Volume 38 · Issue 03 · 2022

To explore the management strategy of subarcuate loop and its anatomic variations identified during vestibular schwannoma surgery.

From January 2017 to December 2020, 504 cases of vestibular schwannomas were resected through the suboccipital retrosigmoid approach at the Department of Neurosurgery, Huashan Hospital, Fudan University, and 12 cases (2.4%) with a subarcuate loop or its anatomic variation were found and treated during the operation. The clinical data of the 12 patients were retrospectively analyzed. All patients were evaluated by House-Brackmann (H-B) classification of facial nerve function and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification guidelines at 1 week after operation. Contrast-enhanced MRI was performed in outpatient clinic 3 months after operation and every year thereafter, and facial nerve function and hearing were evaluated.

Among 12 patients, 5 cases had a normal subarcuate loop adhering to the dorsal surface of the tumor, tumor resection was accomplished after the loop was displaced medially; in 3 cases, the apex of the anomalous subarcuate loop was embedded in the dura surrounding the subarcuate fossa, and tumor resection was accomplished after the loop was freed and mobilized medially with a sleeve of dura; in 4 cases, the apex of the anomalous subarcuate loop was embedded in the bone surrounding the subarcuate fossa, and tumor resection was accomplished after drilling the subarcuate fossa and releasing the loop in 1 patient, and tumor resection was performed from the perivascular space in 3 patients. Tumors were completely resected in 12 cases, and the main vascular loops remained unobstructed. There was no death or cerebrospinal fluid leakage. One patient with intraoperative vascular loop branch rupture and hemorrhage developed postoperative focal infarction of the lateral cerebellum, resulting in ataxia. All 12 patients had grade D hearing after operation. The median follow-up time of the 12 patients was 13 months (range: 10-53 months). AT 3 months after the operation, enhanced brain MRI confirmed that the tumors were completely resected in all 12 cases. By the last follow-up, facial nerve function H-B classification showed that 5 cases were grade Ⅰ, 4 cases were grade Ⅱ, 2 cases were grade Ⅲ, and 1 case was grade Ⅳ. No tumor recurrence was found in 12 patients.

When a subarcuate loop or its anatomic variation is encountered during vestibular schwannoma surgery, an attempt should be made to free and displace it medially before tumor resection. If the apex of the loop is deeply embedded in the bone surrounding the subarcuate fossa and there is enough space to expose the tumor and the internal auditory canal, tumor resection can also be performed from the perivascular space.

To explore the clinical characteristics, surgical efficacy and influencing factors of vestibular schwannoma in adolescents.

A retrospective analysis was conducted on the clinical data of 30 adolescent patients with vestibular schwannoma (<21 years old) who underwent tumor resection at the Department of Neurosurgery, the First Medical Center, Chinese PLA General Hospital from January 2008 to December 2018. Head MRI was reperformed after operation to judge the degree of tumor resection. Assessment using House-Brackman (H-B) facial nerve grading system was performed. A decrease of ≥2 grades from the preoperative level was defined as facial nerve function injury. All patients underwent outpatient follow-up after operation, re-examination of enhanced brain MRI to identify tumor recurrence, and hearing was rated based on American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). The age of onset, gender, clinical manifestations, imaging manifestations of cranial MRI, facial nerve function, operation method, intraoperative blood loss, operation time, degree of tumor resection and hospitalization time of the patients were documented. Univariate logistic regression analysis was used to preliminarily determine the clinical factors affecting the degree of tumor resection, postoperative facial nerve injury and tumor recurrence.

