Volume 38 · Issue 01 · 2022

To discuss the surgical strategies, clinical outcomes, and prognostic factors of endoscopic transnasosphenoidal resection of skull base chordomas.

A retrospective analysis was conducted on the clinical data of patients with skull base chordomas who underwent endoscopic transnasosphenoidal resection at the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January 2004 to March 2021. A total of 373 patients were enrolled in the analysis and underwent 500 surgical operations. The patients undergoing surgery from 2004 to 2019 were enrolled in the early operation group, in whom the surgical strategy was based on the tumor center; those undergoing surgery from 2020 to 2021 were enrolled in the recent operation group, in whom the surgical strategy was based on the growth pattern of tumor which was to perform sequential exploration and resection according to the origin of the tumor and its characteristics of extension and growth along the cranial sutures, spaces between nerves and vessels (turtle-back-like sequence). The resection rates were compared between the two surgical strategies. Kaplan-Meier survival analysis was performed to calculate the progression-free survival (PFS) and overall survival (OS). The The log-rank test was adopted to analyze the prognostic factors associated with PFS and OS.

Among the 500 operations, 413 cases belonged to the early operation group, in which the tumor total resection rate, subtotal resection rate, and partial resection rate were 35.1% (145 cases), 36.6% (151 cases), and 28.3% (117 cases). There were 87 cases were in the recent surgery group, in which the tumor total resection rate, subtotal resection rate, and partial resection rate were 52.9% (46 cases), 37.9% (33 cases), and 9.2% (8 cases), respectively. The difference in tumor resection rate between the two groups was statistically significant (P<0.001). Complete follow-up data of 325 patients (87.1%) were achieved. The median follow-up time was 31 months (3-193 months) and 182 cases (56.0%) relapsed. The estimated median PFS of the overall patients was 24 months (95%CI: 17.5-30.5 months). There were 85 cases (26.2%) of death, and the median OS of the overall patients was estimated to be 106 months. Survival analysis showed that compared with patients with primary tumor, small tumor size, total tumor resection, classical or cartilaginous tumor, postoperative radiotherapy, those with recurrence tumor, large tumor volume, non-total tumor resection, pathologically dedifferentiated or poorly differentiated tumors, and without postoperative radiotherapy had shorter PFS and OS, and the differences were statistically significant (all P<0.05).

According to the characteristics of the growth and invasion of skull base chordoma, the surgical strategy of "turtle-back-like" sequential exploration and resection of the tumor is beneficial to improve the degree of tumor resection. Whether the tumor is primary or recurrent, tumor size, degree of resection, pathological type, and postoperative radiotherapy may be related to PFS and OS in patients with skull base chordoma.

To analyze the clinical effect of endoscopic transsphenoidal surgery for the treatment of Cushing′s disease.

A retrospective analysis was conducted on the clinical data of 133 patients with pituitary Cushing′s disease admitted to the Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2015 to January 2020. All patients were treated with neuroendoscopic transsphenoidal surgery. Gross total resection (GTR) was defined as no residual tumor in MRI 48 hours after surgery.The levels of peripheral serum cortisol and 24-hour urine free cortisol were measured at 1 to 2 days and 6 months after surgery. Clinical symptoms and imaging examinations were followed up regularly to evaluate the efficacy. The criteria for remission was defined according to " Chinese Experts Consensus on the Diagnosis and Treatment of Cushing′s Disease (2015)" .

All 133 patients successfully underwent the operation. Among them, 119 cases (89.5%) had postoperative pathological results suggesting pituitary adenoma or hyperplasia, and the other 14 cases (10.5%) were normal pituitary tissues. There were 19 cases of transient diabetes insipidus, 2 cases of permanent diabetes insipidus, 21 cases of electrolyte disturbance, 32 cases of hypopituitarism, 4 cases of cerebrospinal fluid leakage, 2 cases of intraoperative hemorrhage, and 2 cases of intracranial infection. Among 101 patients (all GTR) with pituitary adenomas detected by preoperative MRI, the immediate postoperative remission rate was 90.1% (73/81) for pituitary microadenoma and 60.0% (12/20) for macroadenoma. Among 32 patients with negative preoperative MRI results, the remission ratio was 14/18 in patients with suspected pituitary adenomas identified during operation (all GTR) and 6/14 in those without obvious adenomas. The overall remission rate of patients immediately after surgery was 78.9% (105/133). The postoperative follow-up time of 133 patients was 2.5±0.3 years (1-6 years). At 6 months post operation, of the 28 patients who did not relieve immediately after the operation, 8 patients achieved delayed remission, 4 patients were relieved by retreatment, and 16 patients did not relieve. At the last follow-up, 24 (22.9%) of 105 patients who had immediate remission after surgery had relapsed. The recurrence time was 2.7±0.4 years (0.5-6.0 years) post operation, and 4 cases had remission again after treatment.

