Volume 38 · Issue 05 · 2022

To explore the basic characteristic of traumatic head injuries in China from 2016 to 2019 and to provide basis for its prevention and control.

Data of head trauma cases from 256 hospitals in the National Injury Surveillance System (NISS) from January 1, 2016 to December 31, 2019 were collected, and the sociodemographic characteristics, basic characteristics and clinical characteristics of head trauma patients were analyzed.

From 2016 to 2019, 27.14% (1 503 196/5 537 821) of the first-visit cases in NISS emergency department or outpatient clinic were head trauma cases. Among children under 1 year old, head trauma accounted for 53.93% (9 668/17 927) of NISS emergency or outpatient injury cases. Among emergency or outpatient head trauma cases, 90.42% (1 359 210/1 503 196) of those were caused by unintentional injuries, and the top causes of head injuries were falling (589 830, 39.24%), blunt injury (320 483, 21.32%) and road traffic injury (273 349, 18.18%). Among emergency or outpatient head trauma cases, 10.67% (160 436/1 503 196) of the patients presented with concussion or cerebral contusion. From 2016 to 2019, the annual proportion of head trauma cases decreased from 27.81% (349 978/1 258 658) to 25.92% (414 262/1 598 413) of NISS emergency or outpatient injury cases. The proportion of cases aged 1-17 years[from 24.88%(87 065/349 978) to 28.90%(119 707/414 262)] and those aged 60 and above [from 11.84%(41 437/349 978) to 13.26%(54 947/414 262)] increased.

Children and the elderly are the key groups of head trauma cases in China. Falls and road traffic injuries are the main causes of head trauma in China. The prevention of falls of children and the elderly as well as road traffic injuries should be the focus of head trauma prevention and control.

To explore the clinical characteristics of hospitalized patients with traumatic brain injury (TBI) in Henan province and to provide a theoretical basis for the prevention and standardization of TBI.

We established a cooperative group consisting of 35 hospitals of different grades in Henan province and designed a questionnaire from January 1, 2017 to December 31, 2020. The questionnaires were filled by competent doctors strictly and accurately. Epidata 3.1 was used for data input and statistical analysis to identify the clinical characteristics of TBI inpatients.

A total of 15 345 hospitalized patients with TBI were enrolled into this study and the ratio of male to female was 3.65 ∶1.00. The patient′s average age was 36.5±16.3 years old (range: 1.5-89.0 years old), and the highest incidence of TBI was in the 16-55 years old group (77.1%, 11 831/15 345). Among patients with severe TBI, the mortality of patients taking anticoagulant and/or antiplatelet drugs (20.5%, 69/336) was higher than that of patients not taking those drugs (10.4%, 581/5 571) (χ²=11.91, P=0.001). Among the causes of injury, traffic accidents accounted for the highest proportion (63.4%, 9 731/15 345), of which riding electric bicycles (25.5%, 2 481/9 731) gradually became the main cause of traffic accidents. The proportion of patients undergoing surgical treatment was 37.7% (5 785/15 345), of which decompressive craniectomy was the main surgical method, accounting for 37.2% (2 152/5 785). Among patients undergoing decompressive craniectomy, the incidence of hydrocephalus was 46.0% (990/2 152). Conservative treatment accounted for 62.3% (9 560/15 345). Glasgow outcome grades Ⅴ, Ⅳ, Ⅲ, Ⅱ and Ⅰ at discharge were reported in 12 445 cases (81.1%), 1 347 cases (8.8%), 476 cases (3.1%), 322 cases (2.1%) and 755 cases respectively (4.9%).

The patients with TBI in Henan Province are mainly male, and the main cause of injury is traffic accidents, particularly riding electric bicycles. After surgery and conservative treatment, the overall outcome of TBI patients is good, but the level of treatment for TBI still needs to be further improved to reduce the mortality and improve the outcome of patients.

To investigate the effects of intracranial pressures (ICP) pre- and post decompressive craniectomy on the outcomes of patients with severe craniocerebral injury (TBI).

A retrospective analysis was conducted on the clinical data of 96 patients with severe TBI who underwent decompressive craniectomy in the Department of Neurosurgery, West China Hospital of Sichuan University from November 2009 to July 2019. All patients underwent ICP monitoring before and after the operation. Glasgow outcome scale (GOS) was used for assessment at 6 months post operation, and the patients were divided into a good outcome group and a poor outcome group. We then compared the differences in clinical data between the two groups of patients, and used a multivariate logistic regression model to analyze the effects of ICPs before and after surgery on the outcomes.

