Volume 37 · Issue 03 · 2021

To investigate the efficacy and complications of Pipeline embolization device (PED) in the treatment of recurrent intracranial aneurysms.

A retrospective analysis was conducted on the clinical data of 14 patients with recurrent intracranial aneurysms who were treated with PED at Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University from January 2016 to April 2019. Of the 14 patients, 10 were treated with PED alone, and 4 with PED combined with coils. All patients were followed up, the outcome was evaluated according to the modified Rankin Scale (mRS), and the embolization outcome of aneurysm was evaluated by imaging [digital subtraction angiography(DSA)] follow-up.

Fifteen PEDs were successfully implanted in 14 patients. All PEDs were positioned in place. DSA examination immediately after the procedure showed that the blood flow in the aneurysms was retained and the branches of the parent vessel were unobstructed. Dyna CT examination showed that the stents covered the neck of the aneurysm accurately and were anchored well. Postprocedural complications occurred in 2 patients, including 1 case of cerebral infarction, which recovered after antiplatelet aggregation therapy, and 1 case died after midbrain hemorrhage. All 13 surviving patients were followed up for a median period of 21.0 months (range: 12-48 months). There was no cerebral hemorrhage or cerebral infarction, and no new neurological deficits were reported. The mRS scores of all patients were 0 at the latest follow-up. Eleven patients were followed up for a median of 6 months (range: 3-16 months). Complete embolization of aneurysm was achieved in 8 patients, including 1 case of aneurysmal recurrence after coil embolization alone, 3 cases of recurrence after surgical clipping, 3 cases of recurrence after stent-assisted coil embolization and 1 case of recurrence after stent implantation. Residual of aneurysm neck was reported in 2 cases, both of which had recurrence after stent-assisted coil embolization. Residual of the aneurysm body was reported in 1 case of recurrence after stent-assisted coil embolization.

The treatment outcome with PED in patients with recurrent aneurysms after coil embolization or surgical clipping seems good, while the efficacy of PED in the treatment of recurrent aneurysms after stent implantation remains to be further verified.

To evaluate the efficacy of mechanical thrombectomy for patients with different types of basilar artery (BA) occlusions.

A retrospective analysis was conducted on the clinical data of 95 consecutively enrolled patients with BA occlusions. All those patients underwent endovascular treatment at the Center of Cerebrovascular Diseases, Changhai Hospital, Naval Medical University from September 2013 to September 2019. According to whether the occlusion was of the tandem type or not, all 95 cases were divided into the non-tandem occlusion group (67 cases) and the tandem occlusion group (28 cases). Comparisons of the proportions of successful recanalization [modified thrombolysis in cerebral infarction (mTICI) score of 2b-3] and good outcomes [modified Rankin Scale (mRS) of 0-3] at 90 d, intraoperative rescue measures and the incidence of adverse events between the two groups were conducted.

Compared with the non-tandem occlusion group, patients in the tandem occlusion group had lower ages (P=0.002), higher ratio of male (P=0.009) and smoking history (P=0.014), higher proportions of the large artery atherosclerosis of TOAST (P=0.001) and unilateral vertebral artery hypoplasia (P=0.036). There were no significant differences between the two groups in the scores of National Institutes of Health Stroke Scale (NIHSS) prior to operation and then at 24 h post operation, time period from the puncture of femoral artery to the reperfusion of BA, ratios of successful recanalization or good outcomes (all P>0.05). Both onset-to-triage time and onset-to-reperfusion time were longer in the tandem occlusion group than those in the non-tandem occlusion group (P=0.049, P=0.046). Furthermore, the proportions of intraoperative rescue measures, including balloon dilatation alone, emergency stent implantation and intravenous administration of tirofiban, were higher in the tandem occlusion group than non-tandem occlusion group (all P<0.05). No significant differences were found between the two groups in the incidence of the procedure-associated adverse events or mortality (bothP>0.05).

No differences have been noted in the clinical outcomes or adverse events between the patients of different types of BA occlusions who undergo mechanical thrombectomy. Nevertheless, studies with large sample size and randomized controlled trials are required to confirm the findings.

To explore the safety and efficacy of endovascular mechanical thrombectomy in treatment of acute anterior circulation large vessel occlusive stroke (AACLVOS) of patients with the Alberta Stroke Program Early CT Score (ASPECTS) <6.