The male to female ratio of the 30 patients was 1.3 ∶1.0, the age was 17.8±3.5 years (16.0-20.0 years), the median course of disease was 10(4-36) months, and the most common clinical manifestations were hearing loss [90.0%(27/30)] and tinnitus [53.3%(16/30)]. Before surgery, most patients (96.7%, 29/30) had good facial nerve function (H-B grade Ⅰ), and a small number of patients (6/17) had practical hearing. The largest tumor diameter was 2.9±1.3 cm (0.5-5.0 cm). Postoperative head MRI results showed that 21 patients (70.0%) had complete resection, and 9 patients (30.0%) had near total resection. Facial nerve function assessment results showed that 9 patients (30.0%) had facial nerve function injury after surgery. The follow-up time of 30 patients was 75.4±44.7 months (6-149 months). During follow-up, 4 patients (13.3%) had tumor recurrence. Among 6 patients with practical hearing before surgery, only 2 still had remaining hearing at the last follow-up. The results of univariate logistic regression analysis showed that the maximum tumor diameter (OR=0.45, 95%CI: 0.20-0.98) and operation time (OR=0.60, 95%CI: 0.40-0.92) were the influencing factors of tumor resection degree in adolescent patients with vestibular schwannoma. The largest tumor diameter (OR=38.21, 95%CI: 1.20-1 258.40) was the influencing factor of facial nerve function damage after surgery. No factors affecting the recurrence of tumor in adolescent patients with vestibular schwannoma have been identified.

Hearing loss and tinnitus are common clinical manifestations of vestibular schwannoma in adolescents. In case of large tumor volume, surgery is the main treatment. Patients with large tumor volume have low complete tumor resection rate and are prone to have facial nerve function injury after operation.

To explore the application value of microscopy combined with neuroendoscopy in skull base tumor resection.

A retrospective analysis was conducted on the clinical data of 100 patients with skull base tumors admitted to the Department of Neurosurgery, the First Affiliated Hospital of Soochow University from July 2016 to July 2020. Among them, 50 patients were treated with microscopy combined with neuroendoscopy (dual-scopy group), and 50 patients underwent microsurgical operations only (microscopy group). There were 30 cases in the dual-scopy group and 24 cases in the microscopy group among the cavernous sinus tumor patients; there were 12 cases in the dual-scopy group and 16 cases in the microscopy group among the petroclival region tumor patients; there were 8 cases in the dual-scopy group and 10 cases in the microscopy group among the foramen magnum tumor patients. The differences in operation time, total tumor resection rate, surgical complications, postoperative symptom improvement, and tumor recurrence were analyzed between the dual-scopy group and the microscopy group of patients with tumors at three sites.

Compared with the microscopy group, the total tumor resection rate in the dual-scopy group was higher for the cavernous sinus tumors [86.7% (26/30) vs. 62.5% (15/24)], petroclival region tumors (11/12 vs. 9/16), and the foramen magnum tumors (7/8 vs. 4/10). During postoperative follow-up period (range: 18-60 months, median: 48 months), the tumor recurrence rate in the dural-scopy group was lower than that in the microscopy group for the cavernous sinus tumors[6.7% (2/30) vs. 29.0% (7/24)], petroclival region tumors (0/12 vs. 5/16), and foramen magnum tumors (1/8 vs. 7/10), and the differences were all statistically significant (all P<0.05). At 1 month post operation, the dual-scopy group had more symptomatic improvement of clinical symptoms than microscopy group among the patients with tumors in the cavernous sinus and petroclival areas (both P<0.05), while there was no significant difference in the symptomatic improvement between the two groups among patients with tumors in the foramen magnum (P=0.407). There was no significant difference in the operation time or the incidence of complications between the two groups (both P>0.05).

Microscopy combined with neuroendoscopy can improve the total resection rate of skull base tumors, reduce the recurrence rate, and dose not increase the operation time. The technique of dual-scopy is similar to microsurgery in controlling surgical complications.

To explore the clinical features, treatment and outcomes of hemangioblastomas in the cerebellopontine angle (CPA) region.

A retrospective analysis was conducted on the clinical data of 31 patients with hemangioblastoma in the CPA region admitted to the Department of Neurosurgery, West China Hospital of Sichuan University from January 2003 to January 2019. All 31 patients underwent tumor resection, and 10 patients underwent preoperative endovascular embolization. Outpatient follow-up was performed every 3 months after surgery, and every 6 months after 1 year. Follow-up content included changes in clinical symptoms of patients and re-examination of enhanced brain MRI to determine whether there was tumor recurrence.

