Volume 36 · Issue 11 · 2020

Since 1992, Jankowski et al.^[1]Since the resection of pituitary tumors by neuroendoscopic transnasal-sphenoidal approach was reported for the first time, the technique of neuroendoscopic transnasal skull base surgery has become more and more mature, its application scope has gradually expanded, and the types of lesions treated have increased day by day. However, postoperative cerebrospinal fluid leakage has always been an important factor restricting the further development of neuroendoscopic transnasal skull base surgery. In the treatment of skull base meningioma, craniopharyngioma and other subdural tumors, the intraoperative skull base dural and bone defects are large, and the incidence of postoperative cerebrospinal fluid leakage is obviously increased. Therefore, higher requirements for skull base reconstruction technology are put forward. The increasing clinical demand has promoted the progress of skull base reconstruction technology, and a variety of new repair materials and repair technologies have been applied in clinic one after another. In 2006, the application of the vascularized nasal septal mucosal flap (Hadad-Bass-agasteguy mucosal flap)^[2]So that the incidence of cerebrospinal fluid leakage after neuroendoscopic nasal surgery was significantly reduced^[3,4,5,6,7]。

Craniopharyngioma originates from the residual epithelial tissue of the craniopharyngeal duct or Rathke sac in the embryonic stage, or from the squamous epithelium metaplasia of the original fovea, and its body is located in the anatomical space consisting of the optic nerve, optic chiasm, Willis ring, hypothalamus and pituitary gland. Because of the deep location of the tumor, the adjacent structure is important and complex, surgical treatment or radiotherapy may cause damage to important structures such as optic chiasm, pituitary stem, hypothalamus, etc. Therefore, the diagnosis and treatment of craniopharyngioma is a major challenge for neurosurgery^[1,2,3,4]。 Because drugs, radiotherapy, chemotherapy, gene immunization and other therapeutic methods are still not effective, it is still the first choice for the treatment of craniopharyngioma to surgically remove the tumor while preserving the hypothalamus-pituitary function as much as possible^[5,6,7,8]。 With the rapid development of modern medical technology, the surgical methods for craniopharyngioma are not limited to craniotomy or nasal microsurgery, and the therapeutic effect of using neuroendoscopic nasal technique to remove craniopharyngioma is more and more ideal^[9,10,11]。

Dystonia is a movement disorder characterized by abnormal movement and/or posture caused by persistent or intermittent muscle contractions, often repeated. Dystonic movements are generally patterned twisting movements that can be tremor-like. Dystonia is often induced or aggravated by voluntary movement with generalization of muscle excitation^[1]。 At present, there is no effective etiological treatment for most dystonia, and symptomatic treatment is mainly used in clinical practice. The goals of clinical treatment include reducing involuntary movements, correcting abnormal posture, reducing pain, improving function and improving the quality of life of patients. Clinically, according to the specific situation of dystonia patients, we should weigh the advantages and disadvantages, and choose comprehensive measures such as support and rehabilitation treatment, oral medication, botulinum toxin injection and surgical treatment to achieve the maximum improvement of individual function and quality of life of patients.

To analyze the clinical classification, surgical treatment and outcome of complex spinal cord lipomas.

The clinical data of 403 patients with complex spinal cord lipomas from January 2008 to January 2017 were retrospectively analyzed. Among 403 cases, 204 were admitted to Department of Neurosurgery of the 7^th Medical Center of PLA General Hospital and 199 cases to Department of Neurosurgery of Tsinghua University Yuquan Hospital. All patients underwent lipoma resection, and their outcomes and complications were documented. According to MRI features before and after operation and intraoperative findings, 403 cases with complex spinal cord lipomas were divided into dorsal type (51 cases), transitional type (289 cases) and chaotic type (63 cases). Among them, dorsal type was subdivided into simple type (42 cases) and cord-wrapping tumor type (9 cases), and chaotic type was subdivided into conus type (56 cases) and tumor-wrapping cord type (7 cases). The outcome was evaluated by clinical and MRI follow-up.

Total or subtotal resection was performed in 287 cases (71.2%), including 42 cases(82.3%) of dorsal type, 239 cases(82.7%) of transitional type and 6 cases(9.5%) of chaotic type. The follow-up period was 3 years post operation. The symptoms deteriorated in 38 cases (9.4%), including 23 cases of chaotic type and 15 cases of transitional type. During the 3 years post operation, the rate of symptomatic progression-free survival (PFS) was 90.6% (365/403) with 100.0% (51/51) in dorsal type, 94.8% (274/289) in transitional type and 63.5% (40/63) in chaotic type.