Endoscopic transsphenoidal surgery is effective in the treatment of pituitary Cushing′s disease, while there could be many postoperative complications and the recurrence rate seems relatively high.

To investigate the efficacy and safety of endoscopic and microscopic vascular decompression for the treatment of hemifacial spasm (HFS).

A retrospective analysis was conducted on the clinical data of 92 patients with HFS admitted to the Department of Neurosurgery, Shenzhen Second People′s Hospital from January 2015 to December 2019. All patients were divided into the neuroendoscopic group (n=38) and the microscopic group (n=54). The efficacy of surgery was evaluated based on the relief of HFS symptoms post operation. HFS symptom remission, recurrence and postoperative complications were followed up regularly. The baseline data, surgical efficacy, postoperative complications and follow-up results were compared between the two groups.

Among the 92 patients, 88 were intraoperatively identified to have compression caused by a single artery: anterior inferior cerebellar artery(AICA) in 73 cases, posterior inferior cerebellar artery (PICA) in 13 cases and vertebral artery (VA) in 2 cases. Among the remaining 4 patients, 2 cases had multi-vessel (AICA and PICA) compression and the other 2 cases had compression caused by AICA and cerebellar pompons. Postoperative symptoms were completely relieved in 87 cases (94.6%) and significantly improved in 5 cases (5.4%). Postoperative cerebrospinal fluid rhinorrhea occurred in 3 cases, hearing loss in 1 case, hearing decline in 4 cases, and mild facial paralysis in 2 cases. The median (interquartile range) postoperative follow-up time of 92 patients was 30.0 (18.8) months. At the end of follow-up, 90 patients showed complete remission of symptoms, and 2 patients in the microscopic group relapsed. There were no significant differences in age, gender, course of disease or offending vessels and tissues between the two groups (all P>0.05). There were no significant differences in postoperative efficacy, postoperative complications, follow-up time, efficacy at the last follow-up between the two groups (all P>0.05).

Preliminary observation has shown that both endoscopic and microscopic vascular are effective and safe for the treating of HFS, and no significant difference in the effectiveness or safety was observed between the two methods.

To preliminarily investigate the surgical effect of endoscopic microvascular decompression for hemifacial spasm via retrosigmoid infrafloccular approach.

A retrospective analysis was conducted on the clinical data of 97 patients with hemifacial spasm admitted to the Department of Neurosurgery, Qilu Hospital of Shandong University from June 2019 to March 2021. Ninety-seven patients underwent preoperative imaging examinations to clarify the relationship between the offending blood vessel and the facial nerve root exit zone (REZ). Neuroendoscopy was used to perform microvascular decompression via the infrafloccular approach. During the operation, the arachnoid membrane on the dorsal side of the cranial nerve was fully dissected under neurophysiological monitoring, so as to expose the REZ of facial nerve, clarify the offending blood vessels, and place the Teflon accurately. Postoperative therapeutic effect was evaluated and divided into: immediate relief, delayed relief, relapse, and no relief.

In 97 patients, the offending vessel was identified to be the anterior inferior cerebellar artery (AICA) in 59 cases, the posterior inferior cerebellar artery (PICA) in 3 cases, and the vertebral-basal artery in 35 cases including 8 cases of merely vertebra-basal artery, 24 cases of vertebral-basal artery combined with AICA and 3 cases of vertebral-basal artery combined with PICA. Immediate postoperative relief was achieved in 68 cases (70.1%). After operation, there were 13 cases of fever, 4 cases of hearing impairment, 2 cases of tinnitus, and 5 cases of transient facial paralysis. The median follow-up time of 97 patients was 9 months (1-19 months). The latest follow-up showed that 93 patients (95.9%) reported complete disappearance of facial spasm, among which 25 achieved delayed relief, and there were 4 cases reporting no relief. There were no cases of recurrence.

