatomy of the internal globus pallidus (GPi) between children and adults to evaluate the feasibility of operation.

All patients were successfully implanted with electrodes without surgery-related complications. The average duration of follow-up was (19.8±9.6) months (12-47 months). The median BFMDRS scores at 3 months and 1 year after surgery were 15.5 (10-50) and 12.5 (4-48) respectively, which, compared with the preoperative score of 49.0(28-103), were significantly different (both P<0.001). The improvement rates of BFMDRS at 3 months and 1 year after surgery were (60.3±17.7) % (34.9%-84.6%) and (68.9±15.6)% (38.5%-93.8%). The AC (anterior commissure)-PC (posterior commissure) distance was (23.0±1.1)mm (20.9-24.7 mm) in the children group and (23.6±1.0)mm (22.0-25.6 mm) in the adults group. There was no significant difference between the 2 groups (P=0.121). The average distance between the GPi and skull was (74.5±5.1)mm (65.5-82.8 mm) in children and that in the adults group was (77.1±3.1)mm (71.8-84.0 mm). The difference was statistically significant (P=0.035). When we excluded the data from 2 youngest patients (4.8 years old and 5.7 years old), the average distance from GPi to the outer skull of the 10 patients with >8 years old was (75.5±4.7)mm (70.0-82.8 mm), which was not statistically different from that in the adults group ( P=0.190).

Preliminary findings suggest that DBS could improve clinical symptoms without serious complications for the treatment of pediatric generalized dystonia with clear etiological causes. The anatomical location of the GPi in children >8 years old is not significantly different from that in adults. However, the long-term prognosis and incidence of complications such as electrode displacement still require more follow-up studies.

To verify the feasibility of remote manipulation of deep brain stimulation (DBS) with 5G communication for the treatment of brain diseases.

In March 2019, 3 patients(2 parkinson′s disease and 1 essential tremor) who planned to undergo DBS at Department of Neurosurgery, the First Medical Center of the PLA General Hospital were prospectively recruited into this study. The 5G communication links were established between Beijing and Sanya, Hainan (Hainan Hospital of PLA Gerenal Hospital). The operation group completed the steps such as installation of head frame, craniotomy, microelectrode puncture for the patients in the operation room in Beijing. The remote-control group completed the steps such as remote surgery planning, remote control of microelectrode recording (MER), and imaging results confirmation of electrode implantation.

During remote surgical procedures under 5G communication, the maximum downlink peak rate was 119 Mbps, the uplink peak rate was 27 Mbs, and the average delay was 76 ms. During the operation, the remote control of the MER drive system ran smoothly and there was no delay of signal transmission. The voice and picture of the operating room and the MER signal were transmitted smoothly. The operation was completed successfully. There were no complications such as puncture bleeding, infection and skin ulceration after the operation. At 3-month follow-up, based on clinical rating scale for tremor (CRST) the score of essential tremor patient was improved by 43.6%; the UPDRS (unified Parkinson disease rating scale)-Ⅲ scores of 2 Parkinson′s disease patients were improved by 84.9% and 90.5% respectively.

The remote control of MER in DBS surgery with 5G communication seems to have certain feasibility.

To investigate the short-term efficacy of STN-DBS (subthalamic nucleus-deep brain stimulation) in patients with Parkinson′s disease and an improvement rate of <30% in levodopa challenge test (LCT).

A retrospective analysis was conducted on the clinical data of 35 patients with Parkinson′s disease and an improvement rate of <30% in LCT who underwent STN-DBS from March 2015 to December 2017 at Department of Neurosurgery, Changhai Hospital Affiliated to Navy Medical University. All those patients were divided into tremor dominant (TD) type ( n=12), postural instability/gait disturbance (PIGD) type (n=17) and indeterminate type (n=6) according to the motor symptoms of Parkinson′s disease. The preoperative LCT improvement rate and the improvement rate of motor symptoms in an on-stimulation off-medication state (referred to as the postoperative improvement rate of motor movement symptoms) were compared in 3 groups of patients. Comparison and analysis were conducted on the improvement rate of LCT before surgery and the improvement rate of motor symptoms at 1 month post STN-DBS.

