Volume 37 · Issue 02 · 2021

Suprasellar arachnoid cysts account for about 10% of intracranial arachnoid cysts and are more common in children^[1,2]。 With the deepening understanding of its origin and pathological mechanism, its treatment strategies and surgical techniques are also constantly improved. At present, the first choice for the treatment of suprasellar arachnoid cyst is neuroendoscopic partial resection of cyst wall through lateral ventriculofrontal approach + cyst-ventriculostomy or cisternostomy; Other surgical methods, including cyst-peritoneal shunt, craniotomy and stereotactically guided cyst fenestration, have been rarely used because of their disadvantages such as high complication rate, large trauma or low efficiency^{[3,4,5,6,7,8,9]}。 However, the incidence of suprasellar arachnoid cyst is low, and some neurosurgeons have insufficient knowledge of its diagnosis and treatment. Therefore, the Neuroendoscopy Professional Committee of Endoscopist Branch of Chinese Medical Physicians Association, the Neuroendoscopy Professional Committee of Neurosurgeon Branch of Chinese Medical Physicians Association, the Neuroprosthetics Professional Committee of Chinese Medical Physicians Association, and the Neurotumor Branch of Chinese Neuroscience Society jointly organized experts to formulate standardized methods and paths for applying neuroendoscopic surgery to treat suprasellar arachnoid cyst, and reached expert consensus to improve the level of neuroendoscopic treatment of suprasellar arachnoid cyst.

To investigate the clinical classification and surgical efficacy of trigeminal schwannomas (TS).

A retrospective analysis was conducted on the clinical data of 51 patients with TS (including those at rare locations and those with maximal diameter ≥6 cm) who underwent surgical treatment at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January 2017 to November 2019. According to MPE classification proposed by Yoshida and Kawase, tumor resection was performed via anterior transpetrous approach in 30 cases, via frontotemporal zygomatic approach in 12 cases, via fronto-orbito zygomatic approach in 4 cases, via retrosigmoid approach in 2 cases, via presigmoid approach in 2 cases and via far-lateral approach in 1 case. Follow-up contents included MRI, newly-developed symptoms and recovery of neurological function.

Among 51 patients, total resection was achieved in 46(90.2%) cases, near-total resection in 4, and subtotal resection in 1. There was no surgery-related death. Among 6 cases of supper-sellar TS, total resection was achieved in 2 cases, near-total resection in 3, and subtotal resection in 1. Among 7 cases with the tumor diameter ≥ 6 cm, total resection was achieved in 6 and tumor-related stroke occurred in 1, and 4 cases underwent skull base reconstruction with free-fat packing and skull base dural suture. All patients were followed up, with an average of 20.2±2.7 months (3-38 months). In 24 patients with preoperative facial numbness, 12(50.0%) reported severe trigeminal nerve palsy during the follow-up. Among the 13(25.5%) cases with newly-developed trigeminal nerve dysfunction after operation, 7 still had mild trigeminal nerve palsy during follow-up. The symptoms related to other cranial nerves improved to some extent after operation, and most postoperative newly-developed neurological dysfunctions recovered during follow-up. Recovery of neurological functions was poor in 6 patients with midline-suprasellar extension subtype.

Although it is rare, the supper-sellar subtype could be an addition to the MPE classification of TS. Its clinical demonstrations are characteristics and total surgical resection is difficult. Therefore, it was advisable to add this subtype to the MEP classification. The surgical effect on the facial numbness seems limited. The functional prognosis of trigeminal nerve is worse in TS patients with preoperative facial numbness.

To explore the clinical features, treatments and outcomes of pediatric diffuse midline gliomas (DMG) with H3 K27M mutation.

A retrospective study was conducted on the clinical data of 10 pediatric patients diagnosed as DMG with H3 K27M mutation who were admitted and treated at Neurosurgery Department of Beijing Children′s Hospital, Capital Medical University between July 2017 and March 2020. Among the 10 children, the location of tumor was at the thalamus in 4 cases, brainstem in 4 cases and spinal cord in 2 cases. All patients underwent surgical treatment, including craniotomy and tumor resection in 7 cases, spinal cord tumor resection in 2 cases and intracranial lesion biopsy in 1 case. Four patients underwent postoperative radiotherapy combined with chemotherapy, 1 underwent radiotherapy alone, and 5 did not undergo radiotherapy or chemotherapy. Subtotal tumor resection is defined as tumor resection rate > 90%. Partial tumor resection is defined as tumor resection rate is between 50% to 90%. Tumor progression, survival time and cause of death were followed up through telephone.