Endoscopic microvascular decompression via retrosigmoid infrafloccular approach could not only improve the relief rate of hemifacial spasm, but also help decrease the incidence of postoperative complications.

To investigate the clinical features and treatment of sellar abscesses after tumor resection by endoscopic transnasosphenoidal approach.

A retrospective analysis was conducted on the clinical data of 11 patients who underwent neuroendoscopic transnasosphenoidal tumor resection from November 2013 to June 2020 in the Department of Neurosurgery, the First People′s Hospital Affiliated with Shanghai Jiao Tong University. Antibiotic medication was not effective for any patient in this series. Ten of them underwent neuroendoscopic transnasal abscess debridement, and the other one patient underwent ventricular drainage due to the ruptured abscess in the third ventricle. All patients were followed up at 1, 3 and 6 months postoperatively. The follow-up included routine blood test and head MRI. Abscess was defined as cured if the patient had no symptoms such as headache and fever, normal result of blood routine test, and no enhancing lesions on postoperative MRI.

The age of the 11 patients was 51.5±11.3 years (39-77 years), and the male to female ratio was 7 ∶4. Seven of them were craniopharyngiomas and 4 were pituitary adenomas. All had headaches after tumor resection, fever occurred in 8 cases and hypopituitarism in 7 cases. The median time interval between surgery and onset of postoperative clinical symptoms was 1 month (15 days to 6 months). In previous operations, non absorbable artificial dura mater was performed to reconstruct the skull base in 5 cases, EC glue with gelatin sponge was performed in 1 case, EC glue with absorbable artificial dura mater was performed in 1 case, absorbable artificial dura mater was performed to reconstruct the skull base in 2 cases, autogenous fat and fascia lata graft were performed in 1 case, in the other 1 case, the skull base was not repaied. The imaging findings of 11 patients included 6 cases of cystic lesion in the sellar region, 4 cases of lesion in the sphenoid sinus, 1 case of nasoseptal flap necrosis with empyema; there were 6 cases of ring-enhancing lesion. The operations of 11 patients were all successful. The postoperative bacteriological examination results showed that there were 5 cases of Gram-negative bacilli (5/11), 5 cases of Gram-positive cocci (5/11) and 1 case of Nocardia (1/11). The follow-up time of 11 patients was 5.5±1.5 months (1-6 months). During the follow-up period, all 10 patients who underwent abscess debridement were cured, and one patient who underwent ventricular drainage died due to uncontrollable infection.

Most patients with postoperative sellar abscess have undergone skull base repair using non-absorbable artificial materials during previous neuroendoscopic transnasosphenoidal tumor resection. The sign of ring enhancement in MRI is observed in most cases. Surgical debridement seems to be an effectively treatment method for sellar abscess when antibiotic treatment fails.

To explore the influencing factors of biochemical remission after neuroen-doscopic transnasosphenoidal surgery for growth hormone (GH)-secreting pituitary adenoma.

A retrospective analysis was conducted on the clinical data of 80 patients with GH-secreting pituitary adenoma who underwent tumor resection by neuroendoscopic transnasosphenoidal approach from January 2017 to March 2021 at the Department of Neurosurgery, the First Affiliated Hospital of Fujian Medical University. All patients underwent a comprehensive endocrine assessment before and after surgery. After surgery, according to the biochemical remission criteria in the 2021 edition of " Consensus on Diagnosis and Treatment of Acromegaly in China" , all patients were divided into biochemical remission group and biochemical non-remission group, and the age, gender, course of disease, preoperative GH and insulin-like growth factor 1 (IGF-1), imaging evaluation results, intraoperative findings and pathological indicators were compared between the two groups. Factors with statistically significant differences among them were included in the multivariate logistic regression analysis to determine the risk factors affecting postoperative biochemical remission of patients with GH-secreting pituitary adenoma.

