MedNexus
Volume 37 · Issue 11 · 2021
MedNexus
glioblastoma (GBM) is the most common primary malignant brain tumor in adult central nervous system[
To explore the clinical and pathological characteristics of diffuse hemispheric glioma, H3 G34-mutant (DHG-G34).
A retrospective analysis was conducted on the clinical data of 6 DHG-G34 patients admitted to the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January 2016 to January 2020. Six patients underwent enhanced MRI scan before operation, 4 of them underwent tumor resection, and the other 2 underwent stereotactic biopsy. Postoperative re-examination of head MRI was performed to determine the extent of tumor resection. All patients were followed up by telephone and inquired about their postoperative treatment and survival status. HE staining, immunohistochemical staining and genetic testing were performed on tumor tissue specimens.
The median age of the 6 patients was 18 years old (14-34 years old) who were mostly males (5/6). The lesions were all located in the cerebral hemisphere, with single focus (3/6) or multiple focus (3/6). The scan showed no obvious enhancement (2/6) or slight uneven enhancement (4/6). The postoperative head MRI of the 4 patients who underwent tumor resection indicated subtotal resection. Five patients (5/6) were followed up. The median follow-up time was 21 months (16-30 months). All patients received concurrent radiotherapy and chemotherapy. At the last follow-up, 3 cases died and 2 cases survived. Histological diagnosis under HE staining microscope included 3 cases (3/6) of anaplastic astrocytoma and 3 cases (3/6) of glioblastoma. Among them, 4 cases (4/6) showed merely high-grade glioma morphology and 2 cases (2/6) showed the mixture with primitive neuron components. The results of immunohistochemical staining showed that the tumor cells all expressed mutant H3 G34R, glial fibrillary acidic protein (GFAP), H3K27me3 orerexpresse p53, and none of them expressed oligodendrocyte transcription factor 2 (Olig2) or α-thalassemia with retarded intelligence syndrome X linkage (ATRX), while synaptophysin (Syn) was focally expressed at moderate levels (2/6). The results of genetic examination of 4 patients undergoing tumor resection showed that there was no isocitrate dehydrogenase (IDH)1/2, telomerase reverse transcriptase promoter (TERT) C228T/C250T or BRAF-V600E mutations, of which 2 cases(2/4) had methylation of O 6-methylguanine-DNA methyltransferase (MGMT) promoter.
DHG-G34 is more common in the cerebral hemispheres, and can show multifocal growth without obvious MRI enhancement. Its histopathological features are heterogeneous, but the molecular pathology changes are consistent. The DHG-G34 patients′ prognosis is poor.
To explore the clinical efficacy of surgical resection of jugular foramen tumors through transpetrosal approach.
A retrospective analysis was conducted on the clinical data of 36 patients with intracranial and extracranial communicating tumors in the jugular foramen region resected through transpetrosal approach at the Department of Neurosurgery, Sanbo Brain Hospital, Capital Medical University from October 2015 to May 2020. Those tumors included 12 cases of schwannoma, 7 cases of glomus jugular tumor, 6 cases of meningioma, 4 cases of chondrosarcoma, 2 cases of perivascular cell tumor, 2 cases of metastatic cancer, 1 case of clear cell carcinoma, 1 case of cavernous vascular malformation and 1 case of squamous cell carcinoma. Glomus jugular tumors were mainly classified as Fisch grades C and D, and schwannomas were mainly classified as Kaye-Pellet type B or D. According to the growth pattern, those tumors were confined to the intracranial-petrous region in 2 cases, petrous bone in 8 cases, petrous bone-neck region in 12 cases, or intracranial-petrous bone-neck region in 14 cases. Surgical approaches included Fisch type A infratemporal fossa approach was used in 12 cases, petrosal occipital approach in 8 cases, and sublabyrinthine transmastoid approach in 16 cases. Patients underwent regular clinical and imaging follow-up after surgery.
Among the 36 patients, total resection was achieved in 14 cases, subtotal resection in 18 cases, and major resection in 4 cases. Two cases of cerebrospinal fluid rhinorrhea occurred after operation, and all improved after surgical repair. One case of cerebrospinal fluid otorrhea occurred, which improved after conservative treatment. One case of cerebral infarction occurred after operation and recovered before discharge. Postoperative subcutaneous fluid around incision was reported in 1 case, infection of incision developed in 1 case, and both resolved after symptomatic treatment. The median follow-up time of 36 patients was 24 months (8-62 months). A total of 29 (80.6%) patients had improved postoperative cranial nerve function (9 cases) or no change (20 cases). Symptoms worsened in 7 cases. Among them, 3 cases of facial paralysis were aggravated, 4 cases of posterior cranial nerve palsy were aggravated. There were 1 case of newly-developed facial paralysis after operation and 1 case of glomus jugular tumor recurrence.