The median age of 10 cases was 8.9 years (4.9-9.9 years) old. The clinical manifestations of intracranial space occupying lesions included headache, nausea, vomiting, limb weakness, epileptic seizure, disturbance of consciousness and cerebral palsy. The clinical manifestation of spinal space occupying lesion was progressive limb weakness. Subtotal tumor resection was achieved in 4 cases, partial tumor resection in 5 cases and biopsy in 1 case.6 patients achieved symptom improvement while 4 patients had no significant change after operation. There was no central nervous system infection.One patient developed hydrocephalus during postoperative radiotherapy. Pathological examinations revealed 10 cases of DMG with H3 K27M mutations (World Health Organization grade Ⅳ). Immunohistochemical test results showed that Olig-2 positive proportion was 9/9, GFAP positive proportion was 10/10, IDH1 mutation positive proportion was 0/9, and the proportion of Ki-67 positive ≥ 40% was 8/10. All 10 cases were effectively followed up after surgery. Until the last follow-up, 2 cases survived and 8 cases died due to tumor progression. The survival time ranged from 1 to 23 months.

Preliminary observation has shown that pediatric DMG with H3 K27M mutation presents a variety of clinical manifestations and could be treated with surgical operation, postoperative radiotherapy and traditional chemotherapy. The survival prognosis of children with DMG seems poor.

To investigate the clinical effect of neuroendoscopic transnasal approach in the treatment of craniopharyngiomas.

A retrospective analysis was conducted on the clinical data of 102 patients with craniopharyngiomas who underwent treatment through endoscopic endonasal approach from October 2018 to April 2020 at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University. There were 82 patients with primary tumors and 20 patients with recurrent tumors. The visual acuity and visual field of the patients were followed up every 3 months. The visual acuity, visual field, the number of pituitary target gland axis injuries and diabetes insipidus were evaluated. The head MRI was reviewed to identify the recurrence and progression of tumor. The degree of tumor resection was evaluated according to the results of MRI at 3 months after operation.

Of the 102 patients, 92 (90.2%) underwent total tumor resection and 10(9.8%) underwent subtotal resection. 77 patients with primary tumors and 15 patients with recurrent tumors underwent total tumor resection. There were 5 cases of cerebrospinal fluid leakage and endoscopic nasal repair and 3 cases of infection of the central nervous system. There was no death or coma. The follow-up time of 102 patients was 12(6-19) months. At the last follow-up, among 96 patients with impaired visual acuity and visual field before operation, 62 cases had significant improvement, 27 cases had stable vision, and 7 cases reported deterioration; among 6 cases with normal preoperative vision, only 1 case had short-term postoperative visual loss, and the visual acuity returned to normal at 3 months after operation. There were 99 cases which were complicated with diabetes insipidus, of which 72 cases had a duration of ≤ 3 months and 27 cases had a duration of > 3 months. At the latest follow-up, there were 73 patients with preoperative pituitary target axis dysfunction who had no improvement after surgery; Of the patients with preoperative normal function of pituitary target axis, 22 reported postoperative pituitary target axis dysfunction. During the follow-up period, no tumor recurrence or progression was identified.

Neuroendoscopic endonasal approach can facilitate the observation of boundaries between tumor and optic nerve, pituitary stalk and hypothalamus, which thus provide clearer surgical field for the surgeons. The total tumor resection rate seems high, and the visual acuity and visual field of some patients are improved. However, the incidence of complications diabetes insipidus and pituitary target gland axis dysfunction might be high.

To explore the clinical efficacy of microsurgery combined with preoperative embolization for solid hemangioblastomas in the posterior cranial fossa.

A total of 13 patients with solid hemangioblastomas in the posterior cranial fossa were admitted to Department of Neurosurgery, Affiliated Cancer Hospital of Zhengzhou University from May 2012 to July 2018 and their clinical data were retrospectively analyzed in this study. All patients underwent preoperative embolization of tumor blood-supplying artery within 72 hours before microsurgery and treatment with gamma knife after operation. The techniques of preoperative embolization and microsurgery were summarized, and the therapeutic effect was analyzed. Karnofsky performance status (KPS) score was used to assess the quality of life of patients on admission and discharge.