Among the 31 patients, 20 were males and 11 were females; the median disease duration was 15.3 months (0.5-72.0 months). The main clinical manifestations were headache (25 cases, 80.6%), hearing loss (19 cases, 61.3%) and tinnitus (13 cases, 41.9%). Ten patients (32.3%) were diagnosed with Von Hippel-Lindau (VHL) syndrome. Preoperative contrast-enhanced MRI showed solid tumors in 18 cases (58.1%) and cystic tumors in 13 cases (41.9%). Ten cases underwent preoperative endovascular embolization. Among the 27 patients with complete surgical data, 22 patients (81.5%) underwent surgery via retrosigmoid approach, and 5 patients (18.5%) underwent surgery via the far lateral approach. One patient had severe bleeding during tumor resection, the tumor was tightly adhered to the cranial nerves, and only subtotal resection was performed. Postoperative re-examination of enhanced brain MRI showed that 30 patients (96.8%) underwent total tumor resection, and 1 patient (3.2%) underwent subtotal tumor resection. There were 4 cases (12.9%) of new-onset facial paralysis, 4 cases (12.9%) of posterior cranial nerve palsy, 2 cases (6.5%) of trigeminal nerve damage, 2 cases (6.5%) of abducens nerve palsy, 1 case (3.2%) of intracranial hemorrhage, 1 case (3.2%) of cerebrospinal fluid leakage and 1 case (3.2%) of pseudomeningocele. At discharge, preoperative symptoms improved in 22 patients, remained unchanged in 6 patients, and worsened in 3 patients. The follow-up time of 31 patients was 39.1±23.4 months (3-144 months). By the last follow-up, preoperative symptoms improved in 25 cases, did not improve in 3 cases, and aggravated in 3 cases. Except for 2 patients with new-onset facial paralysis after surgery whose facial nerve function did not improve, the neurological functions of the rest of the patients with new-onset cranial nerve dysfunction after surgery recovered to normal. Five patients(16.1%) had tumor recurrence in situ during follow-up, including 3 patients with VHL syndrome.

Hemangioblastomas in the CPA region are clinically rare, and there are slightly more male patients. Headache, hearing loss and tinnitus are often the first symptoms. Surgery is an effective treatment and preoperative endovascular embolization can help reduce surgical risks and intraoperative bleeding. Although it is a benign tumor, long-term follow-up is necessary after surgery.

To explore the clinical strategies for surgical treatment of suprasellar meningiomas and protection of optic nerve function.

A retrospective analysis was conducted on the clinical data of 165 patients with suprasellar meningiomas (diameter > 2 cm) who underwent surgical operations at Department of Neurosurgery, Henan Provincial People′s Hospital from January 2017 to December 2020. Intradural tumor resection was used in all operations. According to different intraoperative treatment strategies, the patients were divided into the removal group (n=81) which had surgical removal of the optic canal or/and anterior clinoid process and non-removal group (n=84) which had no removal of skull base. Simpson classification was used to evaluate the degree of tumor resection after operation. Visual acuity and visual field tests were performed before and after surgery to evaluate the improvement degree in both groups.

There was no significant difference in baseline data between the removal group and the non-removal group (all P>0.05). Among the 165 patients, 139 underwent Simpson grade Ⅰ-Ⅲ resection, and 26 underwent Simpson grade Ⅳ resection. Compared with the non-removal group, the removal group could significantly improve the total tumor resection rate, which was 93.8% (76/81) in removal group and 75.0% (63/84) in non-removal group (P<0.05). The 6-month follow-up showed that the visual acuity and visual field improvement rate of the patients in the removal group was significantly higher than that in the non-grinding group, which were 82.9% (58/70) and 64.1% (41/64) respectively (P<0.05). The postoperative visual acuity and visual field deterioration rate of the patients in the removal group (2.5%, 2/80) was lower than that in the non-removal group (12.0%, 10/83) (P<0.05). Among the 109 patients whose tumors did not invade the optic canal based on preoperative imaging, the visual acuity and visual field improvement rate in the removal group (73.5%, 36/49) was also higher than that in the non-removal group (53.3%, 32/60) (P<0.05).

