Volume 36 · Issue 10 · 2020

enhanced recovery after surgery (ERAS) refers to the integration of a series of optimization measures with evidence-based medical evidence through comprehensive application of multidisciplinary management methods during the perioperative period. By effectively, reasonably and appropriately improving the routine surgical treatment process, it reduces surgical stress response, reduces surgical complications and surgical risks, accelerates postoperative recovery, shortens hospital stay, reduces hospital expenses and improves patients' quality of life^[1]。 The core of ERAS is to minimize the stress response of the body during operation, block the transmission of stress signals from afferent nerves, and reduce the psychological and physical damage of patients^[2]To prevent complications, prevention is more important than treatment.

Trigeminal neuralgia is a common neurological disorder characterized by episodic pain like needle, knife, or electric shock on one side of the face. Pain can be triggered by washing your face, brushing your teeth, and speaking. Trigeminal neuralgia is divided into two categories: primary and secondary. The pathogenesis of primary trigeminal neuralgia is mainly related to the compression of trigeminal nerve by blood vessels; The occurrence of secondary trigeminal neuralgia can be caused by meningioma, schwannoma, intracranial vascular malformation, multiple sclerosis, epidermoid cyst, etc. compressing the trigeminal nerve. There are many kinds of treatment methods for trigeminal neuralgia, and drug treatment is the first choice. In the case of aggravated pain and poor drug efficacy, surgery can be selected^[1]。 At present, surgical treatment mainly includes microvascular decompression, balloon compression, radiofrequency therapy, gamma knife radiosurgery (GKRS) therapy, etc. Among them, GKRS treatment, as a minimally invasive radiosurgery technique, has definite efficacy and low risk for trigeminal neuralgia, and should be regarded as one of the important methods for the treatment of trigeminal neuralgia^[2]。 The purpose of this consensus is to establish the indications, contraindications, treatment points and efficacy evaluation of GKRS treatment for trigeminal neuralgia in China, so as to standardize and guide the clinical treatment of GKRS for trigeminal neuralgia.

To investigate the relationship between early Computed Tomography (CT) features and intracranial pressure (ICP) in patients with traumatic brain injury (TBI), and to evaluate the predictive value of CT features.

We retrospectively analyzed the clinical data of 21 patients with unilateral craniocerebral trauma who underwent surgical treatment from January 2018 to December 2019 at Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine. The last CT image before the operation was used to measure the degree of midline shift and obtain the CT values on both sides of the midline; the initial value of ICP during the operation was recorded. Pearson correlation analysis was used to analyze the correlation between the degree of midline shift, the ratio of the mean CT value on both hemispheres and the ICP. The area under the receiver operating curve (ROC) was used to determine the accuracy of prediction in intracranial hypertension (>22 mmHg, 1 mmHg=0.133 kPa).

The preoperative CT of 21 patients showed that the range of midline shift was 0.2-1.6 (median: 1.0, IQR: 0.9) cm; the range of ratio of mean CT value between both hemispheres was 1.0-1.4 (1.1±0.1), and the range of initial ICP during operation was 11.0-45.0 (24.3±8.3) mmHg. Correlation analysis showed that the degree of midline shift and the ratio of mean CT value between both hemispheres were significantly positively correlated with ICP (r=0.44, r=0.58, both P<0.05). The AUC (area under curve) of the ICP increasing evaluation using the ratio of the mean CT value was 0.65, and the AUC of the ICP increasing evaluation using the degree of midline shift was 0.64.

Preliminary studies have shown that the CT features of patients with craniocerebral trauma are related to the level of ICP. The evaluation accuracy of the ratio of the mean CT value on both hemispheres is not lower than the traditional evaluation using the degree of midline shift.

To investigate the changes of serum anion in patients with acute traumatic brain injury (TBI) and to evaluate its relationship with patients′ prognosis.

A retrospective analysis was conducted on the clinical data of 82 patients with acute TBI admitted to Department of Neurosurgery, the First Affiliated Hospital of China Medical University from June 2017 to June 2019. Blood inorganic phosphorus, blood chlorine (Cl^-), bicarbonate (HCO₃^-), and anion gap (AG) were selected as monitored indicators within 48 hours after injury. Glasgow coma score (GCS) was used to assess the severity of TBI, and Glasgow outcome scale (GOS) was used to evaluate the outcomes of patients. The relationship between those indicators and the severity and outcome of patients with TBI was analyzed.