A retrospective study was conducted on the clinical data of a total of 30 patients with AACLVOS and baseline ASPECTS <6 who underwent mechanical thrombectomy at Department of Neurosurgery, Beijing Hospital from July 2015 to January 2020. The median preoperative National Institute of Health stroke scale (NIHSS) score was 17 (range: 7-37), and the average ASPECTS was 3.8±1.0. Preoperative DSA demonstrated that the occlusion sites were MCA in 13 cases (M1 segment in 11 cases and M2 segment in 2), ICA in 13 cases, and tandem occlusion of ICA and MCA in 4 cases. Successful recanalization was defined by a modified thrombolysis in cerebral infarction (mTICI) score of 2b-3 assessed at the end of the procedure. Hemorrhagic transformation was graded according to the European Cooperative Acute Stroke Study Ⅱ, and the safety of endovascular treatment was evaluated according to the incidence of type Ⅱ parenchymal hematoma. Follow-up was conducted at 90 days post operation through outpatient clinic visits or telephone enquiry, and a favorable neurological outcome was defined as an mRS (modified Rankin scale) score of 0-2, while a poor outcome was defined as an mRS score of 3-6.

Successful recanalization was achieved in 24 patients (24/30, 80.0%). Two patients (2/30, 6.7%) had type Ⅱ parenchymal hematomas after the procedure. At 90-day clinical follow-up, ten patients (10/30, 33.3%) achieved favorable outcomes, including 9 re-perfused patients (9/24, 37.5%) and 1 non-perfused patient (1/6). Ten patients (10/30, 33.3%) died, including 7 re-perfused patients (7/24, 29.2%) and 3 non-perfused patients (3/6). For patients with baseline ASPECTS of 3-5, the rate of 90-day favorable outcome was 37.0% (10/27)and the mortality rate was 25.9% (7/27). For patients with baseline ASPECTS of 0-2, the proportion of favorable outcome was 0/3 and the mortality rate was 3/3.

Preliminary observational study has demonstrated that mechanical thrombectomy in patients with AACLVOS and baseline ASPECTS of 3-5 may be relatively safe and effective, while the outcome may remain poor in those with baseline ASPECTS of 0-2.

The aim of the study was to preliminarily determine the role of preoperative high-resolution magnetic resonance imaging vessel wall imaging (HRMR-VWI) in endovascular treatment of severe symptomatic basilar artery (BA) stenosis.

The clinical data of 15 patients with severe symptomatic BA stenosis (≥70% stenosis) who were admitted to Department of Neurointervention, Beijing Anzhen Hospital, Capital Medical University from April 2019 to April 2020 were retrospectively analyzed. All patients underwent HRMR-VWI prior to operation for assessment of the site of atherosclerotic plaques, vulnerability of plaques, and their relationship with major branch arteries. Among the 15 patients, 2 cases underwent balloon dilatation alone and 13 cases underwent balloon dilatation combined with stenting. The perioperative complications, mortality, the modified Rankin Scale (mRS), and adverse events were clinically followed up. Restenosis of BA was assessed by imaging follow-up.

The results of preoperative HRMR-VWI of 15 patients indicated that the atherosclerotic plaques were located on the dorsal side of BA in 9 cases, ventral side in 2, on the left-side wall in 7, and right-side wall in 6. Vulnerable plaques were identified in 4 cases. The atherosclerotic plaques were adjacent to the left anterior inferior cerebellar artery in 2 patients, and located at the lower segment of BA and the junction of bilateral vertebral arteries in 5 patients. Within 30 days post operation, 1 transient ischemic attack was reported in 1 patient and no hemorrhagic stroke or death occurred in 15 patients. All 15 patients were clinically followed up for a median of 7.5 months (range: 5.0-9.0 months) and there was no stroke or death. The median mRS score at the latest follow-up was 1 point (range: 0-1 point). Eight patients underwent imaging follow-up at 6 months post operation, out of whom 1 patient reported the restenosis of 50% and 7 did not have the restenosis of ≥50%.

This preliminary study has suggested that for the treatment of severe symptomatic BA stenosis, HRMR-VWI could be used to assess the location and vulnerability of stenotic plaques, as well as their relationship with major branch arteries. Moreover, it is helpful to increase the safety of endovascular treatment before operation.

To explore the safety and efficacy of endovascular treatment for cavernous sinus dural arteriovenous fistulas (DAVFs) via femoral vein (FeV)-facial vein (FV)-superior ophthalmic vein (SOV) approach.