The improvement rates in LCT of TD, PIGD and indeterminate types of patients prior to operation were (19.38±6.85)%, (23.76±5.02)% and (16.48±10.00)% respectively. There was no statistical difference among the 3 groups (F=2.31, P=0.12). The postoperative improvement rates of motor symptoms in those 3 types were (51.75±8.65)%, (41.52±13.11)% and (38.90±14.15)% respectively. There was significant difference among the groups (F=3.39, P=0.04). The postoperative improvement rate of motor symptoms was significantly higher than the improvement rate in preoperative LCT in 35 patients (t=9.46, P<0.01) and in subgroup aualysis(P<0.01 respectively). The elevation from preoperative improvement rate in LCT to post-DBS improvement rate of motor symptoms in 3 groups of patients was statistically significant (F=4.12, P=0.03), and the difference between TD and PIGD types was statistically significant (P=0.02).

STN-DBS seems effective for improving the motor symptoms of Parkinson′s disease patients with LCT<30%, particularly in TD types in terms of short-term outcome.

To analyze the changes in stimulation parameters post subthalamic nucleus(STN) deep brain stimulation (DBS) for the treatment of Parkinson′s disease.

Ninety-five cases of patients with Parkinson′s disease treated with STN-DBS at Department of Neurosurgery, Zhongnan Hospital of Wuhan University from November 2011 to June 2017 were analyzed retrospectively. The stimulation parameters of 95 patients were as follows: the monopolar stimulation was main (98.3%, 175/178), The stimulus contacts were mainly in the upper STN (90.9%, 171/188), and most of them were single contact stimulation (94.4%, 168/178). Patients were evaluated in 3 months, 6 months, 1 year and 2 years. The primary outcome was assessed included the post-operation parameters, the unified Parkinson′s disease rating scale Ⅲ(UPDRS-Ⅲ), the improvement rate[(preoperative score-postoperative score) / preoperative score × 100%], the stimulus energy(voltage²×frequency×pulsewidth/impedance×1 s), the stimulation-related adverse events.

The electrodes of 95 patients were implanted into preset targets based on intraoperative microelectrode recording and postoperative MRI images.The score of UPDRS-Ⅲ was (12.7 ±6.7)points, which was better than that before operation(P<0.05), and the improvement rate was (70.7±12.1)%. During the follow-up period, the improvement rate of UPDRS-Ⅲ decreased gradually (F=2.421, P=0.048). The voltage increased gradually (F=24.633, P<0.001), the pulse width increased slightly (F=3.118, P=0.015), but the frequency did not change significantly (F=1.332, P=0.257). The energy increased gradually (P<0.05), the contacts in zona incerta (ZI) increased gradually (P<0.05), the bipolar stimulation increased slightly (P<0.05), and the double contacts gradually increased gradually (P<0.05). During the follow-up period, a total of 35 patients developed stimulation-related adverse events, including 14 patients with troublesome dyskinesia, 4 patients with gait disorder or disequilibrium, 1 patients with anxiety and depression, 2 patients with dysphagia or drinking cough, 8 patients with hallucinations, 1 patient with hypophrenia, 2 patients with increased excitability, 1 patient with eye opening difficulty.

With the passage of time in the treatment of Parkinson′s disease with STN-DBS, the stimulation voltage and energy increased gradually, and the stimulation mode of double contacts increased gradually, but it was still dominated by unipolar stimulation, and the upper part of STN is the best stimulus site.

To investigate the short-term outcome of deep brain stimulation (DBS) for the treatment of pain associated with PD (Parkinson′s disease).