The transpetrosal approach could be taken to fully expose the tumor in the jugular foramen area invading the petrous bone and the neck. The total and subtotal tumor resection rates are relatively high, and there are fewer postoperative complications.
To evaluate the long-term outcomes of gamma knife radiosurgery (GKRS) for meningiomas involving the major dural sinuses (MIMDS).
A retrospective analysis was conducted on the clinical data of 151 patients with MIMDS who underwent gamma knife treatment from January 2006 to December 2016 at the Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology. Among the 151 patients, 100 cases were primary medium and small MIMDS, and 51 cases were residual MIMDS after operation; the diameter of the lesions was less than 5 cm. Meningiomas were mainly located in the cavernous sinus (50.3%, 76/151), followed by the sagittal sinus (29.8%, 45/151), the confluence area (8.6%, 13/151), the sigmoid sinus (6.0%, 9/151) and transverse sinus (5.3%, 8/151). The median tumor volume before gamma knife treatment in 151 patients was 3.2 cm3 (0.1-48.9 cm3), the median marginal dose of gamma knife treatment was 14.5 Gy (5-42 Gy), and the median isodose curve was 50% (33%-70%). Clinical and imaging follow-ups were performed after treatment to evaluate post-treatment complications and tumor recurrence. The Kaplan-Meier survival analysis method was used to determine the progression-free survival (PFS). Through univariate and multivariate Cox regression analysis methods, we explored the related factors affecting PFS in MIMDS patients.
All patients were followed up for 70.9±33.6 months (36-172 months). Among 151 patients with MIMDS, 9 cases (6.0%) developed complications after treatment, including 3 cases of vision impairment (2.0%), 3 cases (2.0%) of radiation-induced cerebral edema, 2 cases (1.3%) of hydrocephalus, and 1 case (0.7%) of exophthalmos combined with ulcer. The overall 5-year and 10-year PFS of 151 patients after GKRS were 87.6% and 78.8%, respectively. Log-rank results showed that the PFS of <60 years old patients was significantly higher than that of patients ≥60 years old, and the PFS of patients who underwent GKRS after surgery was generally higher than that of patients who underwent GKRS alone (both P<0.05). During the follow-up period, the tumor recurred in 22 cases (14.6%). The results of multivariate Cox analysis showed that age (P=0.028) and treatment method (P=0.032) were prognostic factors for tumor recurrence in MIMDS patients.
Gamma knife is a safe and effective treatment method for small and medium-sized MIMDS and postoperative residual MIMDS. It can control tumor growth for a long time and has few complications after treatment.
To discuss the selection, technical points and therapeutic effect of cerebral revascularization for skull base tumors involving internal carotid artery (ICA).
A retrospective analysis was conducted on the clinical data of 10 patients with skull base tumors involving ICA admitted to the Department of Neurosurgery of Tianjin Huanhu Hospital from April 2016 to September 2020. There were 6 cases of meningiomas, 2 cases of pituitary adenoma, 1 case of chondrosarcoma, and 1 case of nasopharyngeal carcinoma. According to the tumor's origin, invasion site, and compensation of collateral circulation, the tumors were removed through Dolenc approach combined with STA-MCA bypass in 3 cases, through extended middle fossa approach combined with Fukushima bypass Ⅰ in 3 cases, through extended middle fossa approach combined with Fukushima bypass Ⅲ in 2 cases, and through Dolenc approach or extended middle fossa approach combined with direct reconstruction in 2 cases. Postoperative imaging examination was performed to assess the patency of the anastomosed blood vessel, the degree of tumor resection, the presence or absence of cerebral ischemia, and the presence or absence of tumor recurrence.