Postoperative endocrine evaluation results showed that median postoperative GH level of 80 patients was 6.21 μg/L (0.4-128.2 μg/L)(1 μg/L=0.047 nmol/L), and postoperative IGF-1 level was 407.5±191.4 ng/ml (122.9-804.6 ng/ml). Both were significantly lower than those before operation [both P<0.001; median preoperative GH level: 52.3 μg/L (2.8-456.4 μg/L); preoperative IGF-1 level: 693.6±294.2 ng/ml (163.8-1 970.0 ng/ml)]. According to the biochemical remission standard (2021 edition), 47 cases achieved biochemical remission (biochemical remission group), and the other 33 cases failed to achieve biochemical remission (biochemical non-remission group). Compared with the biochemical non-remission group, the biochemical remission group had lower preoperative GH level and lower proportions of patients with maximum tumor diameter> 3.0 cm, Knosp grade 3, 4 and Hardy stage E (all P<0.05). The results of multivariate logistic regression showed that preoperative GH level (OR=1.033, 95%CI: 1.001-1.066, P=0.046) and Knosp grade (OR=14.498, 95%CI: 3.534-59.317, P<0.001) were risk factors that affected the postoperative biochemical remission of patients with GH-secreting pituitary adenoma.

Patients with GH-secreting pituitary adenoma with lower preoperative GH level and lower Knosp grade are more likely to achieve biochemical remission after endoscopic transnasosphenoidal surgery.

To investigate the effects of intraoperative gastric decompression on postoperative nausea and vomiting (PONV) in endoscopic endonasal skull base surgery.

A retrospective analysis was conducted on the clinical data of 357 patients who underwent endoscopic endonasal skull base surgery at Department of Neurosurgery, Huashan Hospital, Fudan University from January 2019 to August 2019. According to whether or not intraoperative gastric decompression was performed, 357 cases were divided into gastric decompression group (146 cases) and control group (211 cases). Clinical characteristics and the incidence of PONV within 24 hours after surgery were compared between the two groups. Risk factors including intraoperative gastric decompression for the incidence of PONV were assessed by using univariate and multivariate logistic regression analyses in all patients.

The incidence of PONV 24 h post operation was 11.8% (42/357). The proportions of female [58.2% (85/146) vs. 46.4% (98/211), P=0.029] and Apfel risk score 2-3 [64.4% (94/146) vs. 50.2% (106/211), P=0.008] were higher in the gastric decompression group than those in the control group. The incidence of PONV was lower in the gastric decompression group than that in the control group [7.5% (11/146) vs. 14.7% (31/211), P=0.039]. Univariate logistic regression analysis showed that intraoperative cerebrospinal fluid leakage repaired with fat or mucosa graft, intraoperative gastric decompression and blood loss might be influencing factors for PONV (all P<0.05). Multivariate logistic regression analysis showed that intraoperative gastric decompression (OR=0.397, 95%CI: 0.185-0.852, P=0.018) and blood loss (OR=1.133, 95%CI: 1.026-1.250, P=0.013) were independent factors influencing the incidence of PONV.

Intraoperative gastric decompression may decrease the incidence of PONV following endoscopic endonasal skull base surgery.

To evaluate the choice of surgical approach and clinical efficacy of neuroendoscopic transnasal approach in the treatment of heteromorphic invasive pituitary adenomas.

A retrospective analysis was conducted on the clinical data of 117 patients with heteromorphic pituitary adenoma treated with neuroendoscopic surgery in the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from April 2019 to May 2020. Among them, 105 cases invaded the suprasellar area, 80 cases invaded the cavernous sinus laterally and surrounded the internal carotid artery, 19 cases invaded the brain stem behind the sella, and 89 cases invaded the area below the sella. According to the characteristics of the heteromorphic growth of pituitary adenomas, neuroendoscopic endonasal transsphenoid-tuberculum/planum approach was used in 35 cases, transethmoid-pterygoid-sphenoid-cavernous sinus approach in 32 cases, transsphenoid-clivus approach in 5 cases and endonasal multi-corridors approach in 45 cases. The postoperative follow-up content included clinical symptoms, physical examination, head MRI and endocrine examination.