The correct classification of complex spinal cord lipomas can help predict the surgical risk, guide the operation and roughly evaluate the prognosis. The rate of total or subtotal resection for chaotic lipomas seems to be the lowest with the worst outcome. Retethering and neurodysplasia may be the main causes of the long-term deterioration of symptoms.

To explore the early clinical efficacy of posterior percutaneous endoscopic keyhole surgery for single-segment cervical spondylotic radiculopathy (CSR).

A retrospective analysis was conducted on the clinical data of 15 patients with single-segment CSR who underwent posterior percutaneous endoscopic keyhole surgery at Department of Neurosurgery, Minhang Hospital, Fudan University from April 2017 to May 2019. Cervical spine MRI, cervical 3D CT and X-ray were reexamined post operation, and visual analogue scale (VAS), Japanese Orthopaedic Association (JOA) cervical spine score and Neck Disability Index (NDI) were used for efficacy assessment. Clinical follow-up was conducted for all patients, including VAS, JOA and NDI assessment. We measured the changes in the physiological curvature of the cervical spine, the height of the intervertebral space, and the horizontal and angular displacements of the vertebral body before and during the last follow-up. The modified MacNab criteria were employed for efficacy evaluation.

All 15 patients successfully underwent operations, and no postoperative infection, spinal canal hematoma or neurological dysfunction occurred. Postoperative review of MRI showed that all patients had satisfactory decompression of nerve root. Compared with preoperative conditions, the VAS scores (2.1±1.1 points vs. 6.2±1.4 points) and NDI [(32.3±8.2)% vs. (68.9±9.1)%] were decreased 2 days after surgery (both P < 0.001), the JOA cervical spine score (17.0±1.5 points vs. 12.7±1.6 points) were increased 2 days after surgery (P<0.05). The follow-up time of 15 patients was 17±5 months (12-22 months). With the increase of follow-up time, the VAS score of 15 patients showed a downward trend, the JOA cervical spine score showed an upward trend, and the NDI showed a downward trend (F=157.604, 306.701 and 47.309 respectively, all P <0.001). At the last follow-up, the patient′s cervical spine curvature [(9.60 ± 1.84)°] was higher than that before treatment [(7.93 ± 1.53)°, t=-5.801, P<0.05]. There was no significant difference in the intervertebral height of the lesion, horizontal and angular displacements of the vertebral body between preoperative and postoperative conditions(allP>0.05). At the last follow-up, the efficacy evaluation results of 15 patients based on modified MacNab chriteria were excellent in 13 patients, good in 1 patient, and fair in 1 patient.

Posterior percutaneous endoscopic keyhole surgery for single-segment CSR seems safe with few complications and the short-term outcome is satisfactory, which can improve neurological function without affecting the stability of cervical spine.

To explore the clinical features and prognosis of spinal diffuse midline gliomas (SDMGs) with H3K27M mutation.

From May 2015 to October 2017, 12 patients with SDMGs and H3K27M mutation were admitted to Department of Neurosurgery, Beijing Tsinghua Changgung Hospital and enrolled into this study. The clinical features, treatment methods and prognosis were analyzed retrospectively. The patients included 8 males and 4 females and the average age was 28.4±11.9 years(10-53 years). There were 2 cases of dyspnea, 7 cases of limb weakness, 6 cases of paresthesia in body and limbs, and 2 cases of urinary dysfunction. All 12 patients underwent surgical treatment and received temozolomide chemotherapy after surgery without radiotherapy. Survival time was evaluated by out-patient follow-up and telephone follow-up.

Among the 12 patients, major resection of tumor was performed in 8 cases and near-total resection in 4 cases. Postoperative histological examination indicated glioblastoma in 7 cases, anaplastic astrocytoma in 3, and anaplastic oligoastrocytoma in 2. Tumor recurrence was reported in all patients post operation. The SDMGs mainly invaded along the spinal cords, and brain metastasis occurred in 2 cases. Twelve patients died within 30 months after operation. The mean (P₂₅, P₇₅) survival time was 18.0 (5.0, 22.8) months.