Intraoperative fluoroscopy in 10 patients showed patency of the anastomotic vessels, 8 patients underwent digital subtraction angiography (DSA) or CT angiography (CTA) after the operation to confirm that the anastomoses were patent, and 2 patients did not receive DSA or CTA due to postoperative coma. Total resection was achieved in 7 cases, subtotal resection in 1 case, partial resection in 1 case, and 1 case of nasopharyngeal carcinoma with ICA rupture and bleeding only underwent vascular bypass surgery without tumor resection. One case of cerebral ischemia improved after medical treatment; 2 cases developed facial numbness and facial paralysis, and recovered after 3 months; 1 case of meningioma involving bilateral slopes of cavernous sinuses underwent cerebral revascularization combined with tumor resection. The recovery went smoothly, but the patient developed a coma after the second-stage contralateral tumor resection and was discharged at the request of his family. One patient died of respiratory failure 15 days after the operation. The follow-up time of 9 patients was 4 to 26 months. The last follow-up showed that none of the patients had new cerebral ischemia. Among them, 6 patients underwent DSA or CTA reexamination, 5 patients showed patency of reconstructed blood vessels, and 1 patient had partial stenosis. One case of malignant chondrosarcoma recurred 5 months after operation and 1 case of chordal meningioma recurred 1 year after operation.
For skull base tumors involving ICA, different techniques of cerebral revascularization can be selected according to the compensation of cerebral blood flow, tumor location and the degree of ICA involvement, which can reduce the incidence of hemorrhage and cerebral ischemia, and improve the degree of tumor resection.
To explore the application value of mixed reality(MR) technology in the surgical treatment of anterior clinoidal meningioma.
The clinical data of 11 patients with anterior clinoidal meningioma admitted to the Department of Neurosurgery, the Second Hospital of Hebei Medical University from October 2020 to July 2021 were retrospectively analyzed. Before surgery, all patients were examined by head CT, MRI, diffusion tensor imaging (DTI) and magnetic resonance angiography (MRA), and 3D-Slicer software was used to construct a three-dimensional model, which could be presented holographically by applying MR technology, to determine the positional relationship between the tumor and the surrounding important blood vessels and nerves, and to formulate individualized surgical strategy. Postoperative head MRI was reviewed to determine the extent of tumor resection. The patient′s limb muscle strength, sensation, coordination, other neurological functions and complications were documented.
For all 11 patients, a three-dimensional model was successfully constructed before the operation, which could be presented holographically through the head-mounted display system. The tumor volume of 11 patients was 40 485 ± 24 261 mm3 (range: 5 653-100 140 mm3), all of which significantly squeezed the ipsilateral optic nerve. The tumors of 9 patients wrapped the internal carotid artery (ICA) and its bifurcations. Among them, the reconstruction of perforating arteries was successful in 2 cases but failed in the remaining 7 cases. The tumors of 2 patients simply compressed or pushed the ICA and its branch to make it obviously shifted. The intraoperative findings and surgical operations of 11 patients were consistent with the preoperative surgical strategy. Postoperative head MRI showed that the tumor was completely removed in 7 cases. The other 4 cases had subtotal resection. Among them, there was no obvious arachnoid interface between the tumor and the surrounding ICA and middle cerebral artery in 1 case, and tumor invaded the cavernous sinus in 3 cases. There was no cerebrospinal fluid leakage after operation. One week after the operation, the patient′s limb muscle strength was grade Ⅴ in 6 cases and grade Ⅳ in 4 cases, and grade 0 was reported in 1 case. Four patients had mild ataxia on the affected side, and 3 patients had better vision than before surgery.
Mixed reality technology can assist the surgeon to formulate individualized surgical strategies before the surgical treatment of anterior clinoidal meningioma, which can reduce the damage to important structures during the operation and reduce the occurrence of postoperative complications.
To explore the method of identifying the boundary of the normal pituitary gland during neuroendoscopic transnasal pituitary adenoma resection and its clinical significance.
A retrospective analysis was conducted on the clinical data of 502 patients with pathologically confirmed pituitary adenomas who were admitted to the Department of Neurosurgery, Xijing Hospital, Air Force Medical University from January 2010 to December 2013. We analyzed the patients′ preoperative imaging and surgical video data, and summarized the methods for determining the pituitary border and pituitary protection. According to the preoperative and postoperative MRI images, the degree of tumor resection was evaluated. The occurrence of postoperative complications was confirmed.
Among 502 patients, total resection was achieved in 463 (92.2%). Through preoperative imaging and direct observation under neuroendoscope or through intraoperative diving technique, we were able to recognize the normal pituitary gland and the boundary between the pituitary gland and the tumor tissue in 483 cases (96.2%) during the operation, and the pituitary gland tissue was well preserved; we were unable to identify the pituitary tissue in 19 cases (3.8 %), and frozen section was made from the possible pituitary border tissue during the operation for pathological examination. The results showed that there were 12 cases of pure pituitary tissue, 3 cases of pituitary tissue invaded by tumor, and 4 cases of merely tumor tissue. Postoperative complications included loss of smell (1.6%, 8/502), diabetes insipidus (1.4%, 7/502), electrolyte disturbance (1.0%, 5/502), cerebrospinal fluid rhinorrhea (1.0%, 5/502), meningitis (0.4%, 2/502) and hypopituitarism (0.4%, 2/502). There were no deaths in this series.