From January 2013 to November 2019, 15 patients with cavernous sinus DAVFs were admitted to Department of Neurosurgery, General Hospital of Ningxia Medical University and their clinical data were retrospectively analyzed in this study. All patients were treated with Onyx-18 combined with coil embolization via FeV-FV-SOV approach. Digital subtraction angiography (DSA) was performed to observe the immediate postoperative effect of embolization. The outcomes of 15 patients were evaluated by clinical and imaging follow-up.

Immediate postoperative DSA results indicated that the fistulas were completely embolized in all 15 patients. During operation, 2 cases developed subarachnoid hemorrhage and 2 patients had transient reflex bradycardia (including one case of subarachnoid hemorrhage). No intraoperative adverse events were reported in the remaining 12 cases. Fifteen patients were followed up for 1 year. Preoperative clinical symptoms disappeared in 12 cases and their DSA results showed no recurrence of DAVF except for 1 case. In that case, the clinical symptoms recurred at 14 days post operation and complete embolization was achieved through a second operation via the inferior petrosal sinus approach. The remaining 3 patients underwent merely clinical follow-up. The visual acuity of 2 cases had no significant improvement, and 1 case had abducens nerve palsy, while the other clinical symptoms resolved.

Endovascular embolization of cavernous sinus DAVF via FeV-FV-SOV approach can lead to a favorable outcome with few complications.

To explore the influencing factors of postoperative complications and efficacy of combined cerebral revascularization for the treatment of moyamoya disease (MMD) in adults.

A retrospective analysis was conducted about the clinical data of 370 adult patients with moyamoya disease who underwent combined cerebral revascularization (superficial temporal artery-middle cerebral artery anastomosis + encepho-duro-myo-synangiosis) at Department of Neurosurgery, Henan Provincial People′s Hospital from January 2017 to June 2019. The incidence of neurological complications after unilateral operation was observed, and the risk factors of postoperative complications were analyzed by univariate and multivariate logistic regression analyses. The clinical efficacy of the patients was evaluated based on the modified Rankin Scale (mRS), and the cerebral blood flow reconstruction was evaluated according to the Matsushima score standard based on digital subtraction angiography(DSA) results.

All 370 patients underwent successful operation, and 75 cases (20.3%) developed neurological complications after operation, including 6 cases of cerebral hemorrhage, 12 cases of cerebral infarction, 2 cases of subarachnoid hemorrhage, 29 cases of transient neurological defect and 26 cases of epilepsy. The outcomes of 15 patients were poor(mRS 3-6 points), of which 2 patients died. Multivariate logistic regression analysis showed that the development of TIA as the first symptom before operation (OR=2.616, 95%CI: 1.442-4.744, P=0.002), comorbidity with essential hypertension (OR=2.308, 95%CI: 1.326-4.015, P=0.003), and preoperative mRS of 3-5 points (OR=2.371, 95%CI: 1.236-4.547, P=0.009) were risk factors for postoperative complications. The follow-up time of 370 patients was 15.6±5.3 months (6-32 months). The median mRS at the last follow-up was 1 point (P₂₅: 1 point; P₇₅: 2 points), which was significantly different from preoperative mRS (median: 2 points; P₂₅: 1 point; P₇₅: 2 points) (P<0.01). A total of 362 patients underwent DSA examination. Among them, grade 0 was reported in 12 cases, grade 1 in 121 cases, grade 2 in 198 cases, and grade 3 in 31 cases.

The development of TIA as the first symptom before operation, comorbidity with essential hypertension, and the preoperative mRS 3-5 points are risk factors for postoperative complications of combined cerebral revascularization for the treatment of adult moyamoya disease. The cerebral blood flow in most of those patients could be improved to some extent after operation.

To discuss the method and strategy of microsurgical treatment for basilar apex aneurysms (BAA).

A retrospective study was conducted on the clinical data of 55 patients with BAA who were treated with microsurgery at Department of Neurosurgery, Tianjin Huanhu Hospital from January 2010 to January 2020. Based on the size, direction, and relationship of the aneurysm neck to posterior clinoid process, different surgical approaches were employed and included pterional approach in 25 cases, orbito-zygomatic approach in 5 cases, subtemporal approach in 19 cases and pretemporal transzygomatic transcavernous approach in 6 cases. Modified Rankin Scale (mRS) was used to evaluate the outcomes during the follow-up period. Computerized tomography angiography (CTA) was performed to assess the effect of surgical clipping.