The clinical data of 47 cases of PD patients with pain symptoms admitted to Neurosurgery Department of Northern Theater Command General Hospital from January 2017 to June 2018 were retrospectively analyzed. A total of 35 patients underwent STN (subthalamic nucleus)-DBS and 12 patients underwent GPi (globus pallidus internus)-DBS. The stimulation contact selection and parameter adjustment were carried out at 3 weeks post operation. Visual analogue scale (VAS) was used to evaluate the degree of preoperative and postoperative pain severity.

The VAS [median (upper and lower quartiles)] were 1.0 (0.5-1.4) and 1.0(0.7-1.6) respectively at 3 months and 6 months post operation in 47 patients, which was statistically different from that of pre-operation 4.0(4.0-8.0) (both P<0.001). At 3 months post operation, the improvement rate of 35 patients undergoing STN-DBS was (79.5±26.3)%, which was not statistically different from that of 12 patients undergoing GPi-DBS [(76.9±28.4)%] (P=0.78). The improvement rate of 35 patients receiving STN-DBS was (75.1±27.4)% 6 months after operation, which was not statistically different from that of 12 patients receiving GPi-DBS [(82.8±28.9)%] (P=0.86).

Deep brain stimulation could effectively relieve PD-related pain. There seems no significant difference between GPi-DBS and STN-DBS in the treatment outcome of PD-related pain.

To explore the consistency of neurovascular relationships between multimodal image fusion 3D reconstruction and intraoperative findings in microvascular decompression (MVD) for primary trigeminal neuralgia (PTN).

A retrospective analysis was conducted on the clinical data of 50 PTN patients treated with MVD at Department of Neurosurgery, Qingdao University Hospital from January to November 2018. All subjects underwent three-dimensional time-flying magnetic resonance angiography (3D-TOF-MRA) and three-dimensional cyclic phase steady-state acquisition rapid imaging (3D-FIESTA) sequences. Then, the 3D-slicer software was used to reconstruct the multimodal fusion 3D image. Multimodal image fusion 3D reconstruction images and surgical video were analyzed to determine the offending vessels responsible for trigeminal neuralgia. At the same time, the direction of compression, compression site and compression degree of the trigeminal nerve were analyzed. Kappa consistency test method was used to judge the consistency of the two approaches above.

With MVD set as the standard, the accuracies of multimodal image fusion 3D reconstruction images in determining the offending vessels, direction of compression, compression site and the degree of compression were 92.0% (46/50), 92.0% (46/50), 96.0% (48/50) and 58.0% (29/50), respectively. Multimodal image fusion 3D reconstruction images and MVD showed high consistency in judging offending vessels, compression direction and compression position (Kappa values: 0.729, 0.903 and 0.955 respectively, all P<0.001). However, the consistency was poor in judging the degree of compression of offending vessels to the trigeminal nerve (Kappa value=0.227,P=0.002). The degree of compression was higher in intraoperative findings of MVD than that revealed by multimodal image fusion three-dimensional reconstruction (mean values: 2.57 and 1.58 respectively, Z=-4.499, P<0.001).

Preoperative multi-modal image fusion 3D reconstruction could help accurately determine the offending vessel, compression direction and compression position of PTN, which seems highly consistent with intraoperative findings of MVD. Preliminary speculation could be used as one of the methods facilitating preoperative diagnosis.

To explore the efficacy and safety of small-incision untethering surgery in the treatment of tethered cord syndrome (TCS) in children.

We retrospectively collected the clinical data of TCS patients who underwent merely untethering surgery at Department of Neurosurgery, Children′s Hospital, Zhejiang University School of Medicine from May 2015 to May 2018. A total of 72 cases were included and all required transection of merely terminal filament. Among them, there were 33 patients undergoing small-incision operation (small-incision group) and 39 undergoing traditional surgery (traditional group). Comparative analysis of intraoperative incision size, postoperative complications, length of stay and postoperative treatment effect were implemented in both groups.