For most patients with pituitary adenomas, the boundary between the pituitary tissue and the tumor could be identified through preoperative imaging combined with intraoperative endoscopic direct vision or intraoperative diving techniques. For patients whose pituitary boundaries are difficult to identify, frozen section for rapid pathological examinations can be applied to confirm the boundaries during the operation. This method can be used to improve the recognition rate of pituitary tissue, which facilitates the protection of the pituitary, thereby reducing postoperative complications.
To explore the effect of nasal septum bone flap combined with pedicled nasal septum mucosal flap in skull base reconstruction through neuroendoscopic transseptal transsphenoidal extended approach.
A retrospective analysis was conducted on the clinical data of 118 patients who developed high-flow cerebrospinal fluid leakage during operations through the neuroendoscopic transseptal transsphenoidal extended approach at the Neurosurgery Department of the First Affiliated Hospital of Nanchang University from September 2018 to June 2020. Lesions included 42 cases of craniopharyngioma, 18 cases of sellar tuber meningioma, 9 cases of olfactory groove meningioma, 30 cases of giant invasive pituitary adenoma, 8 cases of chordoma, 4 cases of trigeminal schwannoma, 4 cases of sellar arachnoid cyst, and 3 cases of germ cell tumor of the sellar region. After the lesion resection, the nasal septum bone flap combined with the pedicled nasal septum mucosal flap was used for multi-layer skull base reconstruction, and no lumbar cistern drainage was performed after the operation. Postoperative clinical and imaging follow-up were performed to observe the postoperative complications and the conditions of skull base reconstruction.
The nasal septal bone flaps of 118 patients were successfully fabricated. The postoperative reexamination of the paranasal sinus thin-slice CT showed that the nasal septal bone flap was in good condition to repair the skull base. The sellar area MRI scan plus enhancement showed that the pedicled nasal septal mucosa flap showed an inverted " C" shape enhancement. It suggested that the mucosal flap was growing well. Two cases of postoperative intracranial infection, including 1 case of cerebrospinal fluid leakage, were resolved. No cases of skull base repair were performed again. The median time of bed rest after operation was 2.0 days (2-13 days). There were 2 cases of pulmonary infection, no case of deep vein thrombosis of the lower extremities, and neuroendoscopy showed that the mucosal flap of the skull base grew well and there was no leakage of cerebrospinal fluid. The median follow-up time of 118 patients was 11.5 months (2-23 months). No delayed cerebrospinal fluid leakage or intracranial infection was found. Re-examination of the paranasal sinus thin-slice CT showed that the nasal septal bone flap was well healed and the sellar MRI with enhancement showed that the mucosal flap of the nasal septum showed significant enhancement, indicating that the mucosal flap of the skull base was growing well.
During neuroendoscopic transseptal transsphenoidal extended approach, the use of nasal septum bone flap combined with pedicled nasal septum mucosal flap for skull base reconstruction can not only reduce the incidence of cerebrospinal fluid leakage and intracranial infection, but also avoid postoperative lumbar cistern drainage.
To use high-resolution magnetic resonance (HRMRI) to assess preoperative carotid plaque based on modified American Heart Association (AHA) classification of atherosclerosis, and to study its early warning effect on perioperative silent cerebral infarction (SBI) of carotid endarterectomy (CEA).
The clinical data of 254 patients with carotid artery stenosis who underwent CEA treatment at the Department of Neurosurgery of Peking University Third Hospital from March 2018 to July 2019 were retrospectively analyzed. All patients underwent HRMRI examination of carotid artery 1 week before the operation. According to the modified AHA classification, the patients′ plaques were divided into vulnerable plaques (type Ⅳ, Ⅴ, Ⅵ) and stable plaques (type Ⅰ, Ⅱ, Ⅲ, Ⅶ, Ⅷ). Head MRI plain scan and diffusion weighted imaging (DWI) were performed before and 24 hours after the operation. New punctate hyperintensity on postoperative head MRI DWI sequence without corresponding symptoms was decided as the diagnostic criterion for perioperative SBI. The patients were divided into SBI group and non-SBI group. Univariate analysis and multivariate logistic regression analysis were used to determine whether carotid artery vulnerable plaque on the side of operation was a risk factor for perioperative SBI of CEA.