Of all 55 patients, the aneurysm was completely clipped in 46(83.6%) and partially clipped in 9. The operation duration was 4.4±1.1 h (2.8-7.1 h). Eleven patients developed symptoms of ischemia after surgery, of which one died. Twenty-one patients developed oculomotor nerve palsy. Four patients underwent ventriculoperitoneal shunting due to hydrocephalus. A total of 42 patients underwent follow-up. The median follow-up duration was 4.7 years (0.8-9.7 years). Follow-up at 6 months post operation showed that the mRS score was 0 in 32 cases, 1 in 4 cases, 2 in 2 cases, 3 in 2 cases, 4 in 1 case, and 6 in 1 case. Imaging follow-up with CTA indicated that aneurysms clipped completely had no recurrence and all the associated arteries were unobstructed. No obvious enlargement of aneurysm was reported which had been partially clipped.

Microsurgical clipping remains to be a major therapeutic option for BAA. Patients with BAA could achieve satisfactory results via individualized selection of microsurgical approaches.

To establish the risk prediction model of deep venous thrombosis (DVT) in the lower extremities and to evaluate and prevent the lower extremity DVT of patients with hemorrhagic stroke.

Using the convenience sampling method, we collected the clinical data of 547 patients with hemorrhagic stroke who were admitted to the Intensive Care Unit, Department of Neurosurgery, General Hospital of Tianjin Medical University from July 2018 to July 2020. Among 547 patients, 447 were divided into the modeling group and 100 cases into the external verification group. The lower extremity DVT was diagnosed with the color Doppler ultrasound. Univariate and multivariate logistic regression analysis were applied to explore the risk factors of lower extremity DVT and construct the lower extremity DVT risk prediction model. The receiver operating characteristic curve was drawn and the area under the curve (AUC) was calculated. The goodness of fit test of Hosmer-Lemeshow was used to evaluate the effectiveness of the risk prediction model. The external validation data were used to test the sensitivity, specificity and consistency rate of the risk prediction model.

Among the 447 cases in the modeling group, 112 cases (25.1%) developed the lower extremity DVT. Univariate logistic regression analysis showed that age, general anesthetic operation, sedative and analgesic drugs, physical cooling with cooling blanket, GCS, history of diabetes, history of hypertension, muscle strength classification of lower limbs and plasma D-Dimer level were the influencing factors of DVT in patients with hemorrhagic stroke (all P<0.05). Further multivariate logistic regression analysis showed that age (OR=1.063, 95%CI: 1.036-1.092, P<0.001), use of sedative and analgesic drugs (OR=5.115, 95%CI: 2.620-9.986, P<0.001), physical cooling with cooling blanket (OR=34.991, 95%CI: 14.009-87.396, P<0.001), history of hypertension (OR=2.671, 95%CI: 1.275-5.594, P=0.009) and plasma D-Dimer level (OR=7.026, 95%CI: 3.324-14.851, P<0.001) were risk factors of lower extremity DVT in patients with acute hemorrhagic stroke. The test results of risk prediction model showed that the P value was 0.648, AUC value was 0.912, maximum value of Yoden index was 0.714, corresponding sensitivity was 91.4%, specificity was 80.0%, and cut-off value was 0.226. The results of the external validation showed that the predictive sensitivity was 91.4%, the specificity was 80.0%, and the consistency index was 0.84.

The lower extremity DVT risk prediction model developed in this study is simple with good sensitivity and high specificity. It could provide reference for risk assessment, prevention and treatment of lower extremity DVT in patients with hemorrhagic stroke.

To investigate the clinical application of preoperative precise localization in neuroendoscopic surgery for spontaneous basal ganglia hemorrhage (SBGH).

The clinical data of 50 patients with SBGH treated with neurosurgery at Department of Neurosurgery, Southern Hospital of Fujian Provincial Hospital from May 2015 to May 2019 were retrospectively analyzed. Among them, 25 cases underwent neuroendoscopic surgery following precise preoperative positioning (referred to as neuroendoscopic group) and 25 cases were treated with traditional craniotomy microsurgery (referred to as craniotomy group). The operative conditions (including operation time, intraoperative blood loss and hematoma clearance rate), National Institutes of Health Stroke Scale (NIHSS) score, incidence of postoperative complications, length of hospital stay and Glasgow Outcome Scale (GOS) scores in the two groups were analyzed and compared.

