Volume 37 · Issue 01 · 2021

2020 is destined to be an extraordinary year. The beginning of the year is an unexpected pandemic, and the whole world is plunged into unprecedented chaos. The epidemic is like a battlefield. Under the firm leadership of the Communist Party of China, the national system and institutional advantages have exerted a majestic force that has attracted the world's attention. Medical staff have been working on the front line to rescue critically ill patients infected with novel coronavirus, and scientists have worked day and night in the laboratory to make vaccines. At present, with the successful development of a number of novel coronavirus vaccines to get rid of this epidemic, the hope of a global restart is ahead, and a brand-new 2021 is coming to us. On this occasion, all members of the editorial department of Chinese Journal of Neurosurgery sincerely pay high respect to all medical workers who have fought in the front line of the epidemic and have always stuck to their posts. At the same time, they also sincerely thank the leaders of Chinese Medical Association, all the hardworking editorial board members and the authors and readers who have always given us support and help.

neurosurgical central nervous system infections (NCNSIs) refer to intracranial and spinal infections secondary to neurosurgical diseases or requiring neurosurgical treatment, including epidural abscess, subdural empyema, meningitis, ventriculitis and brain abscess after neurosurgery, intracranial infection caused by craniocerebral trauma, ventricular and lumbar cistern external drainage, shunt and implant-related meningitis or ventriculitis, etc.^[1]。 Among them, bacterial infection is the main type of CNSIs, so it is the focus of this consensus.

To explore the clinical characteristics, treatment strategies and prognosis of status epilepticus (SE) in children.

The clinical data of 36 children with SE who were admitted to Department of Neurosurgery, Tangdu Hospital of Air Force Medical University from January 2015 to October 2019 were retrospectively analyzed. After controlling SE with antiepileptic drugs, anesthetics and so on, further surgery or medication was performed to treat epilepsy according to the specific situation of the child. The control of SE, outcome of epilepsy and related complications were documented.

The ages of 36 children were all ≤ 14 years old, among whom 22 children were ≤3 years old. In this series, 29 patients had secondary epilepsy and 7 patients had primary epilepsy. There were 32 patients of CSE (convulsive status epilepticus) and 4 patients of NCSE (non-convulsive status epilepticus). There were 25 patients of ASE (aborted status epilepticus), 7 patients of RSE (refractory status epilepticus) and 3 patients of SRSE (super-refractory status epilepticus). There were 29 patients with predisposing factors, 24 patients with abnormal imaging, 35 patients with abnormal EEG, and 1 patient with EEG suppression. Of all 36 children, SE was completely controlled after antiepileptic therapy in 28 patients, and anesthesia was administered in 8 patients. Thirty-three patients of SE were completely controlled, 1 patient with RSE was partially effective, and 2 patients died (both with SRSE). The interval to control ranged from 10 min to 72 h (median: 40 min). Complications related to SE treatment occurred in 13 patients. Thirty-three children were followed up for 2.5±1.4 years(1.0-5.5 years). Among the 24 patients undergoing surgery, surgery-related complications occurred in 5 patients. Postoperative follow-up indicated Engel I in 20 patients and Engel II in 4 patients. Among the 9 patients treated with drug therapy, a reduction of seizure frequency by ≥50% was reported in 6 and that by ≤ 50% was observed in 3.

Young children, particularly those ≤3 years old, have a high incidence of SE. Most of the children have secondary epilepsy and obvious causes, abnormal imaging and electroencephalography. Antiepileptic drugs and anesthetics can control most of SE, but the outcomes of children with RSE or SRSE are poor. Early surgical treatment is effective in prevention of secondary SE and improvement of outcome.

To investigate the application of target correction method based on electrode deviation in deep brain stimulation (DBS), so as to determine whether target correction could improve the accuracy of electrode implantation.