Preoperative HRMRI of 254 patients showed that 43 cases (16.9%) had stable plaques and 211 cases (83.1%) had vulnerable plaques. Among the 254 patients, 51 cases of SBI (20.1%, SBI group) occurred during the perioperative period, and 203 cases (79.9%, non-SBI group) did not develop SBI. SBI occurred in 23.2% (49/211) patients with vulnerable plaque, and SBI occurred in 4.7% (2/43) patients with stable plaque. The results of univariate analysis showed that the proportion of patients with vulnerable plaques in the carotid artery on the surgical side of the SBI group was higher than that of the non-SBI group, and the difference was statistically significant (P=0.01). The results of multivariate logistic regression analysis showed that the vulnerable plaque of the operative carotid artery was an risk factor for the occurrence of SBI during perioperative period of CEA (OR=0.18, 95%CI: 0.04-0.80, P=0.02), and 12 factors including gender and intraoperative carotid artery occlusion time were not risk factors for SBI during perioperative period of CEA(all P>0.05).
Patients with vulnerable plaques in the carotid artery on the operative side before CEA (modified AHA classification Ⅳ, Ⅴ, Ⅵ) have an increased risk of SBI during the perioperative period. Individualized prevention programs need to be designed to improve the safety of the operation.
To explore the treatment efficacy of common carotid-subclavian artery (SA) bypass in the patients with cerebral ischemia resulting from SA occlusion.
This study enrolled 11 SA-occlusion patients who underwent common carotid artery-subclavian artery bypass in the hybrid operating room at the Department of Neurosurgery, General Hospital of Tianjin Medical University from January 2015 to June 2020. All patients had symptoms of cerebral ischemia. A retrospective analysis was conducted on the clinical effect on those patients and surgical-related complications.
All patients underwent successful operation. Intraoperative ultrasound and digital subtraction angiography (DSA) indicated that the vertebral artery steal syndrome disappeared and the anastomoses were unobstructed. Two patients had lymphatic rupture when SA was dissected during the operation. None of the patients had nerve damage or stroke. At 1-year follow-up, the symptoms of SA steal syndrome were significantly improved or disappeared in all patients. The systolic pressure difference of the upper limbs decreased from 27.6±9.7 mmHg before operation to 7.3±1.9 mmHg after operation (P<0.01, 1 mmHg=0.133 kPa), and the ratio of systolic blood pressure of the patient on the affected side to that on the uninfected side increased from 0.55±0.11 before operation to 0.86±0.30 (P<0.01). All patients had no obvious stenosis of artificial blood vessels or anastomoses, no limb ischemia or cerebral ischemia on the affected side.
Common carotid-SA bypass is a safe and effective treatment for cerebral ischemia caused by SA occlusion.
To evaluate the effect of low-flow bypass surgery in the treatment of giant cavernous sinus aneurysms.
A retrospective analysis was conducted on the clinical data of 7 patients with giant cavernous sinus aneurysms treated by low-flow bypass surgery at the Department of Neurosurgery of Tianjin Huanhu Hospital from May 2013 to August 2018. The surgical method was determined according to the compensation of the collateral circulation before the operation: 6 cases underwent ICA occlusion + STA-MCA anastomosis, 1 case underwent ICA constriction + STA-MCA anastomosis. Intraoperative fluorescein angiography and/or vascular ultrasound were used to assess the patency of the graft vessels. Postoperative imaging follow-up was performed to assess the aneurysm condition, and the modified Rankin scale (mRS) was used to assess the improvement of the patients′ symptoms.
Intraoperative assessment indicated the patency of the graft vessels in 7 patients. Cerebral infarction occurred in 1 patient after the operation, and the outcome was good; none of the patients died. The postoperative follow-up period was 6 to 48 months. During the follow-up period, no recurrence or rupture of aneurysm was observed, the aneurysm disappeared in 6 cases, the aneurysm shrank in 1 case. The mRs score was 0 in 5 cases, 1 in 1 case, and 3 in 1 case.
Preliminary observations show that low-flow bypass surgery for the treatment of giant cavernous sinus aneurysms has a good clinical effect and few complications.
To preliminarily investigate the role of scene reappearance aura in epileptic seizure localization.