The initial ICP of 96 patients [M(range)] was 40.0(31.5-46.0) mm Hg (1mm Hg=0.133 kPa), the ICP measured, immediately after the operation was, 19.0(14.5-25.5) mm Hg, and the difference was statistically significant (P<0.001). Among 96 patients and at 6 months post operation, 57 cases were in the poor outcome group and 39 were in the good outcome group. Compared with the good outcome group, the poor outcome group had higher proportions of patients with dilated pupils, disappearance of the ambient cistern, and GCS score of 3-6. The preoperative and postoperative ICPs in poor outcome group were both higher than in good outcome group, and the differences were statistically significant (both P<0.05). Multivariate logistic regression analysis showed that after adjusting for age, gender, GCS, compression of the ambient cistern, pupil conditions, etc., for every 1 mm Hg increase in initial ICP, the risk of poor prognosis increased by 5% (OR=1.05, 95%CI: 1.01-1.09, P=0.014); for every 1 mm Hg increase in postoperative ICP, the risk of poor outcome increased by 11% (OR=1.11, 95%CI: 1.03-1.19, P=0.004).

Both preoperative and postoperative ICPs have certain influences on the prognosis of patients with severe TBI undergoing decompressive craniectomy.

To investigate the application value of transcranial Doppler ultrasound (TCD) in the assessment of intracranial pressure (ICP) in patients with traumatic brain injury (TBI).

A retrospective analysis was conducted on the clinical data of 26 patients with TBI who underwent invasive ICP monitoring early after admission from October 2018 to December 2020 in the Neurotrauma Department of the First Hospital of Jilin University. The TCD parameters of all patients (260 cases) were collected, including systolic blood flow velocity (FVs), diastolic blood flow velocity (FVd), mean blood flow velocity (FVm), pulsatility index (PI) and resistance index (RI). We documented invasive monitoring parameters during the same period, including ICP and mean arterial pressure (MAP). Modeling formula 1 [non-invasive ICP₁ (nICP₁) = 4.47×PI+ 12.68], formula 2 [nICP₂ = MAP×(1-FVd/FVm) -14], formula 3 (nICP₃ = 10.93×PI-1.28) were utilized to calculate nICP. The bivariate Pearson correlation coefficient was used to analyze the correlation between nICP and ICP at the same time, the Bland-Altman test plot of nICP and ICP was drawn to compare the consistency deviation, the receiver operating characteristic (ROC) curve was drawn for predicting the increase of ICP [ICP≥20 mm Hg (1 mm Hg=0.133 kPa)] using nICP and its predictive power was calculated. According to the applied invasive monitoring technology, the patients were divided into hydraulic group (159 cases) and piezoelectric group (101 cases). According to whether the patients underwent decompressive craniectomy, they were divided into decompressive craniectomy group (201 cases) and non-decompressive craniectomy group (59 cases). Subgroup analyses were performed separately.

Among the parameters of TCD, PI was positively correlated with ICP (r=0.74, P<0.001). The results of Pearson correlation analysis showed that nICP₁, nICP₂, nICP₃ were all positively correlated with ICP (all P<0.001). Bland-Altman test results showed that the deviations of nICP₁, nICP₂, and nICP₃ were 1.3±2.4 mm Hg, -2.1±6.3 mm Hg, -6.2±2.1 mm Hg respectively. Similar results were obtained in subgroup analyses. The ROC curve analysis results showed that the area under curve(AUC) of nICP₁, nICP₂, and nICP₃ for predicting increased ICP were 0.91, 0.79, and 0.89 respectively (all P<0.001), and nICP₁ had higher accuracy, corresponding sensitivity was 94.44%, specificity was 83.48%.

Calculation of nICP based on TCD parameters can assist dynamically assess the changes in ICP in patients with traumatic brain injury, which is simple, accurate, and has certain value of clinical application.

To investigate the surgical efficacy of intratemporal tumor-related peripheral facial paralysis (PFP).

We retrospectively analyzed the clinical data of patients with intratemporal tumor-related PFP who underwent tumor resection combined with facial nerve repair at the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from September 2017 to September 2020, and a total of 17 cases were enrolled. Facial paralysis lasted from 6 months to 10 years (median time was 2 years). Tumor resection and surgical complications were documented, and tumor recurrence was followed up. The improvement of the facial nerve function was assessed by House-Brackmann grading system (H-B grade) and facial nerve needle electrode electromyography (EMG).