Sixty-one Parkinson′s disease patients treated with subthalamic DBS from March 2014 to April 2018 at Neurosurgery Department, the Second Affiliated Hospital of Zhejiang University School of Medicine were retrospectively included. Among those patients, 42 patients (84 electrodes) who underwent DBS from March 2014 to March 2017 were categorized into the uncorrected group. After operation, MRI/CT fusion was performed. Formulas were used to calculate the overall deviation of the electrodes (ΔP) and directional deviation on the X, Y and Z axes. Target correction rules were made based on the deviation of electrodes. Nineteen patients (36 electrodes) who underwent DBS with target correction from April 2017 to April 2018 were categorized into the corrected group. After operation, MRI/CT fusion was performed and ΔP was calculated. The electrode deviation degree was divided into 4 groups: ΔP≤1 mm, >1-2 mm、>2-3 mm and >3 mm. The first successful puncture was defined as follows: the electrode was implanted according to the target without adjustment. The success rate of the first puncture and the electrode deviation were compared between two groups.

The operations in two groups were successfully performed without serious complications such as disability or death. No brain infarction or hemorrhage was observed on postoperative CT. In the uncorrected group, the mean ΔP value of the left electrode was 1.6±0.9 mm, with X shifting medially by 0.1±0.9 mm, Y shifting posteriorly by 1.0±0.9 mm, and Z shifting upwards by 0.5±0.5 mm. The median ΔP value of the right electrode (upper and lower quartile) was 1.4 (1.2, 2.2) mm, with X shifting medially by 0.2±0.9 mm, Y shifting posteriorly by 1.0 (0.3, 1.5) mm, and Z shifting upwards by 0.4±0.5 mm. Target correction was conducted based on the deviation data as above: Y was adjusted by 1.0 mm anteriorly on both sides, and Z was adjusted by 0.5 mm downwards on both sides. The success rate of the first puncture in the corrected group was 94.4% (34/36), which was higher than that in uncorrected group (77.4%, 65/84). The difference was statistically significant (χ²=5.082, P=0.024). In the corrected group, the ΔP value of the left electrode was smaller (t=-3.507, P=0.001) than that in uncorrected group, while the ΔP value of the right electrode showed no statistical difference (Z=-1.646, P=0.100). The deviation degree of bilateral electrodes in the corrected group were statistically different (P<0.05) when compared with uncorrected group.

The target correction method based on electrode deviation can improve the success rate of the first electrode puncture, reduce the deviation, and has clinical application value in accuracy improvement of DBS electrode implantation.

To investigate the therapeutic effect of spinal cord stimulation (SCS) screening trial on neuropathic pain (NP) and its influencing factors.

A retrospective analysis was conducted on the clinical data of 81 patients with NP who underwent SCS screening trial at Department of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University from January 2012 to December 2019. Bipolar mode was employed in all patients with the frequency of 30-60 Hz, pulse width of 180-260 μs, and voltage of 0.5-2.0 V. The rate of pain improvement was used as an indicator of whether the SCS screening trail was effective and calculated as [preoperative visual analogue scale (VAS) score-postoperative VAS score]/preoperative VAS score ×100%. Univariate and multivariate logistic regression analyses were used to analyze the factors affecting the efficacy of SCS screening trail.

A total of 81 patients were successfully implanted with SCS electrode. The overall postoperative pain relief rate was (45.9±2.9)%. Postoperative VAS score was 4.5 ± 2.5, which was significantly lower than preoperative VAS score (8.3±1.2) (t=13.67, P<0.01). Based on the effectiveness criteria of SCS trial, 45 patients were effective, 36 patients were ineffective, and the effective rate in this series was 55.6% (45/81). Univariate analysis showed that age, gender, duration of illness, preoperative VAS score, etiology, side of pain or degree of hypoesthesia in the pain area was not the influencing factors of efficacy of SCS trial (allP>0.05), while the pain territory was the factor affecting the efficacy of SCS trial (P<0.05). Further multivariate analysis showed that lower limb pain was a positive factor for the efficacy of SCS test (OR=3.14, 95%CI: 1.26-7.83, P=0.013).

The overall effective rate of SCS trial in the treatment of NP seems relatively high. Patients with pain in the limb(s), particularly lower limb(s), may have a better trial outcome.

To investigate the application value of surface-based morphometry (SBM) in preoperative evaluation of refractory epilepsy.

Clinical data of 51 patients with refractory epilepsy admitted to Epilepsy Center, Yuquan Hospital, Tsinghua University from November 2013 to July 2018 were retrospectively analyzed. Fifty-one patients underwent resection or radiofrequency thermo-coagulation of epileptogenic zone with the outcome of Engel Ⅰ assessed at over 6 months post operation. The three-dimensional high-resolution MRI T1-weighed imaging data were analyzed to calculate the proportion of positive results by using three characteristic values of cortical surfaces, i. e. gyrification index (GI), sqrt-transformed sulcus depth (SQ) and thickness (TH), which were obtained by SBM post-procession.