During suprasellar meningioma surgery, optic canal and/or anterior clinoid removal, sharp dissection, and tension-free optic nerve displacement can significantly improve the postoperative visual acuity and visual field of patients and increase the total tumor resection rate.

To investigate the predictive value of intraoperative blink reflex (BR) monitoring for the outcome of eyelid closure in patients with large acoustic neuromas.

A retrospective analysis was conducted on the clinical data of 80 patients with large acoustic neuroma who underwent surgical operations at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from December 2020 to April 2021. Intraoperative BR monitoring was performed in all patients, and the decrease ratio of intraoperative BR amplitude was documented. The eyelid closure function of the patients was evaluated according to Terzis facial grading system at 1 week, 3 months, and 6 months after operation, and they were divided into good eyelid closure function group (Terzis grade ≥ 4) and poor eyelid closure function group (Terzis grade <4). Univariate and multivariate logistic regression analyses were used to determine the influencing factors of postoperative eyelid closure function outcome. Receiver operating characteristic (ROC) curves were drawn and the area under the curve (AUC) was calculated to determine the critical value of BR and its predictive value.

Among the 80 patients, 76 patients (95.0%) had BR waveforms, and 1 patient was not included in the analysis due to intraoperative adjustment of anesthesia depth. Among the 75 patients, the facial nerve was closely adhered to the tumor and difficult to separate in 28 (37.3%) cases, and the facial nerve was severely deformed and thin in 14 (18.7%) cases. The proportions of good eyelid closure function at 1 week, 3 months and 6 months after operation were 58.7% (44/75), 77.3% (58/75) and 82.7% (62/75), respectively. The results of univariate analysis showed that there were significant differences in the facial nerve morphology and BR amplitude decrease between the good eyelid closure function group and the poor function group at 1 week, 3 months, and 6 months after surgery (all P<0.05). The difference in the difficulty of facial nerve separation was statistically significant between the good eyelid closure function group and the poor function group at 3 months after operation (P<0.05). The results of multivariate logistic regression analysis showed that the decrease of BR amplitude was the influencing factor of the outcome of eyelid closure function at 1 week (OR=1.11, 95%CI: 1.06-1.16), 3 months (OR=1.08, 95%CI: 1.04-1.13), 6 months (OR=1.08, 95%CI: 1.03-1.13)post operation (all P<0.01); the critical values were 20.8%, 29.4%, and 51.0% respectively; the sensitivities were 90.3%, 94.1%, 84.6% respectively; the specificities were 89.7%, 83.3%, and 92.1% respectively.

Intraoperative BR monitoring can effectively reflect the outcome of postoperative eyelid closure function in patients with acoustic neuroma. A decrease in BR amplitude >50% can be used as an early warning standard during surgery.

To investigate the efficacy and safety of masseteric-facial nerve transfer (MFNT) technique in the treatment of peripheral facial paralysis (PFP).

We conducted a retrospective study on the clinical data of 40 patients with PFP who underwent MFNT at the Department of Neurosurgery, West China Hospital, Sichuan University from June 2017 to September 2020. Facial expression and facial movements as participants attempted to perform a series of facial expression tasks were documented and evaluated based on facial nerve grading scale 2.0 (FNGS 2.0) and Sunnybrook facial grading system (SFGS). Moreover, facial asymmetry index (FAI), width of palpebral fissure, deviation of the philtrum and angles or excursions of the oral commissure were applied to assess the facial symmetry and motor function in order to explore the effect of MFNT.

The occurrence of postoperative complication was 7.5%(3/40), including mild infection, discomfort in eyes and parotid leakage in 1 case each. Forty patients were followed up for 6.6-24.7 months(median: 13.4 months). The median interval to first contraction of facial muscles while biting after surgery was 2.4(0.8-5.6)months in 40 patients. Out of 40 patients, 34 (85%) showed significantly improved facial symmetry and movements. The FNGS 2.0 results revealed that compared to those before operation, the scores of eye closure, nasolabial folds and oral commissure motion on the affected sides post operation were evidently decreased (all P<0.001), while the synkinesis score did not increase (P>0.05). After operation, the median grade of the patients was significantly reduced from 5.0 to 3.5 based on the FNGS 2.0(P<0.001). Patients experienced distinctly improved scores in resting and voluntary movement domains (both P<0.001) with slightly elevated scores in synkinesis domain (P<0.05), resulting in dramatically increased composite score (P<0.001). evaluated by the SFGS. The quantitative facial measurement indicated that both resting FAI and FAI during smiling decreased (both P<0.001). The eyelid closing capacity was notably enhanced, and the deviation of the philtrum was decreased post operation(both P<0.001). After MFNT, the oral commissure excursion on the affected side was significantly increased and the slope of bilateral oral commissure reduced significantly (both P<0.01).