The degree of preoperative tumor embolism was >80% in 4 cases, 60%-80% in 8 cases, and <60% in 1 case. One patient developed focal infarction in the brainstem revealed by MRI post embolization and the clinical manifestations included central facial paralysis and aggravated dysphagia. Among 13 patients, total resection of tumor was achieved in 11 cases and subtotal resection in 2. The average intraoperative blood loss was 620±35 ml and the average operative time was 6.5±1.1 h. The symptoms caused by high intracranial pressure were obviously alleviated in all patients after operation. Postoperative newly-developed complications included dysphagia in 2 cases, hearing loss in 1 case and central facial paralysis in 1 case. The KPS score (85.8±4.9 points) at discharge revealed improvement compared with that at admission (76.6±11.3 points) ( t=3.969, P=0.002) in 13 patients. All patients were followed up for 6 months to 3 years, with the median duration of 22.6 months. The KPS score at the last follow-up was 88.1±3.6 points, which was not significantly different from that at discharge (t=2.065, P=0.062). Only 1 patient who underwent subtotal resection reported tumor progression at 9 months post operation and remained stable after second treatment using gamma knife. No recurrence was observed in the remaining 12 cases. Two cases who developed obstructive hydrocephalus underwent ventriculoperitoneal shunting and their symptoms were alleviated.

For solid hemangioblastomas in the posterior fossa, preoperative tumor embolization can effectively reduce intraoperative bleeding so that tumor can be removed by pieces, which may reduce the surgical risk and improve the efficacy.

To explore the clinical effect of microsurgical treatment of hemangioblastoma (HB) in the central nervous system.

The clinical data of 41 HB patients who underwent microsurgery from January 2016 to January 2020 at Department of Neurosurgery, the First Affiliated Hospital of Kunming Medical University were retrospectively analyzed. Three of them were complicated with Von Hippel-Lindau (VHL) syndrome. Before tumor resection, 2 cases underwent ventricular-abdominal shunting; 1 case underwent third ventriculostomy connecting the third ventricle with the interpeduncular cistern; 3 cases underwent partial embolization of the blood supply artery. Intraoperative neuroelectrophysiological monitoring was performed in all patients. Intraoperative real-time ultrasound with preoperative MRI fusion technology was used in 2 cases, and auxiliary neuroendoscopy was employed in 2 cases. The Karnofsky neurological function score (KPS) was used to evaluate the clinical efficacy at 3 months post operation, and the tumor recurrence was followed up by imaging.

Among 41 patients, total resection of tumor was achieved in 40 cases (97.6%) and partial resection in 1 case (2.4%). One patient (2.4%) died of intracranial infection after surgery, and two patients (4.9%) developed severe lung infection. At 3-month follow-up, 30 out of 40 patients (75.0%) had symptomatic improvement, and 10 patients (25.0%) had no significant changes in symptoms compared with preoperative conditions. The KPS score was 79.8±15.3 points, which had significant difference from preoperative score (70.2 ±14.9 points) (P=0.011). MRI examination showed that 4 cases (10.0%) had recurrence in the original location or new lesions in distant regions, of which 3 cases were patients with VHL and underwent radiation treatment resulting in tumor shrinkage on follow-up MRI.

With the combination of multiple techniques, the total resection rate of HB in the central nervous system seems high with low incidence of complications. HB patients with VHL syndrome may have a higher chance of tumor recurrence rate after surgery.

To investigate the surgical outcomes of anterior clinoid meningiomas and to explore the factors affecting whether the tumor can be completely removed.

The clinical data of 145 patients with anterior clinoid meningiomas treated at Department of Neurosurgery, Changzheng Hospital, Navy Military Medical University from June 1996 to June 2020 were retrospectively analyzed. Patients underwent microsurgery via standard pterional approach in 84 cases, via modified pterional approach in 46 cases and via orbitozygomatic approach in 15 cases. The degree of tumor resection was evaluated using the Simpson classification system. The factors influencing the degree of tumor resection were analyzed using univariate and multivariate logistic regression analyses. The improvement of symptoms was evaluated by clinical follow-up, and imaging follow-up was conducted to identify the tumor recurrence.