Among 82 patients, 47 (57.3%) had hypophosphatemia, 32 (39.0%) cases had hyperchloremia, 31 (37.8%) cases had decreased blood bicarbonate, and 40 (48.8%) cases had increased blood anion gap. Both hypophosphatemia (r=0.363, P=0.001) and hyperchloremia (r=-0.273, P=0.013) following acute TBI were correlated with the severity of TBI, that is, lower blood phosphorus and higher blood chlorine indicated severer brain injury of the TBI patients at admission. The blood phosphorus (r=0.311, P=0.004) and anion gap (r=-0.254, P=0.021) were also related to the patient’s outcome, that is, lower blood phosphorus and higher blood anion gap indicated worse prognosis of the patients.

After acute TBI, hypophosphatemia may indicate the severity and poor prognosis of TBI patients. High blood chloride and elevated anion gap could also indicate severe TBI and poor prognosis respectively.

To describe the clinical characteristics of severe traumatic brain injury (TBI) patients who underwent decompressive craniectomy, and to analyze the preoperative factors that influenced the patients′ postoperative outcomes.

From June 2009 to December 2013, a total of 131 patients with severe TBI underwent decompressive craniectomy at Neurosurgery Department of West China Hospital, Sichuan University whose clinical data were retrospectively analyzed in this study. The patient′s Glasgow Outcome Scale (GCS) score was determined to assess the outcome at 6 months post trauma. Mild disability and good neurological function(Ⅳ-Ⅴ grade) were considered as good outcome. Death, vegetative state and severe disability were(Ⅰ-Ⅲ grade) considered as poor outcome. Influencing factors of the patient′s outcome were identified using univariate analysis and multivariate logistic regression analysis.

Among all 131 patients, the male to female ratio was 1.0 ∶2.7. The age of 79.4% (104/131) of all patients was ≤60 years old, the Glasgow Coma Scale (GCS) score of 80.2% (105/131) of all patients at admission was 3-6 points, and 55.7% (73/131) of the patients had unilateral or bilateral pupil dilation, and types of TBI mainly consisted of cerebral contusion (50.4%, 66/131) and subdural hematoma (42.7%, 56/131). The Marshall classification of CT at admission was mainly type Ⅴ (71.8%, 94/131) and absence of ambient cistern was observed in 93.9% (123/131) of the patients. Postoperative complications of 131 patients included 23 cases(17.6%) of cerebral infarction, 4 cases(3.1%) of hydrocephalus, 3 cases(2.3%) of intracranial infection, 2 cases(1.5%) of cerebral bleeding, 2 cases(1.5%) of subdural fluid accumulation, 2 cases(1.5%) of enlargement of cerebral hematoma, and 1 case(0.8%) of epileptic seizure. Among 131 patients, unfavorable outcomes were reported in 89(67.9%) and favorable outcomes in 42 cases(32.1%). Univariate analysis showed that GCS score at admission, pupil status, type of injury and condition of basal cistern were influencing factors of the patient′s outcome (all P<0.05). Multivariate logistic regression analysis showed that low GCS (OR=2.961, 95% CI: 1.074-8.158, P=0.036) and pupil dilation (OR=0.415, 95% CI: 0.206-0.838, P=0.014) were independent risk factors of unfavorable outcomes.

Common clinical features of severe TBI patients undergoing decompressive craniectomy include GCS of 3-6, type Ⅴ in Marshall CT classification, absence of ambient cistern, subdural hematoma and brain contusion. Low GCS at admission and pupil dilation are independent risk factors of unfavorable outcome.

To investigate the effect of stepwise decompression technique under intracranial pressure monitoring in severe traumatic brain injury (sTBI).