All 72 patients underwent surgery successfully. None of the children in the small incision group needed to have the incision extended. In small-incision and tradition groups, the length of the incision was (2.5±0.3)cm and (4.8±1.9)cm respectively, and the length of stay was (4.4±1.8)days and (6.7±2.6)days respectively. Both differences were statistically significant (P<0.01). In traditional group, 5 cases (12.8%) had surgery-related complications including 2 cases of wound infection, 1 case of cerebrospinal fluid leakage and 2 cases of pain requiring medication. Only 1 case of pain (3.0%, 1/33) required medication in small-incision group. The effective rates in traditional and small-incision groups were 92.3% (36/39) and 93.9% (31/33) respectively at 6 months post surgery, and the difference was not statistically significant (P>0.05). At the end of follow-up, the total effective rate in traditional group (> 6-41 months) was 89.7% (35/39), while that in small-incision group (>6-27 months) was 93.9% (31/33). There was no statistically difference between them (P>0.05).

The small-incision untethering for children with TCS who need merely transection of terminal filament seems as effective as traditional large-incision surgery. It has the advantages of small trauma and short length of stay.

To summarize the clinical epidemiological characteristics of pediatric neurosurgical diseases at a single center.

A total of 5 790 children (≤15 years old) with neurosurgical diseases admitted to Department of Neurosurgery, Xijing Hospital, Air Force Medical University from January 2008 to June 2018 were retrospectively enrolled. Their clinical data were analyzed and included the distribution of various diseases and clinical characteristics such as age, gender and lesion location.

All 5 790 children included 2 259 cases (39.0%) of congenital malformation, 1 561 cases of tumor (27.0%), 953 cases of trauma (16.5%), 360 cases of cerebrovascular disease (6.2%), 159 cases of inflammation (2.7%), 91 cases of functional disorder (1.6%) and 407 cases of other diseases (7.0%). The gender ratio (male ∶female) was 1.76 ∶1.00. In all kinds of diseases, the proportion of male children was higher than that of female children, and the difference was statistically significant (P<0.001). The overall peak age of onset was 0-3 years old. Congenital malformations and tumors were predominant in 0-3 years old (42.9%) and 13-15 years old (26.3%), respectively. Three most frequent congenital malformations were arachnoid cyst (29.6%), hydrocephalus (28.2%) and tethered cord syndrome (20.0%). Temporal lobe was the most common site of arachnoid cyst (45.4%). Three most common tumors were glioma (19.7%), craniopharyngioma (9.0%) and medulloblastoma (8.8%). The ratios of brain tumors to spinal canal tumors, supratentorial tumors to infratentorial tumors and low-grade tumors to high-grade tumors were 5.61 ∶1.00, 1.73 ∶1.00 and 1.67 ∶1.00, respectively. Primary brain injury(365 cases) accounted for 58.6% of traumatic diseases and 59.2% (the highest proportion) of primary brain injury was brain contusion and laceration. In cerebrovascular diseases, the proportion of spontaneous hemorrhage (27.2%) was the highest. The most common inflammatory disease was inflammatory granuloma(22.6%). In addition, with the increase of age, the incidence of congenital malformation decreased gradually, while the incidence of cerebrovascular diseases increased gradually(bothP<0.001).

Pediatric neurosurgical diseases have unique clinical epidemic characteristics. Congenital malformations and tumors are more common, and the incidence of arachnoid cysts and gliomas seems to be the highest. In various diseases, the incidence of male is higher than that of female, and the peak ages are different.

To explore the surgical method and outcome of craniosynostosis combined with Chiari malformation in children.

A retrospective analysis was conducted on the clinical data of 16 children with craniosynostosis combined with Chiari malformation who were admitted to Department of Neurosurgery, Children′s Hospital of Nanjing Medical University from April to December 2017. All cases were retrospectively analyzed and their imaging results were analyzed. Of the 16 children without hydrocephalus, 12 underwent craniofacial reconstruction of cranial suture or craniofacial reconstruction, of which 1 case underwent posterior fossa reconstruction and suboccipital decompression at 7 months post operation. In 4 children with combined hydrocephalus, 3 underwent routine right ventricle-peritoneal shunting and cranial reconstruction, of which 1 case was treated with posterior fossa reconstruction and suboccipital decompression at 5 months post operation. The other 1 case was Pfeiffer syndrome and underwent right ventricle-peritoneal shunting plus posterior fossa reconstruction as well as suboccipital decompression. At 3, 6 and 12 months post operation, all patients were followed up at the outpatient clinic and underwent the reexamination of head MRI for assessment of brain tissue development, ventricle changes and cerebellum tonsil herniation.