A retrospective analysis was conducted on the clinical data of 8 patients who had epileptic seizures with scene reappearance as aura and were admitted to the Department of Functional Neurosurgery, Xuanwu Hospital, Capital Medical University from January 2015 to June 2020. Based on the clinical symptoms, preoperative imaging data, and neuroelectrophysiological results, localization diagnosis of epileptic seizures was performed. Among the 8 patients, 5 patients underwent stereotactic electroencephalography (SEEG) electrode placement to locate the epileptogenic foci and cortical electrical stimulation to locate the functional area and subsequent surgical resection of the epileptogenic foci; the other 3 patients only underwent resection of the epileptogenic foci. The outpatient follow-up was performed at 3, 6, 12 and 24 months after operation. The surgical efficacy was evaluated according to the modified Engel′s classification system.
Among the 8 patients, epileptic seizures originated in the left temporal lobe (5 cases), right temporal lobe (3 cases); basal temporal lobe (2 cases), superior temporal gyrus (3 cases), and medial temporal lobe (3 cases). All 8 patients successfully underwent the resection of epileptic foci. Eight patients were followed up for 1 to 5 years. At the last follow-up, none of the 8 patients had seizures, and the therapeutic outcome grades were all Engel grade Ⅰ.
Preliminary observations have found that most epileptic seizures with scene reappearance as aura originate in the temporal lobe, while no obvious lateralization value has been observed.
To explore the clinical effect and safety of microsurgery through unilateral pterional approach in the treatment of multiple aneurysms on both sides of the anterior circulation.
A retrospective analysis was conducted on the clinical data of 53 patients with multiple aneurysms on both sides of the anterior circulation who underwent microsurgical clipping via the unilateral pterional approach at the Department of Neurosurgery of the Affiliated Hospital of North Sichuan Medical College from January 2015 to December 2019. There were 132 aneurysms in 53 patients, and the Hunt-Hess grades were from Ⅰ to Ⅳ. The safety of the operation was evaluated by intraoperative clipping and postoperative complications. Postoperative clinical follow-up was performed and the Glasgow Outcome Scale (GOS) was used to evaluate the outcome of the patients.
Among the 132 aneurysms, 129 were successfully clipped during the operation, and 3 contralateral unruptured aneurysms were treated with autogenous fascia wrapping and reinforcement. Postoperative intracranial infection occurred in 5 cases (9.4%), hydrocephalus in 10 cases (18.9%), rebleeding in 2 cases (3.8%), delayed cerebral ischemia in 19 cases (35.8%), severe hormonal or electrolyte imbalance in 6 cases (11.3%). At discharge, 44 cases (83.0%) had a good outcome (defined as GOS Ⅳ and Ⅴ); 49 cases (92.4%) had a good outcome at 3 months after operation. The length of hospital stay was 17.4±5.7 days (range: 11-36 days), and the treatment cost was 75±17 thousand yuans (range: 60-168 thousand yuans). The satisfaction rate of discharged patients was 94.3% (50/53).
A subset of bilateral multiple aneurysms of the anterior circulation can be treated with microsurgery via unilateral pterional approach. Through strict preoperative evaluation, reasonable surgical plans and appropriate micromanipulations, satisfactory treatment results can be obtained with fewer postoperative complications.
To explore the risk factors of titanium mesh exposure after cranioplasty in patients with traumatic craniocerebral injury.
A retrospective analysis was conducted on the clinical data of 195 patients with craniocerebral trauma who underwent cranioplasty at Department of Neurosurgery, the 904th Hospital of the Joint Logistic Support Force of PLA from January 2010 to September 2016. All patients were followed up at outpatient clinic or through telephone after the operation. The content of the follow-up included inquiry about the patient′s healing of the incision, whether the patients had seizures, headaches, dizziness or other uncomfortable symptoms, and whether the titanium mesh was exposed. Univariate and multivariate logistic regression analysis were used to determine the risk factors that affected the exposure of the titanium mesh after cranioplasty. The receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) was calculated to evaluate the predictive value of related risk factors for the exposure of titanium mesh after cranioplasty.
All 195 patients underwent decompressive craniectomy and cranioplasty successfully, and the follow-up time was 14.0±6.7 months (2-60 months). During the follow-up period, 20 cases (10.3%) had poor incision healing, 33 cases (16.9%) had epileptic seizures, 45 cases (23.1%) had headaches, dizziness or other discomforts, and 14 cases (7.2%) had titanium mesh exposure. The results of multivariate logistic regression analysis showed that the skull defect lasting for more than 6 months (OR=4.600, 95%CI: 1.691-12.517, P=0.003), and diabetes (OR=28.277, 95%CI: 3.610-221.501, P=0.001), high scalp tension (OR=5.007, 95%CI: 1.172-21.379, P=0.030) and accumulated residual fluid or hemorrhage in the operation area (OR=5.463, 95%CI: 1.149-25.982, P=0.033) were risk factors that affected the exposure of titanium mesh after cranioplasty; the AUC was 0.70 (95%CI: 0.527-0.872), 0.63 (95%CI: 0.454-0.804), 0.75 (95%CI: 0.608-0.891) and 0.69 (95%CI: 0.534-0.850) respectively.