SDMGs have diverse clinical features, are mostly common in children and young people, and have poor surgical outcome and prognosis.

To explore the diagnosis and treatment of adult-onset intradural spinal teratoma.

A retrospective study was conducted on 11 adult patients with intradural spinal teratoma who were surgically treated and pathologically confirmed at Department of Neurosurgery, General Hospital of Ningxia Medical University between January 2013 and August 2019. All patients underwent surgical resection of the tumor via posterior laminectomy approach under neuroelectrophysiological monitoring. The extent of tumor resection was evaluated based on the patient’s postoperative MRI. Limb motor function was assessed using muscle strength score. Bladder function was evaluated by the Japanese Orthopaedic Association (JOA) sphincter function score. The long-term efficacy of the patients was assessed using McCormick clinical classification.

Of the 11 patients in our study, all the lesions were located in the lumbosacral region, and the imaging manifestations were complex and vary greatly. The clinical manifestations included pain in the lumbosacral region and unilateral lower limb in 9 cases, urinary incontinence in 1. Of the 11 included patients, 3 patients received total resection and the other 8 patients received subtotal resection. All results of pathological diagnosis were teratomas, 10 cases were diagnosed with mature teratoma and 1 case was diagnosed with mature teratoma with partial carcinoid tissues. The median follow-up time of the 11 patients was 15 months (9 months to 8 years). During the follow-up period, enhanced MRI was performed, and no tumor recurrence or spinal instability was observed. The McCormick grading scale evaluation results of the last follow-up showed that functional status was improved in 8 cases and remained unchanged in the other 3 patients, and there was no case reporting aggravation.

Adult-onset intradural spinal teratoma are rare and commonly occur in the lumbosacral region. The clinical manifestation of intradural spinal teratoma lacks specificity, and MRI manifestations are complex and diverse. Radical excision of microsurgery under electrophysiological monitoring seems the optimal treatment.

To explore the application value of augmented reality based on Sina in the localization of spinal canal tumors.

The clinical data of 20 patients with spinal canal tumors who underwent surgical treatment at Neurosurgery Department of Peking University Third Hospital from January 2019 to December 2019 were retrospectively analyzed. S-group (based on Sina, 10 cases) and A-group (based on anatomical markers, 10 cases) were randomly divided. Before surgery, the skin projection of tumor was located in both groups. Augmented reality method based on Sina was applied in S-group, while the anatomical markers on the body surface were the only references in A-group. The localization results of the two groups were verified using intraoperative C-arm and compared with the actual location of the tumor shown on MRI. The deviation, total localization time and times of C-arm used were documented and compared between two groups.

The total localization time in S-group (12.5±3.0 min) was longer than that in A-group (9.3±1.7 min) (t=2.913, P=0.009). The localization deviation in S-group (2.98±0.92 cm) was significantly less than that in A-group (4.39±1.87 cm) (t=-2.131, P=0.047), and times of C-arm used (1.3±0.5) in S-group was less than that in A-group (2.2±0.8) (t=-3.077, P=0.006).

It is safe and precise to localize spinal canal tumor using augmented reality based on Sina. However, the accuracy of Sina needs further verification by more clinical practice.

To assess the safety and effectiveness of transcranial MR-guided focused ultrasound (tcMRgFUS) in the treatment of tremor-dominant idiopathic Parkinson′s disease (TDPD).

A prospective study was conducted on 10 patients with TDPD who were admitted to Department of Neurosurgery, the First Medical Center of PLA General Hospital from April to September 2019. All patients underwent unilateral (dominant side) tcMRgFUS ablation of Vim (ventrointermediate) nucleus of thalamus. The occurrence of adverse events after surgery were documented. A linear mixed model was used to compare the clinical rating scale for tremor(CRST) score before operation, 1 month and 3 months after operation to evaluate the effect of treatment.