The clinical data of 47 patients [GCS (Glasgow coma scale) score: 3-8 points] with sTBI who underwent surgery at Department of Neurosurgery, Inner Mongolia People′s Hospital from January 2018 to July 2019 were retrospectively analyzed. Among those, the stepwise decompression technique was applied in 21 patients under intracranial pressure monitoring, and 26 patients underwent conventional large bone flap decompression. We evaluated the postoperative GCS score, operation duration, length of stay at neurological intensive care unit (NICU), temporal muscle thickness, usage of mannitol and GOS score at 3 months post surgery.

The 24 h postoperative GCS scores were 6.7±1.8 points and 5.6±1.5 points in the group of stepwise decompression under intracranial pressure monitoring and the group of conventional large bone flap decompression, respectively. The 24 h postoperative CT showed that the temporal muscle thickness at the sella level was 1.19±0.33 cm and 1.43±0.41 cm in stepwise decompression group and conventional group respectively, and their differences from preoperative conditions were 0.12±0.07 cm and 0.38±0.14 cm, respectively. In stepwise decompression group and conventional group, the usage duration of mannitol was 4.7±1.4 d and 9.4±2.0 d, and the dosage was 500±137 ml/d and 1 250±283 ml/d, respectively; the length of stay at NICU was 10.7±2.3 d and 17.9±2.0 d, respectively. Those inter-group differences as above were all significant (all P<0.05). The operation duration was 120.0±12.3 min and 115.0±13.5 min in stepwise decompression and conventional groups respectively, and there was no significant difference (P>0.05). At 3-month postoperative follow-up in stepwise decompression and conventional groups, the GOS (Glasgow outcome scale) grade Ⅰ-Ⅲ (poor outcomes) accounted for 34.4% (7/21) and 65.4% (17/26) respectively, grade Ⅳ-Ⅴ (good outcomes) accounted for 65.6% (14/21) and 34.6% (9/26) respectively, and both differences between the two groups were statistically significant (P<0.05).

In the surgical treatment of sTBI patients, stepwise decompression under intracranial pressure monitoring could help better control the occurrence of encephalocele and acute brain swelling during operation, relieve high intracranial pressure, shorten the length of stay at NICU, reduce the amount of dehydrate agent and complications, and improve the outcomes of patients.

To reveal the predictive value of intracranial pressure (ICP) related parameters in the prognosis of patients with closed craniocerebral trauma.

A retrospective analysis was conducted on the clinical data of 50 patients with traumatic brain injury (TBI) admitted to Neurosurgical Intensive Care Unit (NICU) of Renji Hospital, Shanghai Jiao Tong University School of Medicine (35 cases) and NICU, the Second Affiliated Hospital of Nanhua University (15 cases) from September 2018 to September 2019. All patients underwent intraventricular puncture and intracerebroventricular ICP probe placement after admission, and initial ICP was measured and documented. The values of ICP, amplitude (AMP) and pressure amplitude correlation index (RAP) were decided based on the average monitoring results of those parameters at NICU. According to the GOS (Glasgow outcome scale) at discharge, 50 TBI patients were divided into the group of poor prognosis (GOS Ⅰ-Ⅱ, n=22) and group of good prognosis (GOS Ⅲ-Ⅴ, n=28). Univariate analysis and multivariate logistic regression analysis were used to determine the clinical factors affecting the prognosis of TBI patients. Receiver operating characteristic curve (ROC curve) was used to evaluate the prognostic value of ICP related parameters.

There was no statistic difference in gender, age, length of stay in NICU, monitoring time and GCS (Glasgow coma scale) score at admission between the two groups (all P>0.05). The GCS score and △GCS in the good prognosis group were higher than those in the poor prognosis group at discharge, while the ratio of cerebral hernia at admission, proportion of decompressive craniectomy, initial ICP, ICP, AMP and RAP in the good prognosis group were lower than those in the poor prognosis group (allP<0.05). It was suggested by multivariate logistic regression that GCS ≤ 13, △GCS ≤ 4, initial ICP ≥ 25.0 mmHg(1 mmHg=0.133 kPa), ICP ≥ 12.5 mmHg, RAP ≥ 0.4, AMP ≥ 5.0 mmHg were independent risk factors associated with the outcomes of the two groups. The area under ROC curve of initial ICP and RAP were 0.92 (95%CI: 0.85-1.00), 0.86 (95% CI: 0.75-0.97), respectively. The sensitivity of initial ICP and RAP were 86.4% and 77.9%, and the specificity of them were 78.6% and 85.7%, respectively.