There were no significant differences in gender, age, time from onset to operation, intraoperative blood loss or preoperative NIHSS score between the two groups (all P>0.05). In the neuroendoscopy group and craniotomy group, the operation time durations were 1.8±0.2 h and 2.4±0.3 h respectively; the intraoperative blood losses were 60.1±5.0 ml and 90.1±7.1 ml respectively; the hematoma clearance rates were (95.4±4.8)% and (80.4±8.7)% respectively; those differences between the two groups were statistically significant (allP<0.001). The NIHSS scores in the two groups at 1 week post operation were lower than those before operation (bothP<0.001). The NIHSS scores in the neuroendoscopy group and craniotomy group were 12.0±2.4 points and 14.2±2.1 points respectively, and there was no significant difference between the two groups (P>0.05). In the neuroendoscopy and craniotomy groups, the hospitalization durations were 12.0±1.2 d and 14.1±1.0 d respectively, and the difference between the two groups was statistically significant (P<0.001). There was no significant difference in the incidence of postoperative complications or GOS score at 6 months post operation between the two groups (bothP>0.05).

For SBGH, neuroendoscopic surgery performed following precise preoperative localization could shorten the operation duration, reduce intraoperative blood loss and improve the hematoma clearance rate.

To preliminarily explore the clinical efficacy of microsurgery for trigeminal schwannomas with intra-extracranial extension via extended middle cranial fossa extradural approach.

A retrospective analysis was conducted on the clinical data of 10 patients of trigeminal schwannomas with intra-extracranial extension via extended middle cranial fossa extradural approach admitted to Department of Neurosurgery, Shiyan Taihe Hospital from January 2013 to December 2019. The maximum diameter of tumors in 10 patients was 3.0-7.5 cm. The tumors broke through the middle skull base and grew into the infratemporal fossa in 7 cases, protruded into the pterygomaxillary fossa in 3 cases, and invaded into the posterior fossa in 2 cases. The middle cranial fossa and petrous apex in 10 patients were destroyed to varying degrees, the petrous segment of internal carotid artery was wrapped in 2 cases, and the cavernous segment of internal carotid artery was wrapped by tumor in 3 cases. All cases were treated by microsurgery via extended middle cranial fossa epidural approach, and the cranial CT and MRI were reexamined within 1 week after operation. The tumor resection rate of 100% showed on MRI was considered as total resection, ≥90% and <100% as subtotal resection, and <90% as partial resection. Regular clinical visits and telephone follow-up were conducted. The follow-up included evaluation of the patients′ functional status after surgery and reexamination of head MRI for detection of tumor recurrence.

Of the 10 patients, total resection was achieved in 8 cases, subtotal resection in 1, and partial resection in 1 case. Subcutaneous effusion occurred in 2 cases, intracranial infection in 1, and all those complications were resolved before discharge. Postoperative newly-developed facial numbness on the operation side was reported in 6 cases, oculomotor nerve palsy in 2, ipsilateral masseter muscle weakness with varying degrees in 6. There was no case of intracranial hemorrhage or cerebrospinal fluid leakage. The 10 patients were followed up for an average of 24.7±4.3 months (6 to 50 months). Until the last follow-up, there was no tumor recurrence in 8 cases undergoing total resection and tumor recurrence was reported in 2 cases. The neurological dysfunctions of the patients with postoperative newly-developed symptoms were improved to varying extents.

Preliminary observation has suggested that microsurgeries of trigeminal neurinomas with intra-extracranial extension via extended middle cranial fossa extradural approach are associated with relatively higher rate of complete tumor resection and favorable clinical outcomes.

To screen the genes related to radiotherapy and chemotherapy sensitivity of primary glioblastomas and to construct a prognostic prediction model for primary glioblastomas based on those genes.

A retrospective analysis was conducted on the clinical data and transcriptome sequencing data of 156 patients with primary glioblastomas who underwent standardized radiotherapy and chemotherapy post operation which were obtained from the Chinese Glioma Genome Atlas(CGGA) Project 2019 database (n=102, experimental group) and CGGA database (n=54, validation group). In the experimental group, the differentially expressed genes between tumors of long-term survivors (n=49, overall survival≥18 months) and short-term survivors (n=22, overall survival ≤9 months) were screened out. Subsequently, candidate genes with prognostic values independent of age, tumor isocitrate dehydrogenase (IDH) mutation status, chromosome 1p/19q co-deletion status, and O⁶-methylguanine DNA methyltransferase (MGMT) promoter methylation status were further screened by multivariate Cox regression analysis. A prognostic prediction model was constructed based on the natural logarithm of the hazard ratio of candidate genes. Whether the high-risk group was an independent prognostic factor was tested by univariate and multivariate Cox regression analyses. Kaplan-Meier method was used to draw the survival curve of the high-risk group and low-risk group. The difference in survival curve between high-risk group (>0 point) and low-risk group (≤0 point) was tested by log-rank test. Pearson correlation analysis was used to screen genes that were positively related to risk scores, and functional enrichment analysis was conducted for them.