According to imaging characteristics and the scope of resection or radiofrequency thermocoagulation of epileptogenic zone, 51 cases were divided into four groups as follows: 13 cases as MRI negative (MN) group, 27 as MRI positive region coinciding with surgical site (PCS) group, 4 as MRI positive region including surgical site (PIS) group, and 7 as MRI positive region noncompatible with surgical site (PNS) group. PCS group was further divided into three types: 13 cases as mesial temporal lobe epilepsy (PCS-MTLE), 5 as focal cortical dysplasia (PCS-FCD), and 9 as encephalomalacia or malformations of cortical development (PCS-EMCD). With all three characteristic values, the lesion positive proportion were 3/13, 21/27, 2/4 and 1/7 for MN group, PCS group, PIS group and PNS group respectively and 8/13, 4/5 and 9/9 for the three types of PCS patients respectively. Lesion positive proportion by using GI was 4/4 in PIS group and 22/27 in PCS group, which were higher than those obtained by SQ(2/4 and 18/27)and TH(1/4 and 21/27). Lesion positive proportion obtained by SQ in MN was 5/13 and that obtained by TH in PNS group was 3/7, while those by GI in MN group and in PNS group were 3/13 and 2/7 respectively.

The preliminary study suggests that for patients with refractory epilepsy who have distinctive lesions, GI could be used to locate the lesions with a relatively high positive proportion and good display on the margins of lesions. For MRI-negative patients, SQ may be a relatively sensitive target for lesion detection. For patients with incongruent indications from MRI and other clinical measures, TH may be the optimal target for lesion detection.

To investigate the relationship between basal ganglia calcification (BGC) and segmental craniocervical dystonia (SCCD) and to explore the clinical characteristics of SCCD patients with BGC.

The clinical data of 90 SCCD patients (experimental group) admitted to Neurosurgery Department of China-Japan Friendship Hospital from March 2015 to September 2018 were retrospectively analyzed, and the outpatient patients with neurological diseases (including 30 patients with cerebrovascular disease, 18 patients with dementia, 22 patients with cerebral hemorrhage) and 20 healthy subjects were taken as the controls. Chi-square test was used to compare the incidence of BGC between the two groups, and the clinical characteristics of SCCD patients with BGC were analyzed.

The incidence of BGC in the experimental group was 38.9% (35/90), which was higher than that in the control group (18.9%, 17/90). The difference between the two groups was statistically significant (χ²=8.762, P=0.003). The proportion of female SCCD patients with BGC (31/35) was higher than that of SCCD patients without BGC (30/55), and the difference was statistically significant (χ²=11.353, P=0.001). The ratios of BGC in SCCD patients with various clinical manifestations was: 30.3% (10/33) in patients with blepharospasm mainly, 33.3% (13/39) in patients with blepharospasm combined with oral and mandibular dystonia, and 12/18 in patients with neck symptoms in addition to the manifestations as above. The difference between the three groups was statistically significant (P<0.05). At the same time, comparative imaging results showed that BGC in patients with blepharospasm mainly was relatively mild, while that in patients with blepharospasm, oral and mandibular dystonia, and neck symptoms were more serious. The degree of BGC in patients with blepharospasm combined with oral and mandibular dystonia was between the above-mentioned two other types.

BGC may be related to the onset of SCCD. Female patients account for the majority of SCCD patients with BGC. SCCD patients with more involved sites and more complex clinical manifestations have higher positive rate of BGC and more serious calcification.

To investigate the long-term efficacy and its influencing factors of gamma knife radiosurgery in the treatment of drug-refractory trigeminal neuralgia (TN).

A retrospective study was conducted on the clinical data of 293 patients with drug-refractory TN who underwent gamma knife radiosurgery at the Head Gamma Knife Treatment Center, Affiliated Hospital of Inner Mongolia Medical University from January 2009 to September 2019. All patients underwent clinical follow-up post treatment. The content of follow-up included the assessment of pain relief degree, postoperative complications and recurrence. The degree of pain relief was rated according to the Pain Intensity Scale of the Barlow Institute of Neurology (BNI), in which BNI grade Ⅰ-Ⅲb grade indicated effectiveness for pain relief, and grade Ⅳ, Ⅴ was invalid for pain relief. Univariate and multivariate logistic regression analyses were used to determine the risk factors affecting postoperative pain relief and facial numbness.