Initial ICP value and RAP have good predictive value for the prognosis of patients with craniocerebral trauma.

To investigate the effect of analgesic and sedative treatments on intracranial pressure (ICP) in patients with severe traumatic brain injury(TBI).

The clinical data of 60 patients with severe TBI admitted to Neurosurgical Intensive Care Unit (NICU) of Renji Hospital, School of Medicine, Shanghai JiaoTong University from September 2018 to May 2019 were retrospectively analyzed in this study. All patients initially underwent intraventricular ICP monitoring probe implantation, which was followed by craniotomy, hematoma removal and craniectomy. According to whether sedative and analgesic treatment based on conventional treatment was administered within 24 hours post operation, the patients were divided into two groups: sedation and analgesia group (30 cases) and routine treatment group (30 cases). We compared the clinical data and ICP related indexes between the two groups. ICP observations included the average value of ICP at 4 time points (6, 12, 18, 24 hours), mean ICP amplitude (MWA), cerebrovascular pressure response index (PRx), and ICP fluctuations per 6 hours.

There were no significant difference in sex, age, cause of injury, Glasgow coma scale(GCS) score at admission, injury time, injury site, or type of craniocerebral injury between the two groups (all P>0.05). There was no significant difference in initial ICP between the two groups (P>0.05). The ICP values in the two groups were normal at the end of operation, and there was no significant difference between the two groups (P>0.05). The ICP of patients in the 6-, 12-, 18- and 24-hour groups were normal after operation, while the average ICP, MWA and PRx of the sedation group were lower than those in the routine treatment group (allP<0.05). Within 24 hours post operation, the ICP fluctuations per 6 hours in sedation and analgesia group was lower than those in routine treatment group (allP<0.05).

Sedative and analgesic treatments in patients with severe TBI at NICU administered within 24 h post operation can reduce their ICP values and fluctuations.

To investigate the diagnostic efficacy and application value of cerebrospinal fluid (CSF) metagenomic next-generation sequencing (mNGS) in the diagnosis of traumatic brain injury (TBI) related central nervous system (CNS) infections.

From August 2018 to January 2020, a prospective study was conducted on the TBI patients with highly suspicion of CNS infection and lack of pathogen results at Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine. The patients′ CSF samples were collected to perform mNGS and microbial culture simultaneously. The clinical diagnosis was taken as the "gold standard" . The sensitivity, specificity, positive predictive value, negative predictive value, Youden index and area under receiver operating characteristic (ROC) curve were calculated for the two methods to assess the diagnostic efficacy of mNGS.

Twenty-one patients were enrolled and simultaneous tests were performed. During 21 test pairs, 11 cases of clinical diagnosis of CNS infections were confirmed, of which 9 cases were mNGS positive and 3 cases were microbial culture positive. The sensitivity, specificity, positive predictive value, negative predictive value, Youden index and area under ROC curve were 81.8%, 90.0%, 90.0%, 81.8%, 0.718, 0.859 (95%CI: 0.639-0.970) respectively for mGNS and 27.3%, 90.0%, 75.0%, 52.9%, 0.173, 0.586 (95%CI: 0.354-0.794) respectively for microbial culture.

The method of mNGS has better diagnostic efficacy compared with microbial culture and reveals its value in the diagnosis of TBI-related CNS infection, which could be used as a necessary complement to conventional diagnostic techniques such as microbial culture.

To analyze the influencing factors of consciousness recovery in patients with chronic disorders of consciousness (DOC) caused by diffuse axonal injury (DAI).