Among all 145 patients, 98 cases (67.6%) underwent gross total resection (Simpson grade Ⅰ-Ⅲ), and 47 cases (32.4%) underwent partial tumor resection (Simpson grade Ⅳ) or merely decompression (Simpson grade Ⅴ). A total of 121 patients were followed up for 1-24 (7.6±5.2) years. Among the 62 patients with preoperative decreased visual acuity, visual acuity was improved in 32 patients (51.6%), remained unchanged in 25 (40.3%) and decreased in 5 (8.1%) post operation. During follow-up, the recurrence rate was 3.8% (3/78) in patients with gross total resection of tumor and the recurrence or progress rate was 23.3% (10/43) in patients with partial resection.Univariate analysis results showed that the maximum diameter of tumor, invasion of the internal carotid artery and cavernous sinus as well as the decrease of preoperative visual acuity may be related to the extent of tumor resection (all P<0.05). Multivariate logistic regression analysis showed that the maximum tumor diameter (OR=3.21, 95%CI: 1.05-10.39, P<0.01) and the degree of invasion of internal carotid artery and cavernous sinus (OR=7.25, 95%CI: 2.35-21.64, P<0.01) were independent risk factors for total tumor resection. The gross total resection rate was 74.8% (89/119) in the patients with the maximum diameter of tumor ≤ 3 cm and 82.8% (72/87) in patients with the tumor partially surrounding the internal carotid artery or not invading the cavernous sinus.

According to the specific situation, the appropriate surgical strategy can lead to high gross total resection rate and low recurrence rate. Anterior clinoid meningiomas with the maximum diameter ≤ 3 cm and partially surrounding the internal carotid artery or without invasion of the cavernous sinus are more likely to be completely removed.

To investigate the application value of preoperative diffusion tensor imaging (DTI) in localization of facial nerve in acoustic neuroma surgery.

A retrospective analysis was conducted on the clinical data of 17 patients with acoustic neuromas who were treated at Department of Neurosurgery, People's Hospital of Deyang City from May 2017 to October 2019. DTI was used to identify the position of facial nerve before operation, and the results of neuroelectrophysiological monitoring were used as the gold standard. The sensitivity, specificity, accuracy and area under curve (AUC) of DTI were calculated.Kappa consistency test was used to evaluate the consistency between preoperative DTI localization and intraoperative neuroelectrophysiological monitoring of facial nerve.

In all 17 cases, the facial nerve was successfully traced with DTI before operation. Intraoperative was used to map the actual position of facial nerve. In this series, neuroelectrophysiological monitoring was consistent with DTI in 15 cases and not consistent with preoperative DTI description in 2 cases. Out of the 2 cases, intraoperative neuroelectrophysiological monitoring showed that the facial nerve was located in the anterior upper part of the ventral side of the tumor in 1 case, while preoperative DTI showed that the facial nerve was in the upper region of the tumor; and the facial nerve was located in the anterior lower part of the tumor by intraoperative neuroelectrophysiological monitoring in 1 case, while preoperative DTI showed that the facial nerve was located in the lower region of the tumor. The sensitivity, specificity, accuracy and AUC of DTI were 83.3%, 80.0%, 76.5% and 0.900 respectively (P=0.011). The location of facial nerve identified by DTI was consistent with that by intraoperative neuroelectrophysiological monitoring (Kappa=0.734, P<0.01).

Preoperative DTI has a high specificity in the localization of facial nerve during operation of acoustic neuroma, which helps to protect the facial nerve during operation and thus reduce the injury of facial nerve.

To explore the clinical efficacy of resection of dumbbell-shaped intra- and extra-thoracolumbar spinal tumors (DIEST) of Eden type Ⅱ and Ⅲ through one-stage paraspinal approach with two lateral incisions.

A total of 12 cases of DIEST were admitted to Department of Neurosurgery, General Hospital of PLA Eastern Theater Command from August 2013 to April 2019 and retrospectively analyzed in this study. Among them, 5 cases were Eden type Ⅱ 7 were type Ⅲ. According to the McCormick classification, there were 8 cases of levelⅠ, 1 of level Ⅱ, 2 of level Ⅲ, and 1 of level Ⅳ prior to operation. All patients underwent tumor resection through one-stage paraspinal approach with two lateral incisions, and 3 patients underwent internal fixation with pedicle screws. At outpatient follow-up, the patients′ symptom improvement and axial symptoms were assessed, and McCormick classification was used for assessment of therapeutic effect. Whether the patient′s multifidus had atrophy was identified and the fatty infiltration degree was graded as Ⅰ (slight) to Ⅲ (severe).