The median follow-up time of 293 patients was 64 months (6-132 months). At the last follow-up, 270 patients had effective pain relief, and the other 23 had no pain relief; the effective pain relief rate was 92.2% (270/293). Among the 293 patients, facial numbness with crawling sensation was reported in 80 (27.3%) cases after operation, merely crawling sensation in 26 (8.9%), twitching in the corner of eye in 14 (4.8%), and eye foreign body sensation and dryness in 6 (2.0%), tinnitus in 3 (1.0%), severely affected taste in 5 (1.7%), and chewing dysfunction in 4 (1.4%). During the follow-up period, 17 patients (5.8%) reported recurrence. The median time to relapse was 24 months (14-81 months). The results of multivariate logistic regression analysis showed that the existence of previous treatment history was an independent risk factor for postoperative pain relief (OR=3.419, 95%CI: 1.264-9.248, P=0.015). The pain relief rate was higher in the patients who′s radiation dose were 80 Gy compared with those less than 80 Gy(OR=0.252, 95%CI: 0.071~0.888, P=0.032). The existence of previous treatment history (OR=2.533, 95%CI: 1.194-5.373, P=0.015) and vascular compression of nerves (OR=5.865, 95%CI: 2.538-13.556, P<0.001) were independent risk factors for facial numbness after surgery.

The treatment of drug-refractory TN using gamma knife radiosurgery is associated with a relatively high pain relief rate, and the most common postoperative complication is facial numbness. Patients with a history of previous treatment have poorer pain relief and a higher probability of facial numbness after surgery. Patients with a radiation dose of 80 Gy have better pain relief, and those with vascular compression of nerves also have a higher probability of facial numbness after surgery.

To explore the preliminary clinical outcome of endovascular recanalization for symptomatic chronic middle cerebral artery (MCA) occlusion.

From January 2019 to December 2019, 24 patients with symptomatic chronic middle cerebral artery (MCA) occlusion were enrolled into this study and underwent endovascular recanalization at Cerebrovascular Division of Inte-rventional Therapy Center, Zhengzhou University People′s Hospital. We retrospectively analyzed the success rate of recanalization, periprocedural complications and clinical follow-up.

Among 24 patients, recanalization was successful in 20 patients [thrombolysis in cerebral infarction (TICI) grade 2b in 6 patients and 3 grade in 14 patients] and failed in 4 patients. Periprocedural complications occurred in six cases (25.0%). Among the 20 successful patients, periprocedural complications occurred in four cases, including subarachnoid hemorrhage in two cases and hyperperfusion cerebral hemorrhage occurred in one case. Those three patients were treated conservatively whose hematomas were absorbed within 2 weeks after surgery with no remaining neurofunctional deficits. One patient died of sudden cardiac arrest after successful recanalization. Of the 4 patients who failed in recanalization, 1 case had vascular rupture and 1 case had vascular dissection. The follow-up time of 23 patients was 5.0±1.3 months(3-6 months). Among the 20 successful patients, the reocclusion occurred in two patients who suffered from subarachnoid hemorrhage and their ischemic symptoms recured at the follow-up. The rest of patients had no recurrence of ischemic symptoms. Imaging results indicated a restenosis of 42% in one patient and stenosis of ≤10% in four patients. All 4 failed patients had recurrence of ischemic symptoms.

With strict indication criteria, endovascular recanalization of symptomatic chronic MCA occlusion is feasible and relatively safe, which could improve the patient's symptoms in the short term, while there is a risk of reocclusion. Further studies are needed to investigate the long-term efficacy.

To explore the application value of image post-processing technology based on image fusion and three-dimensional surface reconstruction in the treatment of intracranial arteriovenous malformations (AVM).