Among 10 patients, 7 cases underwent Vim ablation through tcMRgFUS on the left side and 3 cases underwent the operation on the right side. For 10 patients, sonications transmitted were 10.4±2.6 times; the initial treatment energy ranged from 849 to 2 823 J, the final energy ranged from 6 737 to 20 096 J, and the highest treatment temperature was 56.7±1.7 ℃. The median (Q25, Q75) time period from entering to leaving the treatment room was 140.0 (13.0, 182.5) min, and the time from the first to the last sonication was 62.3±25.4 min. After operation, MRI revealed the ablation site with a diameter of 5 mm in the area of Vim nucleus on the treatment side. All patients completed follow-up within 3 months after surgery. At 3 months after operation, CRST total score, CRST part A, part B, part C, (treatment side) upper extremity and lower extremity tremor scores were all significantly decreased compared with preoperative baseline (all P<0.05). However, those were not significantly different compared with 1 month post operation (allP>0.05). Postoperative adverse events included numbness of the scalp, lips or tip of the tongue (5 cases), decreased muscle strength (2 cases), and equilibrium disturbance (2 cases). Among 5 cases of numbness, 3 cases were relieved and 2 cases were improved at the last follow-up. The muscle strength was recovered in 2 cases, balance was recovered in 2 cases, and 1 case developed gait disorder.

The preliminary observation indicates that MRgFUS has relatively good short-term efficacy and safety in the treatment of tremor in patients with TDPD.

To conduct preliminary analysis of diffusion tensor imaging(DTI) related features of cerebellar mutism syndrome (CMS) in children after surgery of cerebellar tumors.

A prospective cohort study method was used to analyze the clinical data of 16 children with cerebellar tumors who underwent surgical treatment at Department of Pediatric Surgery, the First Affiliated Hospital of Xinjiang Medical University from December 2016 to July 2019. After surgery, the children were divided into CMS group (3 cases) and non-CMS group (13 cases) according to the Darley diagnostic criteria of Mayo Clinic. Three healthy children volunteers were enrolled during the same period as controls (healthy control group). All children underwent DTI scan before surgery. The CMS group underwent DTI scan at 1, 3, and 6 months after surgery, and the non-CMS group underwent DTI scan only at 1 month after surgery. The healthy control group underwent DTI scan for only once. The fractional anisotropy (FA) values of bilateral dentate nucleus, superior, middle and inferior cerebellar peduncles were measured in the 3 groups.

There was no statistically significant difference in age or gender among the 3 groups (all P>0.05). There was no statistically significant difference in gender, age, tumor location, size, pathological type, or brain stem invasion between the CMS group and non-CMS group (allP>0.05). The FA values of the preoperative dentate nucleus, superior, middle and inferior feet of the cerebellum in the CMS group and the non-CMS group were higher than those in the healthy control group (dentate nucleus: 0.65±0.11, 0.53±0.12, 0.33±0.12; superior cerebellar peduncle: 0.70 ±0.03, 0.69±0.11, 0.35±0.15; Middle cerebellar peduncle: 0.74±0.05, 0.71±0.13, 0.34±0.11; inferior cerebellar peduncle: 0.64±0.13, 0.53±0.08, 0.34±0.07; bothP<0.05). Furthermore, the FA values of the dentate nucleus and the inferior cerebellar peduncle in the CMS group were higher than those in the non-CMS group (allP<0.05). At 1 month post operation, the FA values of bilateral dentate nucleus, superior, middle and inferior cerebellar peduncles in non-CMS group were not significantly different from those prior to operation (allP>0.05). With increase of follow-up time, the FA values of bilateral dentate nucleus and inferior cerebellar peduncle in the CMS group showed a trend of rising first, then falling (left:F₁=9.872、F₂=17.960, right: F₃=7.230、F₄=27.330, All P<0.05). There was no statistically significant difference in the FA values of bilateral middle and inferior cerebellar peduncles at different time points post surgery (allP>0.05).

It is preliminarily speculated that the occurrence of CMS in children with cerebellar tumors is related to the dentate nucleus and inferior cerebellar peduncle, and will recover with the prolonged follow-up time; whether the superior and middle cerebellar peduncle are related to CMS still needs further research to confirm.

To assess the clinical efficacy and safety of bilateral deep brain stimulation of globus pallidus internus (GPi-DBS) in idiopathic Meige syndrome (MS).

A retrospective study was conducted on the clinical data of 15 patients with idiopathic MS undergoing bilateral GPi-DBS at Neurosurgery Department of Peking University People′s Hospital from October 2018 to January 2019. DBS device was turned on at 1 month after operation for all patients. The initial stimulation parameters were 160 Hz, 90 μs and constant voltage. And the contact with low treatment threshold and high adverse reaction threshold was selected. At 3, 6 and 12 months after operation, the patients were followed up regularly, and the stimulation parameters were adjusted according to the clinical symptoms and adverse events. Meanwhile, the Burke-Fahn-Marsden dystonia rating scale (BFMDRS) was used to evaluate the symptomatic improvement.