Craniocerebral trauma patients with skull defect lasting for > 6 months, diabetes, high scalp tension, and accumulated residual fluid or hemorrhage in the operation area are prone to exposure of titanium mesh after cranioplasty. Among them, high scalp tension has a certain predictive value for postoperative exposure of titanium mesh.
To investigate the clinical characteristics, biological functions and molecular mechanism of polo-like Kinase 4 (Plk4) in gliomas.
We studied the transcriptome data of glioma samples and clinical data of glioma patients in the Cancer Genome Atlas (TCGA) database (689 cases) and the Chinese Glioma Genome Atlas (CGGA) database (693 cases), and transcriptome data of normal brain tissue specimens in the GTEx database (255 cases) were also included. The differences in the expression of Plk4 in glioma specimens and normal brain tissues and glioma specimens of different pathological grades were compared. Log-rank test was used to compare the differences in overall survival between patients with low Plk4 expression and high expression groups. We took human astrocytes, U87, LN229, U251 and A172 cell lines for related research. Small interfering RNA (siRNA) transfection method was used to knock down the expression of Plk4 in U87 and LN229 cells. Real-time fluorescent quantitative polymerase chain reaction was used to detect the expression of Plk4 mRNA. Western blotting was used to detect the expression of Plk4 protein. EdU experiment and Transwell experiment were used to observe the effect of Plk4 on the proliferation, migration and invasion of glioma cells. Twenty 4-week-old female BALB/c-nu nude mice were taken, and U87 cells were injected into the abdomen of mice to prepare glioma xenogeneic tumor-bearing models. The differences in tumor volume and weight were analyzed between the Plk4 knockdown treatment group (intratumor injection of siRNA-Plk4) and the control group (injection of non-sequence Plk4) after 21 d (7 times) of treatment. We took U87 cells with knocked down Plk4, and used proteomics and phosphorylation analysis to explore the molecular mechanism of Plk4's biological function in gliomas.
Compared with astrocytes, the expression level of PLk4 mRNA in U87, LN229, U251 and A172 glioma cells was higher. TCGA combined with GTEx database data analysis showed that the expression level of Plk4 mRNA in low-grade glioma and glioblastoma specimens was higher than that in normal brain tissue. Analysis of the samples in the CGGA database showed that the expression level of Plk4 mRNA increased with the increase of the WHO pathological grade. In both databases, the overall survival of patients with high expression of Plk4 was shorter than that of patients with low expression of Plk4. The EdU experiment showed that the EdU positive rate of U87 and LN229 cells that knocked down Plk4 expression was lower than that of nonsense sequence cells. Transwell experiments showed that U87 and LN 229 cells that knocked down Plk4 expression had lower number of gel penetration than nonsense sequence cells. In vivo results showed that the growth rate of subcutaneous tumor in nude mice with Plk4 knockdown was significantly reduced. The differences in the above data were statistically significant (all P<0.01 or 0.05). In proteomics analysis, a total of 428 differentially expressed proteins were identified. In the phosphorylation analysis, a total of 1 180 differentially expressed phosphorylated peptides were identified, corresponding to 728 phosphorylated proteins. Correlation analysis of the results of proteomics and phosphorylation revealed that there were 2 197 proteins associated with proteomics and phosphorylation, of which 66 were only changed at the protein level, only 590 changed at the phosphorylation level, and 25 changed at both protein and phosphorylation levels. The GO function annotation and KEGG pathway enrichment analysis of 590 proteins with only changes at phosphorylation level found that the functions of 590 proteins were mainly protein binding and cadherin binding, etc. The main enrichment pathways were neurotrophic protein signaling pathway and long-term enhancement, etc.
Plk4 is highly expressed in brain gliomas, which may be related to the prognosis of patients. Its mechanism may be related to the promotion of the proliferation, migration and invasion of glioma cells through signal pathways such as neurotrophic signaling pathway. Plk4 may be a molecular marker for the diagnosis and prognosis of glioma and a potential target for drug therapy.