Among the 117 patients, total resection was achieved in 67 cases, subtotal resection in 36 cases, and major resection in 14 cases. There were no deaths related to surgery. After operation, the relief rate of headache and dizziness was 67.6% (25/37), and the improvement rate of vision and visual field was 66.7% (52/78). The median follow-up time of 117 patients was 13 months (3-24 months). There were 2 cases of tumor recurrence, 5 cases of postoperative long-term hypopituitarism, and 12 cases of anosmia.

For invasive pituitary adenomas with heteromorphic growth, various endoscopic transnasal approaches and surgical methods could be chosen according to the growth characteristics of the tumor, which can reduce invasiveness, increase the tumor resection rate and be associated with good clinical efficacy.

To summarize the safety and efficacy of the Pipeline embolization device in the treatment of intracranial aneurysms.

A retrospective analysis was conducted on 103 patients with 108 intracranial aneurysms who were admitted to the Department of Neurointervention, the First Affiliated Hospital of Zhengzhou University and treated with PED from February 2015 to February 2020. Among them, 65 cases were small intracranial aneurysms in the internal carotid artery, 23 cases were distal aneurysms of the circle of Willis and 15 cases were vertebra-basilar aneurysms; 83 cases were saccular aneurysms and 20 cases were dissecting and fusiform aneurysms; 9 cases were ruptured aneurysms and 94 cases were unruptured aneurysms. After operation, the O′Kelly Marotta (OKM) grading standard was used to judge the degree of occlusion of aneurysm, and the modified Rankin scale (mRS) was used to evaluate the clinical prognosis.

A total of 109 stents were placed in 103 patients (108 aneurysms), and the success rate of stent placement was 100%. The immediate postoperative aneurysm occlusion results indicated grade A in 45 cases (43.7%), grade B in 42 cases (40.8%), grade C in 6 cases(5.8%) and grade D in 10 cases (9.7%) based on the OKM classification. Among 103 patients, 9 (8.7%) had complications during the perioperative period, including 1 hemorrhagic event (1.0%), 8 ischemic events (7.8%) and 1 death (1.0%). At 12 months postoperatively, 99 patients (97.1%) had mRS scores ≤2 points among 102 patients, and 3 patients (2.9%) scored between 3 and 5 points. A total of 79 patients underwent digital subtraction angiography (DSA) examination, which indicated grade B in 7 cases (8.9%) and grade C in 7 cases(8.9%), grade D in 65 cases (82.2%), and none of the patients had aneurysm recurrence.

For the treatment of small intracranial aneurysms of the internal carotid artery, vertebra-basilar and distal aneurysms of the circle of Willis, PED is associated with fewer perioperative complications and favorable surgical outcomes.

To preliminarily explore the efficacy and safety of Neuroform Atlas stent-assisted coiling in the treatment of intracranial wide-necked aneurysms.

A retrospective analysis was conducted on the clinical data of 64 patients harboring 67 intracranial wide-necked aneurysms treated with Neuroform Atlas stent-assisted coiling at the Department of Neurosurgery, Zhengzhou University People′s Hospital from August to December 2020. Ten patients (12 aneurysms) were treated with the overlap " Y" stent technique. The clinical follow-up was performed 3 months after the operation, and the clinical outcome of the patients was evaluated based on the modified Rankin scale (mRS). Digital subtraction angiography (DSA) was reviewed at 5 to 6 months post operation and Raymond grading scale was used to assess the occlusion status of aneurysm.

A total of 74 Neuroform Atlas stents were successfully implanted in 67 aneurysms and there was 1 case of intraoperative complication. Immediate post-procedural DSA of 67 aneurysms showed that 56 (83.6%) aneurysms were completely occluded (Raymond Ⅰ), 4 (6.0%) had residual aneurysmal necks (Raymond Ⅱ), and 7 (10.4%) had residual aneurysmal domes (Raymond Ⅲ). After the operation, 1 patient died of cerebral herniation and 2 patients had cerebral infarction. Three patients were lost to follow-up and 60 patients completed a 3-month follow-up. The mRS was 0 in 53 patients, 1 in 4, 2 in 2 and 3 in 1. Fifty-three patients (55 aneurysms) underwent imaging follow-up at 5-6 months post procedure, among whom 50 (90.9%) reported complete occlusion (Raymond Ⅰ), 2(3.6%) had residual aneurysmal neck (Raymond Ⅱ), and 3 (5.5%) had residual aneurysmal dome (Raymond Ⅲ), and there was no in-stent stenosis or delayed thrombosis.