All operations were successful and postoperative CT scan showed that all the electrodes were implanted into bilateral GPi. After the operation, there were 3 cases of head heaviness and 1 case of slurred speech. After adjustment of the stimulation parameters and electrode contacts, the symptoms were relieved or disappeared. The mean follow-up time was 7.0±3.8 months (3-12 months). The motor function of 15 patients were improved significantly and the total improvement ratio was 13/15. At 3, 6 and 12 months after operation, the BFMDRS scores of eyes, mouth, speaking and swallowing and neck were significantly lower than those before operation (all P < 0.05). With the extension of treatment time, both the subscores in eyes and mouth and the total BFMDRS scores tended to decrease (all P<0.05). At the last follow-up, the improvement ratios for eye, mouth, speaking and swallowing and neck were 12/14, 8/11, 4/7 and 2/4 respectively.

Bilateral GPI-DBS treatment of primary Meige syndrome could significantly improve the patients motor symptoms, with fewer adverse reactions. With the extension of treatment time, eye and mouth symptoms showed a trend of gradual improvement.

To review the efficacy and experience of endovascular combination therapy for hemorrhagic thrombosis in intracranial venous sinus.

We retrospectively analyzed 8 patients with acute or subacute cerebral venous sinus thrombosis who were treated at Neurosurgical of Department, the First Affiliated Hospital of Soochow University from March 2019 to November 2019. All those cases had intracranial hemorrhage and some of them also suffered from cerebral ischemia simultaneously. All patients underwent endovascular combination therapy including mechanical thrombectomy, thrombus aspiration, balloon dilatation and catheter-directed thrombolysis. In 1 patient, the conditions deteriorated rapidly and decompressive craniectomy was performed following endovascular treatment. The patency of cerebral venous sinus was assessed post operation and at follow-up. The patients′ outcomes were evaluated based on the modified Rankin scale (mRS).

Microcatheter was removed in 8 patients when the patency of the venous sinus was confirmed by CTV or MRV reexamination. The micro-catheter system was reserved in intracranial venous sinus for 4-10 days after the operation. Seven of the patients underwent catheter-directed thrombolysis therapy for 3-8 days. Anticoagulant drug was used regularly for more than 6 months. None of the patients have progression of hemorrhage within 1 week after surgery, most of the occluded sinuses were re-opened. The intracranial hemorrhage was absorbed and the edema was also resolved within 1 month. Eight patients were cured and discharged after treatment, and the follow-up time was 6 to 15 months, with no recurrence of sinus thrombosis and new neurological symptoms. At 6-month follow-up post surgery, the mRS was 0 in 3 cases, 1 in 3 cases, 2 in 1 case, and 3 in 1 case.

Combined with conventional anticoagulant therapy, multiple endovascular treatment schemes could reduce the thrombus load in venous sinus in a short time and was effective and safe treatment of hemorrhagic thrombosis in intracranial venous sinus.

To analyze the effect of carotid endarterectomy (CEA) on patients with stroke caused by atherosclerotic plaque and its relationship with the characteristics of atherosclerotic plaque.

A retrospective analysis was conducted on the clinical data of 61 stroke patients treated with CEA at Neurosurgery Department of the First Affiliated Hospital of Suzhou University from August 2015 to October 2018. All patients were diagnosed with moderate to severe carotid stenosis caused by atherosclerotic plaque. Vascular ultrasonography was performed before operation and 1, 3, 6, and 12 months post operation. According to score change based on National Institutes of Health Stroke Scale (NIHSS) at 30 days after surgery, patients were divided into symptom improvement group (42 cases) and non-improvement group (19 cases). The clinical data of the two groups of patients were compared with the characteristics of the plaques caused by atherosclerosis, and their effects on the improvement of NIHSS after 30 days were analyzed. The restenosis and stroke recurrence were followed up.