Tumor electric field therapy (TTFields) is a new technique for the treatment of tumors. TTFields combined with the traditional Stupp protocol can effectively prolong the survival time and improve the quality of life of patients with glioblastoma. This method has been recommended by relevant guidelines at home and abroad. In this paper, the clinical data of two patients with glioblastoma receiving TTFields admitted to the Department of Neurosurgery of Shanxi Provincial People's Hospital (Fifth Clinical Medical College of Shanxi Medical University) were retrospectively analyzed, and related literatures were reviewed, in order to provide reference for their clinical application.
Kaposiform hemangioendothelioma is extremely rare, and no relevant reports have been retrieved in China for intracranial onset. This article retrospectively reports a child with congenital intracranial Kaposiform hemangioendothelioma, who was treated with "B-ultrasound at 36 weeks of pregnancy found intracranial space-occupying lesions, and there was a mass on the left forehead after birth". Left frontotemporal craniotomy was performed, and the diseased skull and intra-and external dural tumors were resected. At present, the vital signs of the children are stable, and there is no abnormality in the monitoring of coagulation indexes.
Solitary fibrous tumor (SFT) is a rare spindle-shaped mesenchymal tumor. A patient with intracranial SFT accompanied by stroke was retrospectively reported. On admission, he presented with headache with disturbance of consciousness. CT of the head showed intracranial space-occupying lesions on the right forehead with hemorrhage and ventricular casting. Brain tumor resection + intracranial hematoma evacuation + decompressive craniectomy + left ventricular external drainage were performed in emergency department. The patient's consciousness gradually improved after the operation, and the tumor recurred after the second operation. No tumor recurrence was seen after 1 1/2 years of follow-up.
Clinical cases of intracranial dural arteriovenous fistula (DAVF) with onset of spinal cord injury are relatively rare, and there are few reports on its diagnosis and treatment. In January 2018, the Department of Neurosurgery of Drum Tower Hospital affiliated to Nanjing University School of Medicine treated a patient with tentorial DAVF presenting with spinal cord injury by anterior sigmoid approach. The patient recovered well after operation, the muscle strength of both lower limbs was significantly improved, and he could walk normally. Postoperative digital subtraction angiography showed that DAVF and return vein completely disappeared.
Cerebrovascular surgery should protect brain function as much as possible in the course of treatment. With the improvement of treatment methods, the protection of brain cognitive function has been paid more and more attention. With the development of modern brain imaging technology and complex network theory, people gradually realize that brain network is the physiological basis of brain information processing and cognitive expression. Based on the topological characteristics of brain network, neurosurgery put forward the concept of "brain network surgery", which aims to protect nerve function and cognitive function more accurately through the protection of brain network. Based on the literature review and previous research work, this paper reviews three directions of application of the concept of "brain network surgery" in the treatment of cerebrovascular diseases. These include, the protection of key nodes of brain network based on human brain connectomics; Protection of Cognitive Function-Related Blood Supply Areas in Cerebrovascular Disease Surgery; Evaluation of brain networks for effective ischemic cerebrovascular disease surgery by preoperative brain network structural and functional connectivity status. With the rapid development of medical technology, neurosurgery has moved towards a more systematic and delicate comprehensive protection of cranial nerve function and cognitive function. Cerebrovascular neurosurgery will usher in a new stage of "brain network surgery".
Chordoma is a rare and difficult to treat malignant tumor, while skull base chordoma has a worse prognosis due to its complex anatomy. At present, surgery is still the core of comprehensive treatment of skull base chordoma. Despite the continuous innovation of many emerging technologies and the accumulation of related surgical experience, the effect of tumor resection is still not good, and adjuvant radiotherapy is often needed to reduce the risk of disease recurrence and progression. Particle radiotherapy represented by protons and carbon ions has significant advantages in this respect. Targeted chemotherapy drugs for chordoma are limited, and most of them are currently in clinical trials. Combined with the research progress of comprehensive treatment of skull base chordoma, this paper reviews the core strategies of surgery, the superiority of particle radiotherapy and hot chemotherapy drugs.
Serious complications of childhood optic glioma include deterioration of visual function and endocrine dysfunction, the latter can occur throughout the disease process, among which growth hormone deficiency and precocious puberty are the most common, which seriously affect the quality of life of children. The age of diagnosis, tumor location, type 1 neurofibromatosis, and treatment mode all affect the endocrine function of children, so the hormone level of children needs to be monitored during disease development and follow-up. One of the biggest challenges in improving the prognosis of children is how to improve their endocrine function and maximize the quality of life of children. This article reviews the research progress of factors affecting the endocrine function of children with visual path glioma through literature review.
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