There were no statistically differences in the gender, age, degree of tumor resection, IDH mutation status, chromosome 1p/19q deletion status, or MGMT promoter methylation status between the long-term survivors and short-term survivors (all P>0.05). Compared with the short-term survivors, the expressions of 9 genes were significantly increased (allP<0.05) and the expressions of 28 genes were significantly decreased (allP<0.05) in the tumors of long-term survivors. Four candidate genes were selected out by multivariate Cox regression analysis method, which wereAKR1C1(HR=0.910, 95%CI: 0.850-0.974, P=0.006), CPZ(HR=0.947, 95%CI: 0.898-0.999, P=0.044), HIST1H3H(HR=1.299, 95%CI: 1.025-1.647, P=0.031) and TBX5 (HR=1.104, 95%CI: 1.034-1.179, P=0.003). The coefficients of the corresponding genes were -0.0947, -0.0547, 0.2624 and 0.0994. In the experimental group and validation groups, the prognostic risk score (high risk) was an independent risk prognostic factor (HR=2.407, 95%CI: 1.470-3.939, P<0.001 in experimental group,HR=2.054, 95%CI: 1.101-3.830, P=0.024 in validation group). In the experimental group and validation group, the high-risk group (n=51 and 22 respectively) had shorter overall survival than low-risk group (n=51 and 32 respectively), and the differences were statistically significant (both P<0.05). In the experimental and validation groups, genes positively related to the prognostic risk score were enriched in biological functions such as cell proliferation, gene epigenetic regulation, DNA repair, and activation of the nuclear factor κB signaling pathway by functional enrichment analysis.

The prognostic prediction model of primary glioblastomas based on genes related to radiotherapy and chemotherapy sensitivity (AKR1C1, CPZ, HIST1H3H and TBX5) could be used to predict the prognosis of primary glioblastoma patients.

To investigate the clinical characteristics, diagnosis and surgical outcomes of ventriculoperitoneal (VP) shunt dysfunction post hydrocephalus surgery in children.

From October 2015 to October 2019, a total of 96 children were admitted to Department of Neurosurgery, Shanghai Children′s Medical Center, School of Medicine, Shanghai Jiaotong University and 5 (5.2%) of whom had vision problems as the primary symptom of VP shunt dysfunction. We retrospectively analyzed the clinical data of those 5 cases. All 5 cases underwent VP shunt within half a year after birth for hydrocephalus. The course of disease ranged from 2 days to 2 year. Replacement of the catheter was performed in 5 children at our department. Outpatient and imaging follow-up were conducted to assess the surgical outcomes.

Among the 5 children, 2 presented with headache and acute vision decline; 3 cases presented with decreased vision, with or without diplopia or strabismus. Preoperative CT results indicated ventricular enlargement in 1 child rather than the remaining 4. Intraoperative X-ray results showed breakage of the shunt catheters in 4 cases and blockage of the catheter in its ventricular end in 1 case. The postoperative follow-up period of 5 patients ranged from 4 to 49 months. Preoperative headache and other symptoms of intracranial hypertension disappeared, while there was no obvious improvement in visual impairment. Three cases of children had optic nerve atrophy.

The incidence of vision decline as the primary symptom of VP shunt dysfunction post hydrocephalus surgery seems low, which has a tendency of being misdiagnosed as simple visual impairment resulting in delayed treatment. Head CT, X-ray of full-length shunt catheters and fundus examination are important examinations for the diagnosis of VP dysfunction. Shunt repair surgery may not work well for the vision loss that has been caused, and the diagnosis should be confirmed as soon as possible. Active surgery may alleviate or avoid further aggravation of vision problems.

To explore the effect of laparoscope-assisted placement of the peritoneal end of the catheters in ventriculoperitoneal (VP) shunt.

This retrospective study was performed on the clinical data of 32 cases with hydrocephalus admitted to Department of Neurosurgery, Peking University Third Hospital from May 2018 to November 2019. All patients were treated with ventriculoperitoneal shunt and the peritoneal ends of the catheters were placed with the assistance of laparoscopes. The results of clinical follow-up were evaluated by using Salmon criteria and Karnofsky performance status score (KPS). The change of hydrocephalus was assessed based on the Evans index during imaging follow-up.