The results of univariate analysis showed that compared with the symptom non-improvement group, the improvement group had shorter median time interval from symptom onset to operation [14 (10, 96) d vs. 45 (25, 168) d], lower proportion of hypoechoic plaque [28.6% (12/42) vs. 12/19] and ulcerative plaque [11.9% (5/42) vs. 9/19], and faster average blood flow velocity of middle cerebral artery (MVMCA) after intraoperative opening of carotid artery (51.1±14.7 cm/s vs. 41.2±15.2 cm/s). The differences were statistically significant (all P<0.05). Multivariate logistic regression analysis showed that hypoechoic plaques (OR=3.963, 95%CI: 1.037-15.149, P=0.044) and ulcerative plaques (OR=5.657, 95%CI: 1.258-25.448, P=0.024) were independent risk factors that affected the improvement of clinical symptoms 30 days after CEA in patients with carotid stenosis. For 61 patients, the ultrasound follow-up lasted for 12 to 15 months (13.1±1.2 months). At the last follow-up, 3 patients (4.9%) had intraoperative carotid restenosis and included 1 case in the symptom improvement group (moderate stenosis) and 2 cases in the symptom non-improvement group (1 with moderate and 1 with severe stenosis). No stroke occurred during follow-up.

CEA can not only partially improve neurological symptoms but also prevent stroke recurrence. Predominantly hypoechoic and ulcerative plaques are important factors affecting the improvement of neurological symptoms in stroke patients 30 days after CEA.

To investigate the causes of frontal sinus infection post craniotomy and its treatment outcome of microsurgery combined with transnasal endoscopic surgery.

The clinical data of 20 patients admitted to Neurosurgery Department of Beijing Tongren Hospital, Capital Medical University from January 2015 to December 2019 were retrospectively analyzed. All 20 patients underwent microsurgery combined with transnasal endoscopic surgery. The possible causes, intraoperative conditions and therapeutic outcomes of frontal sinus infection post craniotomy were analyzed.

Obstruction of frontal sinus drainage pathway was observed during the operation of all 20 patients. The obstruction was due to artificial materials in 12 cases, bone malunion in 6 cases, and formation of scar in 2 cases. There were 13 positive cases of microbial culture in pus obtained during operation, including 8 cases of Staphylococcus aureus, 3 cases of Streptococcus constellation, 1 case of Enterobacter cloacae and 1 case of Pseudomonas aeruginosa. The 20 patients were followed up for 6 months to 5 years after surgery, and the median follow-up time was 21 months. The patient's scalp incision and skin sinus wounds were healed, and there were no signs of delayed infection in the skull or nasal cavity.

Frontal sinus infection is mainly seen in the patients with residual of artificial foreign body in the sinuses and the obstruction of drainage pathway after craniotomy. The combined treatment of microsurgery and transnasal endoscopic surgery could facilitate the removal of infectious lesion and drainage of the sinuses, which is helpful for the patient’s recovery.

To analyze the application value of preoperative diffusion tensor imaging (DTI) in neuroendoscopic evacuation of intracerebral hemorrhage (ICH).

A retrospective analysis was conducted on the clinical data of 135 patients with ICH admitted to Department of Neurosurgery, Luoyang Central Hospital Affiliated to Zhengzhou University admitted from June 2014 to December 2019. Among those, 93 cases were treated with neuroendoscopic hematoma removal (neuroendoscopic group) and 42 cases were treated with neuroendoscopic hematoma removal based on preoperative DTI (DTI plus endoscopic group). At 3-month outpatient follow-up, the outcomes of all patients was assessed based on the modified Rankin scale (mRS), of which the points of 0-3 were defined as favorable outcomes and 4-6 as unfavorable outcomes.

There were no significant differences in sex, age, past medical history, smoking history, drinking history, Glasgow coma score (GCS) at admission, average arterial pressure, cerebral hemorrhage location, volume of cerebral hematoma, cerebral hemorrhage score, and cerebral hemorrhage breaking into the ventricle (all P>0.05). However, the incidence of postoperative pneumonia in DTI plus neuroendoscopic group was lower than that in neuroendoscopic group [16.7% (7/42)vs. 35.5% (33/93), P<0.05]. The proportion of favorable outcome was higher in DTI plus neuroendoscopic group than in neuroendoscopic group [73.8% (31/42)vs. 52.7% (49/93), P<0.05]. The results of multivariate logistic regression analysis showed that age (increase of 10 years) (OR=2.07, 95% CI: 1.48-3.55, P<0.01), hematoma volume (increase of 10 ml) (OR=1.84, 95% CI: 1.32-2.34, P<0.01), cerebral hemorrhage breaking into the ventricle (OR=1.92, 95% CI: 1.46-3.81, P<0.01), GCS score (decrease of 1 point) (OR=1.15, 95% CI: 1.08-1.32, P<0.01) were risk factors for the outcomes of ICH patients, while neuroendoscopic surgery assisted with preoperative DTI was a protective factor for outcomes of ICH patients (OR=0.71, 95% CI: 0.35-0.87, P<0.01).