All 16 children underwent operation successfully without any surgical complications. Revealed by the postoperative skull CT, all the children′s cranial cavity volume was enlarged, and the cranial malformation was improved. The follow-up time of 16 children was (12.1±2.0) months (10-18 months). The review of head MRI showed that brain tissue developed well and the position of the cerebellar tonsils did not decline further. All children were free of neurological deficits, and parents were satisfied with the improvement in the appearance of their skulls and faces.

The combination of craniosynostosis with Chiari malformation should be fully evaluated before surgery and appropriate individualized treatment program should be selected according to specific conditions. One-stage craniofacial surgery seems an effective treatment method.

The clinical data of 102 patients with closed pediatric skull depression fractures admitted to the Department of Neurosurgery of Hotan District People's Hospital from February 2008 to February 2018 were retrospectively analyzed. All the children were treated by minimally invasive surgery with small incision drilling and prying. After 2-12 months follow-up, all 102 skull fractures healed without postoperative infection or other complications. Minimally invasive treatment of pediatric skull depression fracture by drilling and prying with small incision has good reduction and few complications, which is worthy of clinical application.

To investigate the pathological characteristics and changing trend in primary and local recurrent skull base chordoma, and to analyze their correlation with the outcomes.

A total of 89 samples of primary and local recurrent tumors pathologically confirmed from 38 patients who were treated in Neurosurgery Department of Beijing Tiantan Hospital, Capital Medical University between February 2005 and December 2014 were retrospectively enrolled into this self-control study. After HE staining, the pathological features such as nuclear atypia, mitosis, matrix ratio, necrosis, bone invasion and pathological subtypes were analyzed. The expressions of p53, Ki-67, EGFR, VEGFR and TRAF6 were detected by immunohistochemical staining. The changes of pathological indexes as above in primary and recurrence stages were compared. Cox analyses were used to analyze the effects of above pathological indexes on the progression-free survival (PFS) of patients with primary tumor, and the effects of the changes regarding those factors on the overall survival (OS).

Ten cases (35.7%) of classical subtype changed to myeloid subtype, while none of chondroid chordoma changed to myeloid subtype after recurrence. Twelve cases (31.6%) demonstrated necrosis companied with tumor recurrence. Twenty-five cases (73.5%) of primary tumor showed high-expression of TRAF6, and 19 cases (50.0%) had decreased expression intensity of TRAF6 after tumor recurrence. There were 16 cases (42.1%) and 15 cases (39.5%) with upregulation of P53 and EGFR respectively. Necrosis (HR=7.1, 95% CI: 1.4-37.1, P=0.006), pathological subtype (HR=3.9, 95% CI: 1.2-7.2, P=0.040) and TRAF6≥3 grade (HR=0.2, 95% CI: 0.1-0.5, P<0.001) in primary tumors were directly related to PFS, and TRAF6≥3 grade (HR=0.2, 95% CI: 0.1-0.5, P<0.010) was an independent protective factor for PFS. There was no significant difference in the OS rate among the above pathological changes.

Classical chordoma shows malignant transformation to the myeloid subtype, which is not found in chondroid subtype. The expression of TRAF6 decreases gradually with tumor recurrence, and its high expression in primary tumor is an independent protective factor for PFS.

To analyze the diagnosis and treatment of spinal dural arteriovenous fistula (SDAVF).

The clinical data of 14 patients with SDAVF admitted to Department of Neurosurgery, General Hospital of the Eastern Theater Command from May 2008 to May 2018 were analyzed retrospectively. All patients underwent the examinations of preoperative spinal cord MRI and spinal cord angiography to identify the region of SDAVF and the location of fistula. Microsurgical resection of SDAVF was conducted via semi-lamina approach. The modified Aminoff-Logue score was used to evaluate the spinal function before operation, after operation and during the follow-up period.