The MFNT is an effective technique for facial reanimation, which could achieve satisfactory facial symmetry, and improve facial movement with few complications. The masseteric nerve should be a preferential choice for facial nerve transfer.

To explore the surgical skills and therapeutic effect of resection of cavernous sinus tumors via Dolenc approach.

A retrospective analysis was conducted on the clinical data of 36 patients with cavernous sinus tumors resected via the Dolenc approach at the Department of Neurosurgery, Shiyan Taihe Hospital (Affiliated Hospital of Hubei University of Medicine) from January 2014 to March 2021, including 13 cases of schwannoma , 5 cases of cavernous hemangioma, 8 cases of meningioma, 4 cases of invasive pituitary adenoma, 2 cases of chordoma, 2 cases of chondrosarcoma, 1 case of cholesteatoma and 1 case of dermoid cyst. The degree of tumor resection and surgical complications were evaluated, and the degree of tumor recurrence and progression was followed up.

Of the 36 patients, 29 (80.6%) had total tumor resection, 4 (11.1%) had subtotal tumor resection, and 3 (8.3%) had major tumor resection. There were 13 cases of new-onset (8 cases) or aggravated symptoms of neurological deficit (5 cases) post operation; none of the patients had complications such as intracranial hemorrhage and cerebrospinal fluid leakage. The median follow-up time of the 36 patients was 13 months (range: 3-73 months). Among the patients with subtotal resection, 3 patients with meningioma underwent Gamma Knife treatment after operation; 1 patient with schwannoma recurred 50 months after operation and underwent total resection again; those 4 patients had no tumor progression or recurrence. Among the 3 patients undergoing major resection, 2 patients with invasive pituitary adenoma underwent Gamma Knife treatment after surgery, of which 1 patient died of tumor recurrence 26 months after surgery, and 1 patient had no tumor progression; 1 patient of chordoma had recurrence at 11 months after surgery and did not undergo further treatment. In total resection group, 2 cases of chondrosarcoma and 1 case of chordoma underwent postoperative radiotherapy, and no recurrence was found during follow-up. Among 13 patients with symptoms of neurological deficit, 8 recovered during the follow-up period.

For resection of cavernous sinus tumors, the Dolenc approach can be adopted to fully expose the lesions and important nerves and blood vessels, reduce brain tissue traction, and improve the safety of surgery and the degree of complete tumor resection.

To preliminarily explore the efficacy of posterior straight incision sacrococcygeal fenestration for resection of presacral tumors.

We retrospectively analyzed the clinical data of 9 patients with presacral tumors admitted to the Department of Neurosurgery, Union Hospital Affiliated to Fujian Medical University from April 2018 to April 2020. The length of the incision, intraoperative blood loss, operation time and hospital stay of all patients were counted. Postoperative CT or MRI of the lumbosacral region was performed to determine the degree of tumor resection. After discharge, outpatient follow-up was performed for all patients. The follow-up included re-examination of lumbosacral CT or MRI to determine tumor recurrence and evaluation of pain improvement using the visual analog scale (VAS).