All patients successfully underwent laparoscope-assisted VP shunt. The operation time ranged from 65 to 75 minutes with an average of 70.1±2.9 minutes. The operation time at the abdomen was 16.1±1.5 minutes (range: 14-20 minutes). The length of hospital stay post operation ranged from 6 to 9 days with a median of 7 days. The median length of bed rest was 2 days post operation with the range of 2-3 days. No intracranial infection, cerebrospinal fluid leakage, abdominal organ injury, shunt occlusion or death was reported. One patient developed the symptom of hiccup which was resolved after conservative treatment. The patients were followed up for 3 to 22 months with an average of 12.2±6.1 months. According to the Salmon criteria, grade 3 was reported in 2 cases (6.3%), grade 2 in 18 cases (56.2%) and grade 1 in 12 cases (37.5%). The KPS score of 32 patients improved from an average of 59.1±10.0 points (40-80 points) prior to operation to an average of 77.5±10.8 points (50-100 points) at the latest follow-up with significant difference (t=-13.826, P<0.001). There was also significant difference between postoperative Evans score (median: 0.29, quartile: 0.04) and preoperative Evans score (median: 0.36, quartile: 0.02) (Z=-4.961, P<0.001).

Laparoscopically assisted VP shunt has the advantages of being minimally invasive and accurate, which can help to accelerate postoperative recovery and reduce the incidences of abdominal catheter blockage, abdominal complications as well as infections.

To evaluate the effect of transnasal endoscopic continuous dural suturing for closure of high-flow cerebrospinal fluid (CSF) leakage post intracranial tumor resection.

A retrospective study was conducted on the clinical data of 106 patients who underwent transnasal endoscopic resection of intracranial tumors from July 2018 to January 2020 at Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University. All patients developed interoperative high-flow CSF leakage (Esposito grade 3) during operation. Among them, continuous dural suturing was performed for closure of CSF leakage in 48 patients who were categorized into the suturing group, while continuous dural suturing was not performed in 58 patients who were divided into the non-suturing group. The time spent in closure of CSF leakage, occurrence of postoperative CSF leakage and other complications were compared between the two groups.

The time spent for closure of CSF leakage in the suturing group was longer than that in the non-suturing group (63.0±7.5 min vs. 31.0±6.2 min), and the difference was significant (P<0.01). 2.1%(1/48)in the suturing group developed postoperative CSF leakage, and the proportion was significantly lower than that in the non-suturing group in which 19.0%(11/58) reported postoperative CSF leakage (P<0.05). There were 4.2%(2/48) of intracranial infection in the suturing group and 8.6%(5/58) of intracranial infection in the non-suturing group. The difference was not significant (P=0.599). There was no significant difference in the rate of lumbar drainage, second operation or the incidence of severe electrolyte disturbance between the two groups (all P>0.05). The follow-up duration was 6-12 months. Among 12 patients developing postoperative CSF leakage, one patient in the non-suturing group had recurrent craniopharyngioma and died because of severe hypothalamic syndrome and intracranial infection, and the remaining 11 patients reported favorable outcomes.

The technique of transnasal endoscopic continuous dural suturing for closure of high-flow CSF leakage post intracranial tumor resection seems to be associated with increased operative duration. However, it could effectively reduce the incidence of postoperative CSF leakage without increasing the incidences of related complications.

To investigate the clinical effect of microvascular decompression (MVD) with polyester pad in the treatment of trigeminal neuralgia (TN) caused by basilar artery (BA).

A retrospective analysis was conducted on the clinical data of 31 patients with TN caused by BA who were admitted to Department of Neurosurgery, Daping Hospital, Army Military Medical University from January 2012 to December 2019. All 31 patients were treated with polyester as the only decompression material during MVD, and no other decompression methods were used. The posterior sigmoid approach was used for MVD to place pads between the brain stem and the offending artery. Surgical outcomes were assessed using the Barrow Neurological Institute (BNI) pain scale.