No abnormal fistulas or tortuous dilated drainage veins were detected by spinal cord angiography after operation in 14 patients. The modified Aminoff-Logue score [median (upper and lower quartiles)] before operation and post operation in those 14 patients were as follows: gait: 2.0 (1.0, 3.0) pointsvs. 2.0 (1.0, 2.0) points, urinate: 2.0 (0, 2.0) points vs. 1.0 (0, 2.0) points, defecate: 1.0 (0, 2.0) points vs. 0.5 (0, 1.0) points. The postoperative scores were improved compared to preoperative scores (all P<0.05). Of those 14 patients, 6 were lost to follow-up and 8 were followed up for 7.5 (4.5, 12.0) months. The gait, urinate and defecate scores were 0.5 (0, 1.0), 0 (0, 0.7) and 0 (0, 0.5) respectively, which have improved compared with those before operation (allP<0.05). No recurrence of the lesion was found in 8 patients during the last follow-up.

Spinal cord angiography is the gold standard for the diagnosis of SDAVF. Microsurgery via semi-lamina approach is an effective method for the treatment of SDAVF. The spinal cord function of patients can be improved significantly.

To assess the clinical outcomes of various surgical methods of radiation-induced encephalopathy (REP) mainly featured with cystic change in the temporal lobe.

A retrospective study was conducted on the clinical data of 56 patients with REP mainly featured with cystic change in the temporal lobe who underwent surgery at Department of Neurosurgrey, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University from January 2010 to December 2016. Among them, 24 peoples underwent merely lesionectomy (control group), while the other 32 peoples underwent lesionectomy and cistern opening (experimental group). According to the postoperative outcome, KPS (Karnofsky performance status) score, the volume of lesion on MRI and clinical follow-up , we compared the surgical effect between the 2 groups.

In control group, 7 patients (29.2%) reported relief of chief complaint, while 23 patients (71.9%) in experimental group had relief. The difference was statistically significant (P<0.05). The KPS score was 70.13±19.10 in control group and 84.16±13.47 in experimental group, which had significant difference (P<0.05). The volume of lesion post surgery was (32.35±20.85)cm³ in group and (13.31±6.44)cm³ in experimental group, which had statistical difference (P<0.05). The follow-up data showed that the readmission rate in experimental group (18.7%, 6/32) was lower than that in control group (75.0%, 18/24). which had significant difference(P<0.05).

For REP mainly featured with temporal lobe cyst, the surgical operation should include further dissection of cisterna ambiens and cisterna interpeduncularis in addition to merely lesionectomy, which could help prevent the formation of isolated cyst cavity with space-occupying effect and achieve better therapeutic results.

To investigate the roles of plasma D-lactate, endotoxin and diamineoxidase (DAO) in assessment of intestinal mucosal barrier function post traumatic brain injury (TBI).

We retrospectively studied 70 patients with TBI (TBI group) admitted to Department of Neurosurgery, the 904^th Hospital of the Joint Service of Chinese People′s Liberation Army from January 2017 to August 2018, and 45 healthy subjects were enrolled as well (healthy control group) at the physical examination center during the same period. All TBI patients were treated conservatively or surgically. Peripheral blood of patients and healthy subjects were collected to detect levels of plasma D-lactic acid, endotoxin, and DAO. Further use of Spearman correlation analysis was conducted to determine the correlation between preoperative serum D-lactic acid, endotoxin and DAO and Glasgow Coma Scale (GCS) in patients with TBI.

Compared with the healthy control group, the levels of D-lactic acid (24.7±9.4 mg/L vs. 9.8±4.0 mg/L), endotoxin (9.1±5.8 U/L vs. 4.0±2.2 U/L) and DAO (36.3±22.6 U/L vs. 15.2±3.6 U/L) were significantly increased (t=9.82, 2.84 and 3.49, respectively, all P<0.05). Further correlation analysis showed that serum D-lactic acid, endotoxin and DAO levels were negatively correlated with preoperative GCS scores (r=-0.543, -0.617 and -0.672, respectively, all P<0.01).