Total resection was achieved in all 12 cases. Intraoperative iatrogenic destruction of transverse processes occurred in 3 patients. The pathological results revealed 10 cases of schwannoma, 1 case of primitive neuroectodermal tumor and 1 case of melanocytoma. Postoperative urinary infection occurred in 1 case, which was significantly relieved after anti-infection treatment. Based on the McCormick classification system, there were 8 cases of levelⅠ, 1 of level Ⅱ, 2 of level Ⅲ, and 1 of level Ⅳ post operation. The follow-up duration of 12 patients was 32.1±21.7 months (6-62 months). By the last follow-up, 6 cases had improved symptoms, 5 cases had stable symptoms, and 1 case (primitive neuroectodermal tumor) had aggravated symptoms; McCormick level Ⅳ changed to level Ⅲ in 1 case, level Ⅲ to Ⅱ in 1 case, level Ⅲ to Ⅳ in 1 case, while the remaining cases of level Ⅰ and Ⅱ were unchanged; only 1 patient developed symptoms of axial pain; spinal MRI showed that tumor recurrence occurred in 1 patient, all internal fixations were in good position with no loosening, and good bone healing and spinal stability were reported as well. Multifidus atrophy was observed on the affected side in 10 patients, and there were 12 cases of multifidus fatty infiltration of Ⅰ-Ⅱ degrees.

Preliminary observations have shown that surgical operation of DIEST via one-stage paraspinal approach with two lateral incisions is associated with relatively good clinical efficacy and total resection of tumor could be achieved.

To investigate the clinical efficacy and influencing factors of emergency salvage surgery (ESS) for progressive intramedullary spinal cavernomas (ISC).

A retrospective analysis was conducted on the clinical data of 27 patients with progressive ISC including 21 cases admitted to Department of Neurosurgery, Huashan Hospital, Fudan University, 3 cases admitted to Department of Neurosurgery, Huashan Hospital Putuo branch-Shanghai Putuo District People′s Hospital, and 3 cases admitted to Department of Neurosurgery, Huadong Hospital, Fudan university from January 2013 to January 2018.According to the timing of surgery, all patients were divided into two groups: emergency salvage surgery (ESS) group (15 cases)-the time from the first acute onset to surgery <3 d or the most resent onset to surgery <7 d; Non-ESS group (12 cases)-following the usual surgical schedule. All patients underwent clinical follow-up post operation, including reexamination of spinal MRI to determine whether the ISC remained or recurred and assessment of spinal function based on Aminoff-logue scale(mALs). Compared with pre-operation, an increase of ≥ 1 grade was regarded as improvement, no change as stable, and a decrease of ≥ 1 grade as deterioration. The clinical efficacy in the two groups was compared. Univariate and multivariate logistic regression analysis were applied to determine whether ESS was a key clinical factor affecting postoperative recovery of spinal cord function.

The surgery was successfully performed in all 27 patients. The average duration of follow-up was 51.7±19.9 months (12-80 months). No ISC recurrence occurred in this series during follow-up. At the last follow-up, 17 patients showed spinal cord function improvement and 10 were stable. There was no inter-group difference in the clinical factors including gender, age, type of clinical course, family history, segment of lesion, presence of intracranial cavernous malformation or multiple ISC, preoperative mALs score, transverse diameter ratio of lesion and sagittal diameter of lesion (all P>0.05). The onset to surgery in ESS group (3.8±1.9 d) was significantly shorter than that in non-ESS group(10.7±4.7 d) (P<0.05). ESS group had higher proportion of improvement of spinal cord function (13/15) than non-ESS group (4/12) (P<0.05). Multifactor logistic-regression analysis showed that ESS was an independent protecting factor of postoperative spinal cord function recovery (OR=0.077, 95%CI: 0.011-0.521, P=0.009).

ESS may improve spinal function in patients with deteriorated ISC and the time of surgery is a risk factor for postoperative spinal cord function recovery.Compared with conventional surgery, ESS could significantly improve spinal cord function of patients with progressive ISC, which is a positive factor for recovery of spinal cord function.

To preliminarily investigate the surgical method and clinical effect of contralateral seventh cervical nerve transfer in the treatment of central spastic paralysis in the contralateral upper limb.