Neuroendoscopic hematoma evacuation assisted with preoperative DTI is associated with lower incidence of postoperative pneumonia and higher proportion of favorable outcomes in patients with ICH. The application of DTI before surgery is the protective factor for the outcomes of ICH patients.

To explore the risk factors and therapeutic effect of epidural fluid collection (EFC) as a complication of cranioplasty after or during ventriculoperitoneal (VP) shunting.

Fifty-nine patients who underwent cranioplasty with titanium mesh after or during VP shunting from June 2014 to June 2019 were reviewed at Department of Neurosurgery, the 900^th Hospital of the Joint Logistics Team. There were 33 patients who developed the complication of EFC after operation, 7 of which were symptomatic EFC (SEFC). Supine position and increased rehydration were prescribed to all patients. In addition, the patients with SEFC underwent percutaneous puncture and continuous negative pressure external drainage for 3-5 days and the pressure of the shunt valve was increased. We observed the therapeutic effect and analyzed the risk factors associated with EFC.

The effusion of 33 patients was absorbed after treatment. Among them, the absorption time of effusion in 26 non-SEFC patients was 25.1±6.2 d and that in 7 patients with SEFC was 12.7±1.8 d. The difference was statistically significant (t = 8.906, P < 0.05). None of the patients had EFC recurrence during follow-up lasting for 3-6 months. Compared with non-SEFC subgroup, the pressure of shunt valve in EFC subgroup was higher (65.9±9.1 mmH ₂O vs. 60.0±8.9 mmH₂O) and the proportion of meningeal suspension was lower [45.5% (15/33) vs. 76.9% (20/26)]. There was significant difference between the 2 subgroups (P<0.05). Multivariate logistic regression analysis showed that higher pressure of shunt valve (OR=1.079, 95%CI: 1.010-1.154, P=0.025) and no meningeal suspension (OR=4.169, 95%CI: 1.251-13.900, P=0.020) were risk factors for EFC.

For cranioplasty in patients who have undergone VP shunting or undergo simultaneous shunting, increasing the pressure of the shunt valve before operation and performing the meningeal suspension during operation could reduce the chance of EFC and its absorption in those who have developed EFC.

To investigate the expression level of ADP-ribosylation-like factor 4C (ARL4C) in gliomas and its clinical significance.

Clinical data of 325 patients with gliomas from Chinese Glioma Genome Atlas (CGGA) and 609 patients with gliomas from The Cancer Genome Atlas (TCGA) databases were retrospectively analyzed. Specimens from additional independent 45 cases of gliomas admitted to Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University were used in this study, and the expression level of ARL4C from the tumor specimen was determined both by RT-PCR and immunohistochemistry. Based on the database and 45 glioma patients’ data, univariate analysis and multivariate Cox analysis were used to explore the relationship between the expression level of ARL4C and pathological grade and overall survival (OS) of patients.

The analysis results of CGGA and TCGA database were as follows: (1) The expression level of ARL4C was elevated with the increase of pathological grade (all P<0.001); (2) Compared withARL4C low-expression patients, ARL4C high-expression patients had lower IDH mutation ratio and older ages (all P<0.001) in both CGGA and TCGA database; (3) Multivariate Cox analysis showed that the expression level ofARL4C was related to the poor outcomes, and OS in patients with high expression levels of ARL4C was shorter than that in those with low ARL4C levels (both P<0.001). The analysis results from the tumor specimens from 45 patients were as follows: (1) RT-PCR experiment showed that the mRNA expression level ofARL4C in gliomas was elevated with the increase of pathological grades (P=0.013), and immunohistochemistry experiment validated the same trend (P=0.001); (2) The OS of high-ARL4C patients was shorter than that of ARL4C low-expression patients (HR=2.590, 95%CI: 1.193-5.621, P=0.016).

The expression level of ARL4C in glioma seems to be associated with pathological grade, and ARL4C high-expression patients have unfavorable outcomes. ARL4C may serve as a prognostic factor in patients with glioma and new potential therapeutic target.