The preliminary results have suggested that the levels of D-lactic acid, bacterial endotoxin and DAO in the serum could be used as important indexes in evaluation of the intestinal mucosal barrier function in patients post TBI.

The clinical data of 9 patients with acute occlusion of the initial segment of internal carotid artery combined with distal occlusion were retrospectively analyzed from May 2015 to May 2018 in the Department of Interventional Vascular Surgery of Hebei University Affiliated Hospital using distal-proximal reverse manipulation technique. Among the 9 patients, 1 case was complicated with terminal occlusion of internal carotid artery, 7 cases were complicated with ipsilateral middle cerebral artery occlusion, and 1 case was complicated with ipsilateral middle cerebral artery and anterior cerebral artery occlusion. The occluded vessels were successfully recanalized in all 9 patients, and there were no serious complications such as symptomatic intracranial hemorrhage and distal embolism. The modified Rankin scale score (mRS) of 9 patients 90 days after surgery showed good prognosis (0~3 points). Distal-proximal reverse manipulation may be a safe and effective treatment option for patients with carotid artery tandem lesions complicated with acute ischemic stroke. This article focuses on the selection of interventional devices, the formulation of surgical strategies and the specific operation details.

To comparatively analyze the differences between endoscopy and microscopy in area of exposure and surgical freedom in posterior fossa through the intradural subtemporal keyhole approach and to explore the advantages of neuronavigation in that approach.

Twenty endoscopic intradural subtemporal keyhole approaches (EISKA) were performed on 10 cadaveric adult heads. An intradural Kawase approach and a navigation-assisted intradural Kawase approach were then carried out on a random side of each specimen. Related anatomic structures were observed through endoscope and microscope at the end of each approach. Anatomic exposure and surgical freedom were measured by transparent graph paper and were analyzed.

Compared with microscopy, the superior, inferior and medial limits through endoscopic exposure were increased by 2.9±1.0 mm, 15.7±1.5 mm and 10.2±1.1 mm, and the surgical freedom was increased by 2.9±1.0 mm, 7.6±1.9 mm and 6.0±1.7 mm (P<0.05) in the intradural subtemporal keyhole approach. In intradural Kawase approach, the anatomic exposure was increased by 2.7±0.9 mm, 20±1.2 mm and 29.5±0.7 mm and the surgical freedom was increased by 2.7±0.9 mm, 14.8±1.4 mm and 8.8±1.4 mm (allP<0.05). In navigation-assisted intradural Kawase approach, the anatomic exposure was increased by 3.1±1.0 mm, 20.3±2.4 mm and 29.9±0.7 mm, and the surgical freedom was increased by 3.1±1.0 mm, 15.3±1.6 mm and 8.8±1.3 mm (P<0.05). Using a frameless navigational device, the inferior limit of the anatomic exposure was increased by 3.8±2.2 mm in endoscopy and 3.5±0.7 mm in microscopy, and the surgical freedom was increased by 2.7±0.9 mm in endoscopy mm and 2.2±1.2 mm in microscopy (allP<0.05).

The EISKA could provide more anatomic exposure and surgical freedom mainly in the superior, inferior and medial directions of the brainstem regions. More inferior anatomic exposure and surgical freedom of the posterior cranial fossa could be obtained by navigational assistance.

Ten perfused cadavers (20 cases) were selected to simulate the approach of bifrontal large bone flap decompression craniotomy, and the anatomical landmarks were determined, dissected layer by layer, and the relevant anatomical data of frontal sinus, superior sagittal sinus and inferior sagittal sinus were measured to provide anatomical basis for the approach of bifrontal large bone flap decompression craniotomy. It is recommended that the bone window of bifrontal large bone flap decompression is not less than 13 cm ×23 cm; If the frontal sinus needs to be preserved, the frontal bone should be kept 2.5 cm from the midpoint of the brows to the left and right sides, and 1.5 cm upward. To minimize damage to the draining vein, the site of ligation of the superior sagittal sinus and cutting of the falx should be 2 cm before the midpoint of the decompression window.