A retrospective analysis was conducted on six patients with central spastic paralysis in unilateral upper limb underwent contralateral seventh cervical nerve transfer at Department of Neurosurgery, Affiliated Hospital of Binzhou Medical University from November 2018 to March 2019. Postoperative comprehensive rehabilitation treatment was administered for all patients. The change of motor function were evaluated based on Fugl-Meyer (FM) motor function rating scale and Brunnstrom functional recovery stage table. The change of muscle tension was evaluated based on modified Ashworth grading standard (MAS), and motor evoked potential (MEP) was used to evaluate the growth of transferred nerve.

None of the 6 patients had vascular or nerve injury during operation. Transient weakness and numbness to varying degrees were reported in the upper limb on the healthy side, and both recovered at 1 to 3 months post operation. Postoperative follow-up duration was 17.3±1.4 months (15-19 months). The postoperative (at 1 month and 1 year post surgery) scores of FM motor function rating scale and Brunnstrom functional recovery stage table both gradually increased compared with preoperative scores and the differences were statistically significant(all P<0.01). Among the 6 patients, preoperative MEP examination showed no waveforms on the affected side in 5 patients, and waveforms could be induced in all at 1 year post surgery. In 1 patient, the latency and amplitude of preoperative MEP were 29.7 ms and 0.8 mV respectively, and those at 1 year post operation were 22.0 ms and 1.9 mV respectively.

Preliminary clinical observation has suggested that the contralateral seventh cervical nerve transfer is effective with few complications in the treatment of central spastic upper limb paralysis.

To investigate the relationship between the origin of vertebral artery and the height of transverse foramen of cervical vertebra using three-dimensional CT angiography (CTA).

The clinical data of 480 patients who underwent head, neck and upper chest CTA examinations from March 2017 to March 2019 at Department of Neurosurgery, the Second Hospital of Hebei Medical University were retrospectively analyzed. The images were transferred to the image post-processing workstation for bone and vascular reconstruction, and the origin and course of bilateral vertebral arteries and the height of the vertebral arteries entering the cervical vertebrae transverse foramen were documented. Patients with normal origin of the right vertebral artery were divided into groups C₄, C₅, and C₆ according to the height of vertebral artery entering transverse foramen of cervical vertebra. Ten cases were randomly selected from each group to measure the distance from the origin of right vertebral artery to the origin of right common carotid artery (L₁) and to the right thyroid cervical trunk (L₂). We calculated the relative position of the origin of vertebral artery with L1/(L₁+ L₂)×100%.

Among 480 patients, 457 cases (95.2%) had normal origins of bilateral vertebral arteries which were from the subclavian artery, and the other 23 cases (4.8%) had abnormal origins. Among them, the left vertebral artery originated from the aortic arch in 19 cases, and left vertebral artery originated from the left external carotid artery in 1 case; the right vertebral artery originated from the right common carotid artery in 3 cases, all of which were complicated with aberrant right subclavian artery. Among the 480 patients, 405 cases (84.4%) had bilateral vertebral arteries entering the C₆ transverse foramen. The remaining 75 (15.6%) had vertebral arteries entering the cervical transverse foramen with abnormal height, which was observed on the left side in 34 cases (left vertebral arteries entering transverse foramen of C₃, C₄, C₅, C₇ in 1 case, 4 cases, 24 cases and 4 cases respectively, and directly entering the foramen magnum in 1 case) and on the right side in 41 cases (right vertebral artery entering C₃, C₄ and C₅ in 1 case, 14 cases, 26 cases respectively). The height of vertebral artery entering transverse foramen of cervical vertebra was mostly abnormal when the origin of left vertebral artery was abnormal. In patients with abnormal vertebral artery origin, the left vertebral artery originating from the aortic arch accounted for the highest proportion (19/20), and most of the vertebral arteries entered the transverse foramen of cervical vertebra with abnormal height (18/19). The right vertebral artery originating from the right common carotid artery were complicated with aberrant right subclavian artery (3/3), and the height of vertebral artery entering transverse foramen of cervical vertebra was abnormal (3/3). In patients with normal vertebral artery origin, 96.7% (445/460) of left vertebral artery entered transverse foramen of cervical vertebra with normal height, and 92.0% (439/477) of the right vertebral artery entered transverse foramen of cervical vertebra with normal height. Comparison of patients with normal right vertebral artery origin in the 3 groups showed statistically significant differences in the relative position of the vertebral artery origin (C₄ group: 24.3±2.1 %, C₅ group: 47.9±6.6 %, and C₆ group: 77.7±1.7 %, H=20.178, P<0.001).