A total of 51 DAI-induced DOC patients admitted to Department of Neurosurgery, the 7^th Medical Center of PLA General Hospital from January 2014 to December 2019 were retrospectively reviewed in this study. According to the state of consciousness, all patients were divided into recovered group (29 cases) and non-recovered group (22 cases). Univariate analysis method was used to explore the possible factors that might affect the recovery of consciousness in patients with chronic DOC, including the patient′s age, sex, cause of injury, course of illness, preoperative coma recovery scale-revised (CRS-R) score, level of consciousness (minimally conscious state or vegetative state), length of stay in the intensive care unit (ICU), length of use of the ventilator, number of DAI lesions and injury degrees, diffusion tensor imaging (DTI) fractional anisotropy (FA) value of DAI key sites, and postoperative complications (including hydrocephalus, epilepsy, infection, and paroxysmal sympathetic overactivity syndrome). The independent influencing factors of DOC patient′s consciousness recovery were identified by multivariate logistic regression analysis.

The results of univariate analysis showed that the age of onset, proportion of patients with minimally consciousness state, preoperative CRS-R score, postoperative combined hydrocephalus, DAI degree on imaging, FA value of key sites of DAI may be the influencing factors of patient′s consciousness recovery (all P<0.05). The results of multivariate logistic regression analysis showed that age (OR=1.316, 95%CI: 1.078-1.580, P=0.006), preoperative CRS-R score (OR=0.200, 95%CI: 0.044-0.910, P=0.037), brainstem white matter damage (OR=3.991, 95%CI: 0-21.261, P=0.040), and postoperative hydrocephalus (OR=11.874, 95%CI: 0.308-76.078, P=0.045) were independent influencing factors in the recovery of consciousness in DOC patients.

In DAI-induced DOC patients, comorbid hydrocephalus, older age, severe injury of DAI key sites and low CRS-R score at admission are unfavored factors for their consciousness recovery.

To investigate the safety and efficacy of the treatment of unruptured intracranial vertebral artery dissection aneurysms (IVADA) with flow diverters (FD).

The clinical data of 25 patients with 25 unruptured IVADA who were treated with FD (Pipeline and Tubridge) at Cerebrovascular Interventional Therapy Center of Zhengzhou University People′s Hospital from June 2016 to July 2019 were retrospectively analyzed. Statistical analysis was performed on the surgical procedure, perioperative complications, and follow-up results. The modified Rankin scale (mRS) was used to evaluate the clinical outcomes at follow-up, and O′Kelly-Marotta (OKM) grading scale was used to evaluate the occlusion of aneurysms.

In this series, a total of 26 devices of FD were implanted in 25 cases, including 16 Pipelines in 16 cases and 10 Tubridges in 9 cases. There were 2 cases with FD implantation combined with coil embolization, 24 cases with a single FD and 1 case with 2 FDs. All FDs fully covered the lesions and had good adherence to the vascular wall. The success rate of operation was 100%. Immediately after surgery, the contrast agent retention in the aneurysms was observed. All 25 patients underwent clinical follow-up. The follow-up period lasted for 3-39 months with the median of 7 months. The mRS score was 0 points in 19 cases and 1 point in 6 cases. One case had caudate hemorrhage breaking into the ventricle at 8 months post operation and was cured with conservative treatment. Nineteen cases underwent imaging follow-up. The follow-up duration was 3-29 months with the median of 5 months. Among the 19 patients, 11 were grade D (OKM grading scale), 2 were grade C, and 6 were grade B. No recurrence of aneurysm was reported.

The treatment of unruptured IVADA with FD is safe and effective with a high success rate, while the long-term results need further observation.

To explore the safety and effectiveness of the Willis covered stent (WCS) in the treatment of large or giant paraclinoid aneurysms.

We retrospectively reviewed the clinical data of 17 patients with 17 large and giant paraclinoid aneurysms who were admitted to Department of Neurosurgery, Daping Hospital, Army Medical University between December 2014 and November 2018. Among them, there were 7 cases of Hunt-Hess grade Ⅱ, and 2 cases of grade Ⅲ. The maximal diameter of aneurysms was 18±5 mm (11-28 mm), including 15 large aneurysms and 2 giant aneurysms. There were 12 aneurysms with the neck width of >4 mm. All patients underwent phase-Ⅰ endovascular reconstruction with WCS implantation. Postoperative follow-up was performed for all patients. Digital subtraction angiography (DSA) was used to confirm whether the aneurysms had residual or recurrence and assess the patency of the parent artery. Modified Rankin scale (mRS) was used to evaluate the neurological recovery of the patients.