The treatment of paraclinoid aneurysms of internal carotid artery brings great challenges to neurosurgeons due to the complex anatomical location and tumor shape. In recent years, the application of Willis-covered stent (WCS) has achieved good results in the treatment of paraclinoid aneurysms of internal carotid artery, but endoleakage is still one of the main complications, among which type Ⅲ endoleakage is rare. This paper reports a case of paraclinoid aneurysm of internal carotid artery with advanced type Ⅲ endoleakage after WCS treatment, and achieved good clinical results after WCS treatment again.

Blood flow guidance devices (PFD) represented by Pipeline are more and more used in the treatment of intracranial aneurysms. After nearly 10 years of clinical application, PED has gradually become an important means for the treatment of complex aneurysms (large, giant aneurysms and recurrent aneurysms, etc.). However, in clinical application, serious ischemic and hemorrhagic complications still occur after surgery. The specific reasons for this are not very clear. This article focuses on the causes of two hemorrhagic complications: delayed aneurysm rupture after PED treatment of intracranial aneurysm and cerebral parenchymal hemorrhage unrelated to aneurysm rupture.

As a new type of endovascular therapeutic material, blood flow guiding device has been widely used in the treatment of intracranial aneurysms, and its superiority has been highlighted in the application of vertebrobasilar artery dissection aneurysms. At present, the main blood flow guiding devices used in vertebral-basilar artery dissection aneurysm are Pipeline embolization device and Tubridge blood flow guiding device. The effectiveness and safety of Pipeline embolization devices for vertebral-basilar artery dissection aneurysms has been continuously demonstrated, while the effectiveness and safety of Tubridge flow steering devices have yet to be demonstrated.

DNA methylation plays an important role in brain development, disease development and other physiological processes. Recent studies have found that TET protein family hydroxylases can demethylate 5-methylcytosine (5mC), thereby regulating the balance of DNA methylation. The intermediate product of this process, 5-hydroxymethylcytosine (5hmC), is specifically highly expressed in mammalian neural tissues and plays an important role in nervous system development. At present, several studies have evidenced that 5hmC expression levels change significantly during the occurrence and development of central nervous system diseases. This paper summarizes the latest research progress on the expression and regulation of 5hmC in common tumors and neurodegenerative lesions of the central nervous system.

Exosomes are cystic vesicles secreted by cells with a diameter of 30-100 nm, which contain proteins, lipids, mRNAs and miRNAs and other molecules. Among them, exosomes derived from mesenchymal cells (MSCs) have attracted much attention for their intervention and therapeutic potential for certain neurological diseases. Recent studies have shown that injection of MSCs-derived exosomes into traumatic brain injury (TBI) animals has the effects of alleviating neuroinflammatory response, promoting nerve regeneration and restoring nerve function. In view of the advantages of exosomes derived from MSCs, such as small size, inability to proliferate, easy preservation and low immunogenicity, it may be a new strategy for the treatment of TBI. In this paper, the biological characteristics and functions of exosomes derived from MSCs will be described, and the relationship between them and the inflammatory response, nerve regeneration and therapeutic prospect after TBI will be discussed.

Traumatic craniocerebral injury (TBI) is the main cause of death and disability in adults, and its incidence is increasing year by year. Microglia is the most important central immune cells. After TBI occurs, microglia can exhibit different phenotypes with pro-inflammatory or anti-inflammatory effects, participate in the regulation of inflammatory response, and play an important role in injury and repair of TBI. This paper reviews the activation of microglia in TBI and the phenotype after activation, emphasizing the role and molecular mechanism of microglia in TBI, and provides new thinking for the clinical treatment of TBI patients.