In case of abnormal origins of vertebral arteries, the heights of vertebral arteries at the transverse foramen of cervical vertebra are mostly abnormal. When the relative position of origin of right vertebral artery is closer to the right common carotid artery, the height of right vertebral artery at the transverse foramen of cervical vertebra seems higher. When the relative origin of right vertebral artery is closer to the right thyroid cervical trunk, the height of right vertebral artery at the transverse foramen of cervical vertebra seems lower.

To investigate the risk factors for post-traumatic hydrocephalus (PTH) after decompressive craniectomy (DC) in patients with severe traumatic brain injury (sTBI).

A retrospective study was performed on the clinical data of 349 patients with sTBI who were admitted to Department of Neurosurgery, the 904^th Hospital of the Joint Logistic Support Force of PLA and underwent DC between January 2013 and December 2018. The follow-up duration was ≥6 months. The onset time of PTH post DC was documented. The factors including gender, age, high blood pressure and diabetes, Glasgow coma scale (GCS) on admission, open injury, cerebral hernia, injury type and injury site, Fisher scale, intraventricular hemorrhage, midline shift, bilateral DC, intraventricular external drainage, duration of coma , transcalvarial brain herniation and subdural hygroma site were analyzed using univariate analysis. Factors with statistically significant differences were incorporated into multivariate logistic regression analysis to identify the risk factors related to the development of PTH.

At 6-month follow-up post operation, 103 (29.5%) of all 349 patients developed PTH. Among those 103 patients, 91 (88.3%) developed PTH at 0 to 3 months post operation. The incidence of PTH was the highest at 1 to 2 months post operation; 48 cases developed PTH during that period and accounted for 46.6%. Compared with 246 patients in the non-PTH group, 103 patients in the PTH group had lower GCS on admission, higher preoperative Fisher scale, and higher proportion of bilateral DC. PTH group was associated with higher incidences of transcalvarial brain herniation, intracranial infection, coma duration > 30 days, contralateral, bilateral and interhemispheric subdural hygroma compared with non-PTH group (all P<0.05). There were no statistically significant differences in other factors between two groups (allP>0.05). Multivariate logistic regression analysis indicated that coma duration > 30 d (OR=3.640, 95%CI: 1.956-6.772), bilateral (OR=3.995, 95%CI: 1.612-9.901) and interhemispheric subdural hygroma (OR=5.324, 95%CI: 2.310-12.271) were risk factors for PTH (all P<0.001).

The peak incidence of PTH occurs at 1-2 months post DC. Postoperative coma duration > 30 d, bilateral and interhemispheric subdural hygroma are risk factors for PTH.

To investigate the clinical efficacy of long-term continuous drainage (LCD) in treatment of ipsilateral tension subdural effusion (SE) after decompressive craniectomy (DC) in patients with severe traumatic brain injury (sTBI).

A retrospective analysis was conducted on the clinical data of 14 patients with sTBI who developed ipsilateral tension SE after DC (accounting for 19.7% of 71 sTBI patients admitted during the same period)and admitted to Department of Neurosurgery, Shenzhen Second People′s Hospital from January 2014 to January 2019. Among them, 7 patients admitted from January 2014 to August 2017 were treated with traditional methods (TT group), and 7 patients admitted from September 2017 to January 2019 were treated with LCD (LCD group). Time of SE onset post operation, treatment effects, postoperative complications were compared between the two groups. All patients were followed up for 1 year.

Fourteen sTBI patients developed tension SE at a mean time of 15.6±7.1 days after DC. The median time of disappearance of tension SE in LCD group and TT group were 21.0 d(interquartile: 6.0 d)and 69.0 d (interquartile: 65.3 d) respectively. There was significant difference between those two groups (P=0.002). In 14 patients, tension SE disappeared after treatment. There was no recurrence or intracranial infection. Nine patients developed hydrocephalus after treatment of tension SE and included 5 patients in TT group and 4 patients in LCD group. Poor wound healing was observed in 3 cases including 1 case in LCD group and 2 cases in TT group.