A total of 18 WCS were deployed in 17 patients. No treatment-related acute complications such as intraoperative aneurysm rupture, displacement or collapse of the stent, acute thrombosis occurred in this series. Immediate post-procedural angiography revealed mild endoleak into the aneurysm sac in 3 cases, which almost disappeared in 2 cases after balloon dilatation and remained in 1 case. The other 14 patients showed complete aneurysm occlusion and patent parent artery. Among the 17 patients, occlusion of the ophthalmic artery was revealed in 10 patients who did not develop related clinical symptoms. The head CT scan immediately post procedure and at discharge did not show any evidence of bleeding or ischemia. The median follow-up time of 17 patients was 18 months (6-30 months). The DSA at 14-month follow-up showed the type Ⅲb endoleak in 1 case, which resolved by a second operation of stacking another WCS. At the last follow-up, aneurysms of all patients were completely occluded and no recurrence was observed. The mRS score at follow-up was 0 in 13 patients and 1 in 4 patients.

Preliminary observation suggests that endovascular reconstruction with WCS for the treatment of large or giant paraclinoid aneurysms seems relatively safe with good short-term therapeutic effect.

To evaluate the effectiveness and safety of ibrutinib combined with methotrexate, ifosfamide, liposomal doxorubicin and methylprednisolone (I-MIDD regimen) for the treatment of relapse/refractory primary central nervous system lymphoma (R/R PCNSL).

The clinical data of 18 R/R PCNSL patients admitted to Department of Hematology, Beijing Tiantan Hospita1, Capital Medical University from September 2017 to December 2019 were analyzed retrospectively. All patients received ibrutinib (560 mg/d for 21 consecutive days), methotrexate (d₁: 3.5 g/m²), ifosfamide (d₂: 1.5 g/m²), liposomal doxorubicin (d₃: 25 mg/m²) and methylprednisolone (d_1-3: 80 mg/d) for chemotherapy. Every 21 days were considered as a course of treatment, and the patients were treated for 1-6 courses. The therapeutic effect of patients was evaluated according to the therapeutic evaluation criteria formulated by the international PCNSL collaborative group in 2005. Complete remission or partial remission was regarded as effective. Adverse drug reactions were evaluated according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Kaplan-Meier method was used to draw the survival curve, and the 1-year progression free survival rate and 1-year overall survival rate were evaluated.

A total of 18 patients were treated with 3.8±1.7 (1-6) courses of I-MIDD regimen, among them 10 patients achieved complete remission, 5 achieved partial remission, 1 had stable disease and 2 had progression of disease. The total effective rate was 15/18. The median follow-up time of 18 patients was 13 (3-27) months. At the latest follow-up, 6 patients achieved complete remission, 5 had relapse, 6 had progression and 1 died. The median progression-free survival (PFS) was 6 (1-27) months, the overall survival (OS) ranged from 3 to 27 months, and the median OS was not achieved. The 1-year PFS and OS were 42.8% and 87.4% respectively. The adverse reaction of chemotherapy was mainly bone marrow suppression, and 17 out of 69 (24.6%) adverse events were grade Ⅲ to Ⅳ leukopenia, neutropenia and thrombocytopenia in the course of the disease. The only grade Ⅲ non-hematologic toxicity was infectious disease which occurred in 2 cases including 1 case of fungal pneumonia and 1 case of urinary tract infection. Grade Ⅰ to Ⅱ non-hematologic toxicity occurred in 21 events.

I-MIDD regimen is both effective and safe in the treatment of patients with R/R PCNSL and may be a new salvage therapy for R/R PCNSL.

To explore the application value of electrocorticography (ECoG) combined with depth electrode electroencephalography (EEG) in surgery of refractory epilepsy caused by focal cortical dysplasia (FCD) type II.

A retrospective study was conducted on 15 patients who underwent surgical treatment of refractory epilepsy caused by frontal lobe FCD Ⅱ at Department of Neurosurgery, the 988^th Hospital of PLA Joint Logistic Support Force from March 2015 to March 2019. During operation, ECoG and depth electrode were used in combination for continuous monitoring to locate epileptogenic zone (EZ) to guide the range and depth of surgical resection of FCD lesion and surrounding EZ. Engel grade was used to evaluate the efficacy after operation.