A total of 21 patients with intracranial AVM underwent surgical treatment at Neurosurgery Department, the First Affiliated Hospital of Soochow University from January 2018 to December 2019 and their clinical data were retrospectively analyzed. All patients underwent the examinations of preoperative CT, 3.0T MRI and 3D-DSA. Multimodal images were then co-registered with software iplan, followed by three-dimensional image reconstruction to generate preoperative models. The location and range of AVM, relationship to eloquent area, and locations of feeding artery and draining vein were evaluated based on the model and compared with intra-operative findings. The AVM was resected under craniotomy microscope. Head MRI and DSA were followed up post operation, as well as the patient’s limb movement, language function and vision.

For all 21 patients, preoperative model reconstruction was successfully made. The location of AVM, eloquent area, feeding artery and draining vein were identified during operation using the model. Comparison could not be performed in one case, because there was no obvious large blood vessel in the operative field, and the hematoma in the brain caused compression on the brain sulcus and unclear shape of the gyri. The rate of consistency between preoperative modeling and intraoperative findings was 95.2% (20/21). Among the 21 patients, total resection was performed in 20 cases and subtotal resection in 1. Of the 5 patients with hemiplegia caused by AVM bleeding before operation, 4 recovered within 3 months. One patient with hemianopsia due to bleeding before operation reported improvement of the visual field at 3 months after operation. Postoperative dysfunction of limb movement was observed in 1 case because of rebleeding after the first surgery who and recovered to normal in 2 weeks. For 21 patients, the follow-up lasted for 15.8±6.7 months (3-25 months) and there was no case of rebleeding. Among the 4 patients with epileptic seizure as the initial symptom, 3 had no seizure after operation and 1 still had seizures within 3 months after surgery. The seizure stopped following the adjustment of antiepileptic drugs.

The technology of image post-processing can help to make an accurate assessment of the position and range of AVM, its relationship to functional area, the location of feeding arteries and drainage veins before surgery, which can improve the total resection rate of AVM and reduce the occurrence of postoperative complications.

To investigate the hemodynamic changes after the submaximal angioplasty in severe stenosis of M1 segment of MCA (middle cerebral artery).

Data from 20 patients with severe stenosis of the M1 segment of MCA who underwent the treatment with Enterprise stent at Cerebrovascular Division of Interventional Therapy Center, Zhengzhou University People′s Hospital from January 2016 to May 2020 were prospectively enrolled into this study. The DSA examination of the skull was performed before and after surgery on all patients. A digital model was established of cerebrovascular rotational DSA data, and a hemodynamic software was used to analyze the wall shear stress (WSS) and total pressure (TP) at the stenosis site, proximal normal segment of artery, distal normal segment of artery and root of the lenticulostriate artery before surgery, after surgery, and after digital stenosis repairing with computer technology. The extent of stenosis was assessed post operation, and the residual stenosis rate <30% was used as standard for successful operation.

The operations were all successful in 20 patients. Immediate postoperative radiography showed that the rate of stenosis decreased significantly (29.9±13.2% vs.86.6±10.0%, t=15.31, P<0.05). The values of WSS at the stenosis and root of the lenticulostriate artery decreased significantly (stenosis: 25.1±4.6 Pavs. 49.0±13.2 Pa, root of the lenticulostriate artery: 1.1±0.2 Pa vs. 3.5±0.4 Pa, P<0.05). However, the values of WSS in proximal and distal normal segments of artery were higher than those before operation (proximal normal segment: 7.2±3.8 Pavs. 3.6±2.6 Pa, distal normal segment: 12.6±5.8 Pa vs. 4.9±2.6 Pa, both P<0.05). The TPs at the stenosis and proximal normal segment of vessel were lower than those before operation (stenosis site: 276.5±86.3 Pavs. 992.6±15.7 Pa, proximal normal segment: 605.4±27.8 Pa vs. 992.6±15.7 Pa, both P<0.05). The TP values at root of the lenticulostriate artery and distal normal segment of artery were higher than those before operation (root of the lenticulostriate artery: 58.2±5.6 Pavs. 2.7±0.3 Pa, distal normal segment: 101.0±43.35 Pa vs. 10.3±4.3 Pa, both P<0.05). However, there was no significant difference between TP and WSS values at the stenosis, proximal and distal segments of artery as well as root of the lenticulostriate artery after submaximal angioplasty and those after stenosis repairing with computer technology (allP>0.05).