LCD is an effective treatment for sTBI patients with ipsilateral tension SE after DC, which can eliminate SE as soon as possible, reduce the complications such as poor wound healing, improve the cerebrospinal fluid circulation and thus facilitate the patient’s recovery.

To explore the influencing factors of secondary cerebral infarction of craniocerebral trauma in the sub-plateau area.

A retrospective analysis was conducted on the clinical data of 260 patients with craniocerebral trauma admitted to Department of Neurosurgery, the First People's Hospital of Honghe County from September 2013 to February 2018. The cerebral infarction was diagnosed based on the patient's head CT or MRI results. At discharge and outpatient follow-up, the Glasgow Outcome Scale (GOS) was used for outcome assessment: grade Ⅳ-Ⅴ for good outcomes and grade Ⅰ-Ⅲ for poor outcomes. Univariate and multivariate logistic regression analysis were used to determine the influencing factors of secondary cerebral infarction caused by craniocerebral trauma.

Among 260 patients, there were 13 cases (5.0%) of secondary cerebral infarction including 7 cases (2.7%) of large-area cerebral infarction. At discharge from hospital, the assessment results based on GOS for 13 cases of secondary cerebral infarction were grade Ⅴ in 3 cases, grade Ⅳ in 1 case, grade Ⅲ in 5 case and grade Ⅰ in 4 cases .The follow-up duration of 9 patients was 6-12 months. At follow-up, 6 cases had good outcomes and 3 had poor outcomes. The results of univariate analysis showed that brain herniation, coma and surgical treatment at admission were the influencing factors of secondary cerebral infarction of craniocerebral trauma in the sub-plateau area (all P<0.05). There were no statistically significant differences in factors such as gender, age, cause of injury, craniocerebral trauma, comorbid underlying diseases at admission, intracranial infection, hemoglobin (Hb) ≥ 160 g/L or Hb <110 g/L at admission (allP>0.05); multivariate logistic regression analysis showed that coma at admission was a risk factor for secondary cerebral infarction (OR=4.818, 95%CI: 1.225-18.954, P=0.024).

Patients with craniocerebral trauma in the sub-plateau area who are comatose at admission have an increased risk of secondary cerebral infarction.

To establish the U251 glioma polyploidy giant cells (GPGCs) and to study their characteristic of temozolomide (TMZ) resistance in vitro.

We obtained the U251 glioma cells carrying EGFP and mCherry glioma markers respectively by lentivirus infection, acquired the GPGCs by phytohemagglutinin-polyethylene glycol (PHA-PEG) fusion methods, and obtained the fusion cell clones by fluorescence activated cell sorting (FACS). DNA content was detected by PI staining and flow cytometry analysis. We evaluated the cell proliferation rate and cell survival rate under TMZ (temozolomide) by CCK-8 method.

U251 glioma cells carrying EGFP or mCherry marker were firstly obtained. The fusion rate was significantly increased (from <1% to >5%) by the PHA-PEG fusion method compared to PEG fusion method. Then the U251 GPGCs were successfully acquired. DNA content of the U251 GPGCs was transfected from 2 N/4 N to 4 N/8 N. The proliferation rates of the U251 cells were (99.5±2.6)%, (236.7±4.7)%, (348.9±8.8)%, (656.5±18.5)% and (715.7±48.2)% respectively at 1 d, 2 d, 3 d, 4 d and 5 d after cell implantation, while the proliferation rates of the U251-C1 cells were (100.6±2.1)%, (114.5±1.3)%, (138.4±1.7)%, (316.7±23.1)% and (347.7±13.1)%, and the proliferation rates of the U251-C2 cells were (100.3±1.2)%, (114.7±1.2)%, (186.4±0.6)%, (307.1±9.5)% and (432.9 ± 37.7)% respectively at 1 d, 2 d, 3 d, 4 d and 5 d after cell implantation. The proliferation rate of the U251 GPGCs was significantly decreased compared to U251 cells(all P<0.05). The survival rate of the TMZ group was significantly decreased compared to control group (allP<0.01), while the survival rate of the U251 PGCCs group was significantly increased compared to U251 group (allP<0.01).

The U251 GPGCs model could be successfully established using the phytohemagglutinin-polyethylene glycol (PHA-PEG) fusion methods. GPGCs may play important roles in the TMZ resistance of gliomas.