The preliminary observation suggests that Neuroform Atlas stent-assisted coiling has high occlusion rate and low complication rate in the treatment of intracranial wide necked aneurysms.It seems effective and safe.

To evaluate the safety and efficacy of endovascular treatment in patients with low-grade (Hunt-Hess grade Ⅰ-Ⅲ) ruptured anterior communicating artery (ACoA) aneurysms complicated with intracranial hematomas.

The clinical and imaging data of 42 patients with low-grade ACoA aneurysm combined with intracranial hematomas who underwent endovascular treatment at the Interventional Radiology Department of the First Affiliated Hospital of Nanjing Medical University from March 2015 to March 2020 were retrospectively analyzed. Among 42 cases of ACoA aneurysms, 32 cases underwent simple coil embolization and 10 cases underwent stent-assisted embolization. Intracranial hematomas were treated conservatively. Digital subtraction angiography (DSA) or CT angiography (CTA) was used for postoperative imaging follow-up, and Raymond classification was used to evaluate the embolization effect of aneurysm. For clinical follow-up, we used Glasgow Outcome Scale (GOS) (at discharge) and modified Rankin scale (mRS) (at 6 months).

For 42 cases of ACoA aneurysm, immediate DSA post embolization showed complete occlusion (Raymond Ⅰ) in 21 cases (50.0%), near-complete occlusion (Raymond Ⅱ) in 20 cases (47.6%), and partial occlusion (Raymond Ⅲ) in 1 case (2.4%). The overall complication rate was 9.5% (4/42), including 1 case of stent-assisted postoperative thromboembolic event and 3 cases of delayed cerebral ischemia. Postoperative reexamination of the head CT showed absorption of hematoma compared with preoperative conditions. At the time of discharge from the hospital, there were 34 cases of GOS grade Ⅴ (80.9%), 7 cases of grade Ⅳ(16.7%), and 1 case of grade Ⅲ(2.4%). There was no death. Among 42 patients, 36 patients (85.7%) underwent DSA review, and the median time for review was 6.5 months (4-12 months). Among them, 32 patients (88.9%) were in Raymond Grade Ⅰ and 4 patients were in Grade Ⅱ(11.1%). One case of aneurysm recurrence was treated with stent-assisted re-embolization. Clinical follow-up at 6 months after surgery showed that the patient's favorable prognosis (mRS of 0-2 points) rate was 97.6% (41/42).

Endovascular treatment for low-grade ACoA aneurysms with hematomas is safe and effective, and stent-assisted coiling embolization does not significantly increase the risk of complications. The hematoma can be absorbed after aneurysm embolization. However, those need to be further confirmed by large sample data and long-term follow-up.

To explore the feasibility and effect of microchannel keyhole technique in minimally invasive resection of symptomatic sacral cysts.

The clinical data of 45 patients with symptomatic solitary sacral cyst who were admitted to the Department of Neurosurgery, Peking University Third Hospital from February 2017 to December 2019 were retrospectively analyzed. All 45 patients underwent individualized laminectomy of posterior wall of sacral canal and then microsurgical resection of cyst through microchannel (width ≤1.5 cm). The patients′ pain conditions were evaluated based on the visual analogue scale (VAS) and their neurological functions were assessed using the Japanese Orthopedics Association (JOA) scale. The recurrence of cyst was evaluated by imaging follow-up.

The operation duration was 97.0±12.6 min (75-120 min). The length of hospital stay post operation was 6±1 days and ranged from 5 to 9 days. Of 45 patients, total resection of sacral cysts was achieved in 41 cases and subtotal resection with distal cyst wall remaining in 4 cases. Pathological results showed that all of sacral cysts were simple cysts. Except for 4 patients with numbness in the sacrococcygeal region after operation, the remaining 41 patients did not experience aggravation of neurological dysfunction. Forty-five patients were followed up for 3 to 36 months after surgery (median: 15 months). All 4 patients with sacrococcygeal numbness returned to normal, and no cyst recurrence was seen. The last follow-up VAS was 0 to 3 points (median: 0 points), and compared with 1 to 10 points before surgery (median: 3 points), the difference was statistically significant (Z=-5.866, P<0.001). The JOA score at the last follow-up (28.7±1.1 points; range: 22-29 points) increased compared with that prior to operation (21.6±3.9 points; range: 14-28 points) and the difference was statistically significant (t=-13.726, P<0.001).