In patients with severe stenosis of M1 segment of MCA after the submaximal angioplasty, the hemodynamics parameters at stenosis site, proximal normal segment, distal normal segment and root of the lenticulostriate artery have significant changes compared those before operation and reach an ideal hemodynamic state.

To investigate the method and related anatomy of the endoscopic prelacrimal recess approach to the pterygopalatine fossa and infratemporal fossa and to provide anatomical data for clinical practice.

Eight adult cadaver heads(16 sides) were dissected through the endoscopic prelacrimal recess approach to the pterygopalatine fossa and infratemporal fossa and relevant data were measured and pictures were collected. The uncertain structures and data of endoscopic anatomy were confirmed by simulating the open approach of subtemporal infratemporal fossa under microscope.

The nasolacrimal duct was located in the osseous nasolacrimal duct and open to the inferior meatus. Its length was 14.3±3.6 mm and diameter was 5.3±1.8 mm. The infraorbital nerve and the infraorbital artery formed the infraorbital neurovascular bundle at the infraorbital fissure and ran through the infraorbital canal in the top wall of the maxillary sinus. After the buccal nerve was separated from the mandibular nerve and it passed through the superior and inferior head of the lateral pterygoid muscle and travelled forward between the temporalis muscle and the lateral pterygoid muscle to innervate the buccal muscle.

The key to the prelacrimal recess approach to the pterygopalatine fossa and infratemporal fossa is the exposure and protection of the nasolacrimal duct. The infraorbital neurovascular bundle can be used as a landmark to identify the structure of the pterygopalatine fossa, and the buccal nerve can be used as a landmark to identify the muscles in the infratemporal fossa.

To analyze the expression and significance of protein tyrosine phosphatase non-receptor type 12 (PTPN12) in gliomas based on the Chinese Glioma Genome Atlas (CGGA) and the Cancer Genome Atlas (TCGA) datasets.

We retrospectively analyzed the clinical data and RNA sequencing data of glioma patients in the CGGA dataset (325 cases) and TCGA dataset (636 cases). We measured the different expression levels of PTPN12 in glioma patients with different World Health Organization (WHO) grades, subtypes, isocitrate dehydrogenase(IDH) mutation status and O⁶-meth-ylguanine-DNA methyltransferase(MGMT) promoter methylation status. According to the expression level of PTPN12, the patients were divided into PTPN12 high-expression group and PTPN12 low-expression group. Kaplan-Meier survival curve was used to compare the survival between the two groups. Univariate and multivariate Cox regression analysis were used to determine the prognostic effect of PTPN12 in glioma patients. Gene ontology (GO) function enrichment analysis and the Kyoto Encyclopedia of Genes and Genome (KEGG) pathway enrichment analysis were further used to analyze the related functions and pathways.

In the two datasets, the expression level of PTPN12 increased with the increase of the glioma grade (all P<0.01). The expression level ofPTPN12 in the IDH wild type was elevated compared with the IDH mutant type (all P<0.01). The expression level ofPTPN12 in MGMT promoter unmethylated type was higher than that in MGMT promoter methylated type (all P<0.01). The expression level ofPTPN12 was highest in mesenchymal subtype than the other subtypes (all P<0.01). In the two datasets, the patients with highPTPN12 expression had a shorter survival time than those with low PTPN12 expression (both P<0.01). The results of multivariate Cox regression analysis showed that the expression level ofPTPN12 was an independent prognostic factor of patients with gliomas (CGGA dataset, HR=1.433, 95%CI: 1.094-1.876, P=0.009; TCGA dataset, HR=1.588, 95%CI: 1.018-2.477, P=0.042). GO analysis results showed that the positive related genes with PTPN12 were more enriched in proliferation, apoptosis, adhesion, proteolysis, immune response, angiogenesis, drug response, hypoxia response, tumor cell G₂/M phase transformation, tumor cell G₁/S phase transformation and many other functions related to the malignant progression of glioma. KEGG analysis results showed that the positively related genes with PTPN12 were more enriched in tumor related pathways, PI3K-Akt pathway, MAPK pathway, TNF pathway, HIF-1 pathway, p53 pathway, apoptosis pathway and cell cycle pathway.

PTPN12 expression levels vary in patients with different WHO tumor levels. PTPN12 can be used as an independent prognostic factor for patients with gliomas, and it is associated with multiple functions and pathways related to the malignant progression of gliomas.