The ureter or aorta was not damaged during the operation in 9 patients. The length of the incision [M(range)] was 8 (2.0-12.0) cm, the median intraoperative blood loss[M(range)] was 50 (30-500) ml, the operation time was 180 (100-390) min, and the hospital stay[M(range)] was 7(5.0-14.0) days. One patient developed blisters around the wound after operation, which healed after active treatment. Postoperative re-examination of lumbosacral CT or MRI showed that complete tumor resection was achieved in 8 cases and major resection in 1 case. Postoperative pathological examination revealed 4 cases of schwannoma, 3 cases of chordoma, 1 case of intestinal adenocarcinoma, and 1 case of well-differentiated chondrosarcoma. The follow-up time[M(range)] of 9 patients was 21 (13-37) months. During the follow-up period, 1 patient had tumor recurrence (chordoma) and underwent surgery again; the other 8 patients did not have recurrence. At the last follow-up, the VAS[M(range)] score of 9 patients was 0 (0-5), which was significantly lower than that before operation [7(6-8), u=-2.53, P=0.011].

Posterior straight incision sacrococcygeal fenestration for resection of presacral tumors seems to be associated with less damage, less intraoperative blood loss, low postoperative complication rate and faster postoperative recovery.

To investigate the preliminary application value of three-dimensional positron emission tomography (PET) and MRI co-registration and fusion in the presurgical evaluation of drug-resistant epilepsy in children.

A retrospective analysis was conducted on the clinical data of 32 children with refractory epilepsy admitted to the Department of Neurosurgery, Children′s Hospital of Nanjing Medical University from February 2019 to April 2021. Preoperative non-invasive examinations [including head MRI, PET, scalp video-EEG (electroencephalography)] were performed, and PET results were co-registered and fused with MRI data and presented in a three-dimensional presentation to guide presurgical evaluation and surgical strategy development. The Engel grading criteria were used to assess surgical efficacy.

Among the 32 children, the interictal epileptic discharges were located on the ipsilateral hemisphere of the lesion in 9 cases (28.1%)and on both sides in 23 cases (71.9%). Of those, ictal EEG was recorded in 25 cases, and 24 cases had focal onsets. Preoperative MRI showed positive findings in 30 cases (93.7%), negative in 2 cases (6.3%). PET results were all positive and were all positive after three-dimensional PET-MRI co-registration and fusion, which indicated single lesions in 29 cases (90.6%) and multiple lesions in 3 cases (9.4%). Operations were successfully performed based on intraoperative electrocorticography combined with preoperative plans, which included 31 cases of epileptogenic zonectomy and 1 case of left temporo-parieto-occipital lobe transection. Postoperative head MRI showed that the range of surgical resection was consistent with the preoperative surgical plan. Pathological results included 23 cases of focal cortical dysplasia, 5 cases of encephalomalacia, 2 cases of dysembryoplastic neuroepithelial tumor, 1 case of post-encephalitis change, and 1 case of vascular malformation. The median follow-up time for 32 children was 15.9 months (4 to 30 months). The last follow-up showed that Engel grade I was reported in 29 cases, Grade II in 1 case, and Grade III in 2 cases.

The three-dimensional PET-MRI co-registration and fusion technique can improve the detection rate of epileptic foci in children with drug-refractory epilepsy, facilitate preoperative evaluation and surgical planning, and thus improve the success rate of surgery.

To investigate the survival of children medulloblastoma (MB) after operation and its influencing factors.

A retrospective analysis was conducted on the clinical data of 57 children with MB who underwent surgical treatment and had complete clinical data at the Department of Neurosurgery, the First Affiliated Hospital of Xinjiang Medical University from January 2011 to June 2017. Among them, 26 and 21 children underwent postoperative radiotherapy and chemotherapy respectively, and 20 out of them underwent radiotherapy + chemotherapy. The postoperative survival, radiotherapy and chemotherapy of the children were followed up. The Kaplan-Meier survival curve was drawn for survival analysis, and the log-rank test was used to analyze the possible factors affecting the overall survival of children.

The median follow-up time of the 57 children was 27 (6-64) months. At the end of follow-up, 20 children (35.1%) survived, and the 1-, 3-, and 5-year survival rates were 71.4%, 40.2%, and 22.2% respectively. The Kaplan-Meier survival curve showed that the median survival time of 57 children was 27.3 months. The median survival time of patients with and without radiotherapy after surgery were 41.0 and 15.0 months respectively; the median survival time of children with radiotherapy and chemotherapy after surgery was 42.5 and 15.0 months respectively, and the differences were statistically significant (both P<0.01). The median survival time of 20 children with radiotherapy and chemotherapy was 61.4 months, which was significantly different compared with that of 27 children with radiotherapy or chemotherapy alone (40.7 months) (P=0.009). However, there were no significant differences in survival time among patients varying in the gender, age, ethnicity, degree of tumor resection, tumor metastasis, or pathological type (all P>0.05).