The application of microchannel keyhole approach in the minimally invasive treatment of symptomatic sacral cysts can effectively relieve the clinical symptoms with few complications and low recurrence rate.

To investigate the therapeutic outcomes of surgical treatment of dural terminal cystoid meningocele (DTCM) in children.

From January 2015 to January 2021, 11 children with DTCM underwent surgical treatment in the Department of Neurosurgery of the Children′s Hospital of Soochow University, of which 8 cases underwent cutting of the terminal filum + resection of intraspinal cyst + repair of terminal dural defect, 2 cases only underwent cutting of the terminal filum, 1 case underwent cutting of the terminal filum + partial resection of cyst wall + fat packing of cyst cavity. We retrospectively observed the clinical and imaging improvement of the children′s conditions.

None of the children had complications such as infection and cerebrospinal fluid leakage after surgery. The postoperative follow-up period was 3 months to 5 years and 4 months (median: 3 years and 6 months), and none of the patients developed new neurological symptoms. The original symptoms of 4 children with preoperative symptoms were significantly improved in 3 cases. Re-examination of MRI 3 to 6 months after surgery showed that all the children had cut terminal filum. In 8 patients who underwent repair of the terminal dural defect, postoperative MRI showed that the sacral cysts disappeared. In the patient who underwent cutting of the terminal filum + partial resection of cyst wall + fat packing of cystic cavity, postoperative MRI showed that the cyst was replaced by packed fat tissue. In 3 children with preoperative extreme dilation of the central canal of distal spinal cord and terminal filum, postoperative MRI showed that the dilation was significantly improved.

Surgical treatment of DTCM in children is safe, which can improve the clinical symptoms and imaging changes of the children to a certain extent.

To discuss the treatment and prognosis of poor healing of scalp incision after craniotomy.

A retrospective analysis was conducted on the clinical data of 22 patients with poor healing of scalp incision after elective surgery in the Sixth Ward of Neuro-Oncology, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January 2014 to November 2020. Those patients accounted for 0.6%(22/3 667) of patients undergoing elective surgery in the same period. According to the scope of poor healing of the incision and the presence or absence of skin defects, the patients were divided into groups: poor healing of scalp incision without scalp defection (Group A1); poor healing of chronic wounds with cerebrospinal fluid leakage rather than defection of scalp (Group A2); poor scalp healing with skin defects (Group B); complex healing defect with osteomyelitis (Group C); complex healing defect, osteomyelitis and epidural abscess or brain abscess (Group D). Group A1 and A2 were given suture after exploring the scalp wound; Group B was given an incision dressing, and then underwent a second stage of suture; Group C and Group D were given debridement, bone flap removal and incision suture. Regular telephone or outpatient follow-up was performed to evaluate the patients′ incision healing.

Among the 22 patients, 7 were in group A1, 7 were in group A2, 4 were in group B, 1 was in group C, and 3 were in group D. Among 22 patients, 1 patient with recurrent craniopharyngioma in group D died of secondary subcutaneous empyema and brain abscess, and the remaining 21 patients completed the clinical follow-up of 3 to 60 months. One patient in group A2 after suboccipital far-lateral craniotomy had cerebrospinal fluid leakage lasting for 2 months and underwent ventriculoperitoneal shunt at another hospital due to hydrocephalus. By the last follow-up, the incisions of 21 patients were all healed, and the median healing time was 14 days (range: 7-42 d).

Patients with poor incision healing after craniotomy have a generally good prognosis after individualized treatment according to the scope of the incision and the presence or absence of skin defects.

To observe the efficacy of early ventriculoperitoneal shunt (VPS) in the treatment of neonatal congenital hydrocephalus.