All 15 patients successfully underwent the operation, during which both ECoG and deep electrode EEG at the FCD lesions recorded continuous or paroxysmal sharp waves, spikes and spike-and-wave discharges (SWDs). Deep electrode EEG also recorded epileptiform discharges (EDs) such as sharp waves, spikes and SWDs in normal brain tissue around FCD, while the discharge frequency was lower than that in the FCD region. According to the real-time monitoring results, merely excision of abnormal lesions were undergone in 5 cases, resection of lesion and surrounding tissues with EDs in 7 cases, and resection of lesion and surrounding tissues with EDs plus anterior corpus callosotomy in 3 cases. There was 1 case of postoperative emotional indifference, 1 case of disturbed language fluency, and 1 case of light paraplegia, which were all temporary complications and recovered within 2 months. No cases of postoperative acute seizures were reported. Postoperative MRI showed that FCD was completely removed in 12 cases and partial residual was observed in 3 cases. Pathological results showed that there were 6 cases of FCD IIa and 9 cases of FCD Ⅱb. The follow-up time of 15 patients was 26.5±8.9 months (14 to 62 months). Engel grade Ⅰ was reported in 10 cases, grade Ⅱ in 4 and grade Ⅲ in 1.

The combination of intraoperative ECoG and depth electrode for continuous dynamic monitoring can accurately locate the range and depth of EZ, which is thus suitable for surgery of refractory epilepsy caused by FCD Ⅱ.

To investigate the risk factors of postoperative unfavorable outcomes in patients with spontaneous intracerebral hemorrhage (SICH) and to analyze their predictive value for prognosis.

The clinical and imaging data of 325 patients with adult SICH admitted to Department of Neurosurgery, Fuyang Fifth People′s Hospital from January 2015 to June 2019 were retrospectively analyzed. All patients were all followed up for 6 months. Univariate and multivariate logistic regression analysis were performed to study the relevant factors affecting the outcomes of postoperative patients at 6 months. The receiver operating characteristic (ROC) curves were applied to analyze the predictive value of risk factors for the prognosis.

Among 325 SICH patients at 6 months post operation, 210 cases (64.6%) had good outcomes [Glasgow Outcome Scale (GOS) Ⅳ-Ⅴ], 115 cases (35.4%) had poor outcomes (GOS Ⅰ-Ⅲ). Univariate regression analysis showed that age, external ventricular drainage (EVD), type of surgery, cerebral hernia, pre-operative obstructive hydrocephalus, pre- and post-operative Glasgow Coma Scale (GCS), pre- and post-operative intraventricular hemorrhage (IVH), post-operative midline shift (MIS), subdural effusion, intracranial infection (ICI), the modified Graeb Scale (mGS) and chronic hydrocephalus (HCP) were possible influencing factors for outcomes (P<0.05). Multivariate binary logistic regression analysis revealed that age (OR=1.075, 95%CI: 1.041-1.110, P<0.001), pre-operative mGS (OR=1.083, 95%CI: 1.010-1.162, P=0.026), post-operative MIS (OR=2.716, 95%CI: 1.274-5.790, P=0.010), post-operative ICI (OR=12.898, 95%CI: 2.225-74.760, P=0.004), chronic hydrocephalus (OR=3.665, 95%CI: 1.519-8.838, P=0.004) and post-operative GCS score (OR=0.790, 95%CI: 0.649-0.961, P=0.018) were independent risk factors for poor outcomes. ROC curves showed that areas under the curve (AUC) of those independent influencing factors of poor outcomes were 0.617 (68 years as the threshold for age), 0.674(11 points as the threshold for mGS), 0.654, 0.532, 0.705 and 0.798(8 points as the threshold for post-operative, GCS). The AUC of independent risk factors combined to predict the prognosis was 0.875.

Age (>68 years), pre-operative mGS score (>11 points), post-operative GCS score (<8 points), post-operative MIS, post-operative ICI and chronic HCP are independent risk factors for unfavorable outcomes. Those indexes could be jointly applied to predict early prognosis for the patients with SICH.