The postoperative survival time of children with MB in Xinjiang is short, and postoperative radiotherapy and chemotherapy are important factors affecting.

To investigate the diagnosis, surgical treatment strategies, outcomes and safety of scalp arteriovenous fistula (AVF) in pediatric patients.

A retrospective analysis was conducted on the clinical data of 8 children with scalp AVF admitted to the Department of Neurosurgery, Children′s Hospital of Nanjing Medical University from February 2017 to January 2021. All 8 patients presented with painless frontotemporal scalp pulsatile mass, of which 5 were congenital, 2 were iatrogenic, and 1 was post-traumatic. All children underwent head CT angiography (CTA), and 5 of them underwent digital subtraction angiography (DSA). The fistulas of 8 children were all located in the frontotemporal region, and the feeding arteries were unilateral or bilateral superficial temporal arteries. All 8 patients underwent microsurgical resection, and 1 patient underwent neroendoscopy-assisted resection with a small incision.

The lesions in all those cases were resected smoothly. All 8 children were followed up for 4 to 50 months. None of the children had recurrence or scalp necrosis, and the incisions healed well.

Children′s scalp AVF is a rare vascular disease, which can be diagnosed based on the clinical symptoms, signs and head CTA. Surgical resection of scalp AVF in children can lead to curative effect with low recurrence rate and few complications.

To explore the correlation between vesicle amine transport protein 1 (VAT1) expression and the immune microenvironment of glioblastomas (GBMs).

The clinical data and transcriptome data of 135 GBM patients in the Chinese Brain Glioma Genome Atlas (CGGA) dataset were retrospectively analyzed. The algorithm CIBERSORT was used to analyze the proportion of various immune cells in 135 tumor tissues. According to the median value of VAT1 gene expression, it was divided into a high expression group (gene expression level greater than or equal to the median; n=68) and a low expression group (gene expression level less than the median; n=67). The gene set enrichment analysis (GSEA) was performed on the differentially expressed genes between the two groups. Tumor tissue samples from 9 GBM patients who underwent craniotomy and tumor resection at the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from November 2018 to April 2019 were randomly selected, and immunohistochemical staining was used to detect the expression of protein VAT1, p65 and CD80 proteins. The staining results were evaluated by semi-quantitative method.

According to the CIBERSORT analysis, the infiltration of follicular helper T cells and natural killer cells in VAT1 high expression group declined compared with VAT1 low expression group (P=0.019 and P=0.045, respectively). The result of GSEA analysis indicated that VAT1 expression was functionally involved in the immune process, regulation of immune response and inflammatory response (all P < 0.001). High expression of VAT1 was closely related to the regulation of nuclear factor kappa B inhibitor (IκB) kinase/nuclear factor kappa B (NF-κB) signaling and the upregulation of IκB kinase/ NF-κB signaling (both P = 0.001). With increased expression of VAT1, multiple specific genes of NF-κB signaling pathway showed positive correlation (all P<0.001). The result of immunohistochemical staining from 9 GBM patients indicated that the expression levels of p65 and CD80 were positively correlated with VAT1 (r=0.92 and 0.93 respectively, both P=0.004).

The preliminary study suggests that high expression of VAT1 could affect the immune response in GBMs and might alter the infiltration of peritumor immune cells via regulating NF-κB signaling pathway.

To investigate the propensity for mechanical thrombectomy for acute ischemic stroke with medium vessel occlusion (MeVO).