Of 31 patients, complete pain remission immediately post operation (BNI class Ⅰ) was reported in 27 (87.1%), complete pain remission within 3 months post surgery (BNI class Ⅰ) in 3, and partial pain relief (BNI class Ⅲ) in 1. Five patients (16.1%) developed facial hypoesthesia after surgery, and 3 of them recovered later. One patient presented with progressive hearing loss. The 31 patients were followed up for 6 to 85 months (median: 40 months), and recurrence (BNI class Ⅳ-Ⅴ) was reported in 4 (12.9%) patients during follow-up, of which 2 underwent a second surgery and the other 2 cases were treated with stereotactic radiotherapy combined with medication resulting in partial control of facial pain.

Microvascular decompression with polyester pad alone for TN caused by BA is associated with significant effect immediately post operation, while the recurrence rate and incidence of complications may be high.

To explore the role and mechanism miR-20a/106b in the malignant progression of pediatric brainstem gliomas (BSG).

A total of 13 patients with BSG (13 pediatric and 5 adult patients) who underwent surgical treatment at Department of Neurosurgery, Tianjin Huanhu Hospital(Tianjin Central Hospital for Neurosurgery and Neurology) from January 2012 to December 2017 were retrospectively enrolled into this study. The level of MICA was detected in pediatric and adult BSG tissues by immunostaining. The miRNAs regulating the expression of MICA was screened out by bioinformatics. The human glioma cell lines LN229 and U251 were used to verify the relationship between the selected miRNA and MICA by the luciferase reporter assays, and the expression of MICA following transfection of antisense miR-20a/106b into LN229 and U251 were detected by Western blotting (WB). The lactate dehydrogenase (LDH) release assay was used to detect the cytotoxic activity of immune cells against the LN229 cell line. BSG juvenile (J-rat) and adult (A-rat) models were prepared for regain of function experiments by stereotactic injection of the LN229 cell line into the pontine area of athymic juvenile (3 weeks old) and adult (10 weeks old) male Sprague Dawley rats. Each of those two groups was further divided into 3 subgroups according to the different cell lines injected, which were J-rat, J-rat-scr, J-rat-miR-20a/106b-d and A-rat, A-rat-scr, A-rat-miR-20a/106b-u subgroups with each subgroup containing 3 rats. The expression of MICA in each subgroup was detected by immunohistochemical staining, the invasion of tumors in each subgroup was detected by MCID, and the apoptosis of cells in each subgroup was detected by TUNEL method.

The total positive expression rate of MICA in adult patients was higher than that in children (5/5 vs. 10/13, P<0.05). The screening results showed that there were 23 miRNAs that might regulate MICA, including miR-20a and miR-106b. In the LN229 cell line, the luciferase reporter assay showed that the fluorescence activity of those transfected with wild-type pGL3-MICA plasmid was stronger than those of controls and cells transfected with mutant pGL3-MICA plasmid (bothP<0.05). WB results showed that, compared with the sham control group and the nonsense sequence group, the expression of MICA in the antisense miR-20a group, antisense miR-106b group and antisense miR-20a/106b group all increased (allP<0.05). In the above experiments, similar results were obtained in U251 cell line. Under different effector to target ratios (20 ∶1, 10 ∶1, 5 ∶1), the LDH activity of the antisense miR-20a/106b group was higher than that of the control group and the group with combined blocking of MICA (allP<0.05), while the latter two groups had no significant difference (allP>0.05). The postoperative head MRI results showed that the 3 groups of juvenile rats and 3 groups of adults rats were all successfully modeled. The results of the MCID method showed that theI value of the J-rat-miR-20a/106b knockdown group of the juvenile rat model was lower than that of the J-rat group and the J-rat nonsense control group (both P<0.05). TheI value of A-rat-miR-20a/106b overexpression group was higher than that of A-rat group and A-rat nonsense control group (both P<0.05). The results of immunohistochemical staining showed that the intensity of MICA staining in the J-rat-miR-20a/106b knockdown group of the juvenile rat model was higher than that of the J-rat group and the J-rat nonsense control group (bothP<0.05). The staining intensity of MICA of the model A-rat-miR-20a/106b overexpression group was lower than that of the A-rat group and the A-rat nonsense control group (bothP<0.05). In vivo apoptosis experiments showed that the apoptosis index of the J-rat-miR-20a/106b knockdown group in the juvenile rat model was higher than that of the J-rat group and the J-rat nonsense control group (bothP<0.05). The apoptosis index of the A-rat-miR-20a/106b overexpression group in the adult rat model was lower than that of the A-rat group and A-rat nonsense control group (bothP<0.05).

The immune evasion mediated by miR-20a/106b through NKG2D is an important factor for the high malignancy of pediatric BSG.