A retrospective analysis was conducted on 98 cases of neonatal congenital hydrocephalus treated by VPS in the Department of Neurosurgery of the Third Affiliated Hospital of Zhengzhou University from January 2017 to June 2020. The diagnosis of fetal hydrocephalus was made by ultrasound and fetal MRI before delivery, and neonatal hydrocephalus was diagnosed by head CT on the first day after delivery [lateral ventricle body width (LVW) >10 mm], combined with ventricular diameter/biparietal diameter (V/BP, >0.25 for hydrocephalus) to judge the severity of hydrocephalus. VPS was performed within 1 month after birth. One year after the operation, the head CT was rechecked to assess the improvement of LVW and V/BP, and the Gecell Developmental Scale was used to assess the development of the child.

All 98 children underwent successful operations. After VPS, 11 cases (11.2%) had subcutaneous tunnel infection, 7 cases (7.1%) had shunt infection, 14 cases (14.3%) had cerebrospinal fluid infection, and 5 cases (5.1%) had blockage of the shunt, and shunt rupture occurred in 1 case (1.0%). One year after the operation, the LVW and V/BP of 98 children were 15.3±6.5 mm and 0.27±0.08 respectively, which were significantly different compared with preoperative values (33.3±9.4 mm and 0.39±0.12) (both P<0.01). In this series, 77 cases (78.6%) of the children had a decrease in LVW compared with preoperative conditions, and 21 cases (21.4%) had little improvement or an increase in LVW compared with preoperative conditions. The evaluation based on Gecell Developmental Scale showed that 74 cases (75.5%) developed in line with the age of the month, 24 cases (24.5%) did not meet the age of the month, of which 16 cases (16.3%) were slightly behind, and 8 cases (8.2%) were moderately or severely behind. In a total of 87 cases (88.8%), the assessment result through LVW on skull CT was concordant with that using Gecell Developmental Scale, while those were not concordant in 11 cases (11.2%).

Early surgery after delivery has a good efficacy in the treatment of neonatal congenital hydrocephalus, and the comprehensive evaluation of the therapeutic effect should include imaging changes and developmental indicators.

To explore the influencing factors of hematoma enlargement in patients with spontaneous intracerebral hemorrhage (sICH).

A retrospective analysis was conducted on the clinical data of 224 patients with sICH admitted to the Department of Neurosurgery, the First Affiliated Hospital of Soochow University from September 2018 to September 2019. All patients underwent initial head CT scan at admission (interval between disease onset and hospital admission ≤ 8 h), and the head CT was re-examined 24 hours later. An increase of ≥33% or an increase of ≥12.5 ml in the volume of hematoma at the time of the re-examination was defined as hematoma enlargement. All patients were divided into hematoma enlargement group (n=70) and hematoma non-enlargement group (n=154). Clinical data were collected and included age, gender, history of diabetes, initial hematoma volume, systolic blood pressure at admission, Glasgow coma score (GCS) at admission, and whether there was abnormal coagulation function. It was further determined whether there was irregular mixed density sign at the edge of the hematoma, black hole sign, vortex sign, lobulation sign or hybrid sign on the first head CT scan. Univariate and multivariate logistic regression analyses were used to determine the factors affecting hematoma enlargement.

Among the 224 patients, 71 had irregular mixed density signs at the edge of hematoma, 56 had black hole signs, 51 had vortex signs, 53 had lobulation signs and 58 had hybrid signs. There was no significant difference in age, gender or initial hematoma volume between the hematoma non-enlargement group and hematoma enlargement group (all P>0.05). Compared with the hematoma non-enlargement group, the hematoma enlargement group had a higher proportion of people with a history of diabetes and abnormal blood coagulation function, lower GCS at admission, higher systolic blood pressure, presence of irregular mixed density sign at the edge of the hematoma, black hole sign, vortex sign, lobulation sign and hybrid sign on head CT (all P<0.05). The results of multivariate logistic regression analysis showed that the medical history of diabetes, low GCS at admission, high systolic blood pressure at admission, abnormal blood coagulation function, and presence of irregular mixed density sign at the edge of the hematoma, black hole sign, vortex sign, lobulation sign, and hybrid sign on head CT were all risk factors for hematoma enlargement in patients with sICH (all P<0.05).

Patients of sICH with a history of diabetes, low GCS, high systolic blood pressure, abnormal blood coagulation function, and certain CT imaging signs at admission are at high risk of hematoma enlargement.