From January 2019 to January 2020, doctors from 150 tertiary hospitals in China capable of performing mechanical thrombectomy were selected as the survey subjects. Questionnaires from 131 physicians in 126 hospitals were collected for the study. Referring to the Advanced Live Interventional Course of Essen (ALICE), the research questionnaire was designed, and the questionnaire was collected by Sojump. The contents of the questionnaire included: (1) Information about the hospitals and doctors was interviewed. (2) Six cases of mild MeVO were designed (3 cases in each group with and without contraindications to alteplase thrombolysis), and each group included 1 case with occlusion at the M3 segment of the middle cerebral artery, 1 cases with occlusion at the A2 segment of the anterior cerebral artery, and 1 case with occlusion at the P2 segment of the posterior cerebral artery. The treatment plan adopted by the interviewed doctors for 6 cases was investigated (immediate mechanical thrombectomy, refusal to perform mechanical thrombectomy, and mechanical thrombectomy after failure of thrombolysis). (3) Five typical MeVO cases with ages of 40-, 50-, 60-, 70-, and ≥80 years respectively were designed to investigate the treatment strategies for cases of different ages. (4) We investigated the difficulties of using mechanical thrombectomy for MeVO in clinical practice and relevant possible solutions.

Among the 131 physicians, the proportion of physicians refusing mechanical thrombectomy in 6 cases was 30.5% (40) to 47.3% (62). For M3 segment occlusion without contraindications to thrombolysis, the proportion of physicians choosing immediate mechanical thrombectomy was 11.5% (15), that was 33.6% (44) and 29.8% (39) for A2 and P2 occlusion respectively, and the differences were significant (P<0.001). The proportion of physicians considering mechanical thrombectomy after failure of thrombolysis was 58.0% (76) for M3 segment occlusion, that was 22.1% (29) and 22.9% (30) for A2 and P2 occlusion respectively, and the differences were significant (P<0.001). For M3 segment occlusion patients with contraindications to thrombolysis, the proportion of physicians choosing immediate mechanical thrombectomy was 55.7% (73), that was 68.7% (90) and 58.0% (76) for A2 and P2 occlusion respectively, and there was no significant difference (P=0.720). For patients aged 40-, 50-, 60-, 70- and 80-, the proportion of doctors choosing mechanical thrombectomy were 86.3% (113), 84.8% (111) , 85.5% (112) , 77.9%(102) and 48.9%(64) respectively. the differences were significant (P<0.001). The challenges of mechanical thrombectomy for MeVO mainly included the lack of thrombectomy instruments, assessment tools, and related technical experience.

At present, there is a large heterogeneity in the endovascular treatment of MeVO, and the overall preferred ratio of mechanical thrombectomy is low.

To explore the feasibility and application value of microvascular anastomosis training with inguinal blood vessels in rats.

Seventy sides of 35 male Sprague-Dawley rats were used for microvascular anastomosis in the inguinal region. According to different anastomosis methods, 70 sides were divided into 4 groups: group A (femoral artery end-to-end anastomosis group) including group A1 (two-point anchoring method) and group A2 (one-way up method); group B (half-ring group); group C (arteriovenous shunt end-to-side anastomosis group) including group C1 (femoral artery to femoral vein group) and group C2 (femoral vein to femoral artery group); group D (femoral artery to vein side-to-side anastomosis). General status and mortality were observed in 35 rats. The suturing time and immediate patency rate were documented.

Seventy cases of inguinal microvascular anastomosis were successfully completed. There were 5 cases of anastomotic occlusion and 4 cases of anastomotic leakage. The immediate patency rate was 93% (65/70). None of the 35 rats died during or after the operation, and the blood supply and limb movement on the operation side were normal after operation. The anastomosis time of group A1 and group A2 was 36.5±7.6 min and 43.1±8.5 min respectively, and the difference between the two groups was statistically significant (t=-2.09, P=0.048). The anastomosis time of group B was 93.9±6.7 min. The anastomosis time of group C1 and group C2 group was 45.1±8.6 min and 50.4±10.1 min respectively, and the difference between the two groups was not statistically significant (t=-1.92, P=0.178). The anastomosis time of group D was 34.5±4.0 min.

Rat inguinal blood vessels can be used for training of anastomosis with various methods. The dissection of the inguinal blood vessels during operation is simple, fast and safe, and the postoperative disability and mortality rate of rats are low. It can be used as an ideal model for microvascular anastomosis training.