All 17 patients underwent total resection of tumor and facial nerve repair. Cerebrospinal fluid leakage occurred in 3 patients after operation, and no tumor recurrence was indicated on MRI examination at 3 to 6 months post operation. There were 8 cases of preoperative H-B grade Ⅵ, 7 cases of grade Ⅴ, and 2 cases of grade Ⅳ. At 3 to 6 months after surgery, the facial nerve function deteriorated, including 11 cases of H-B grade Ⅵ, and 6 cases of Ⅴ. At 9 to 12 months after surgery, facial nerve function was improved in all patients expect 2 patients with H-B grade Ⅵ, who included 2 patients with H-B grade Ⅴ, 9 patients with H-B grade Ⅳ and 4 patients with H-B grade Ⅲ. Among the 12 patients followed up 24 months after surgery, 2 patients were classified as H-B grade Ⅴ, 3 patients as grade Ⅳ, 3 patients as grade Ⅲ, and 4 patients as grade Ⅱ. After 9-12 months, the orbicularis oris muscle function was improved in 7 cases and not improved in 1 case among 8 patients who underwent EMG. Frontal muscle function was improved in 5 cases and not improved in 3 cases. The orbicularis oculi muscle function was improved in 3 cases, not improved in 4 cases, and deteriorated in 1 case.

The surgical outcome of intratemporal tumor-related PFP seems relatively favorable, and the facial nerve function of most patients could improve after facial. The orbicularis oris muscle seems to have the most improvement effect and the orbicularis oculi muscle has the least.

To preliminarily observe the efficacy and postoperative complications of epileptogenic zonectomy in the treatment of epilepsy arising from supplementary motor area (SMA).

A retrospective analysis was conducted on the clinical data of 9 patients with SMA epilepsy admitted to the Department of Functional Neurosurgery, Xuanwu Hospital of Capital Medical University from June 2015 to December 2020. In all 9 patients, their seizures were confirmed by stereotactic electroencephalography (SEEG) to originate from SMA, and they underwent epileptogenic zonectomy. All patients underwent daily examinations of limb muscle strength, muscle tone and language function (comprehension, reading, repetition, etc.) during the postoperative hospital stay. Outpatient follow-up was performed at 1, 3, 6, 12 and 24 months after operation, and electroencephalography was performed. The postoperative outcome was evaluated according to the modified Engel grading system.

Among the 9 patients, 5 underwent epileptogenic zonectomy in the left hemisphere and 4 in the right hemisphere. The resected area included ipsilateral SMA. Postoperative pathological examination revealed focal cortical dysplasia in all cases. After operation, 8 patients reached seizure free, and 1 patient reported occasional short periods of loss of consciousness. Nine patients had different degrees of limb movement impairment, and all returned to normal one month after surgery. Four patients had language dysfunction, out of whom 1 patient recovered 7 days after surgery and 3 returned to normal 1 month after operation. The median follow-up time of 9 patients was 3 years (1-5 years). At the last follow-up, 8 cases were classified as Ⅰa and 1 case as Ⅰb according to the modified Engel grading system.

Preliminary observation has suggested that epileptogenic zonectomy for patients with epilepsy originating from SMA has good long-term efficacy. Although SMA syndrome often occurs after surgery, patients would recover within 1 month after surgery.

To investigate the feasibility and clinical value of microsurgical resection of tumors in the ventral foramen magnum and jugular foramen via a suboccipital far lateral approach.

The clinical data of patients with ventral foramen magnum tumors or jugular foramen tumors admitted to the Department of Neurosurgery of the Affiliated Provincial Hospital of Anhui Medical University from August 2011 to October 2020 were retrospectively analyzed. There were 14 cases of ventral foramen magnum tumors and 21 cases of jugular foramen tumors. All patients underwent tumor resection via suboccipital far lateral approach. MRI examination was performed within 72 h post operation to determine the degree of tumor resection. Karnofsky Performance Status Score (KPS) was used to evaluate the neurological status of the patients.

Among the 35 patients, total resection was achieve in 32 patients (91.4%) and subtotal resection in 3(8.6%). No patient died after surgery, and no recurrence occurred. A total of 9 cases of central nervous system infection and 1 case of cerebrospinal fluid leakage occurred after operation, and all recovered after treatment. The postoperative KPS was 80-100 in 31 cases and <80 in 4 cases. Thirty-one cases were followed up, and 4 cases were lost to follow-up. The median follow-up time was 19 months (1-110 months). At the end of follow-up, KPS was 80-100 in 30 cases (96.8%) and <80 in 1 case (3.2%). Compared with preoperative KPS (80-100 in 23 cases and <80 in 12 cases), postoperative KPS (P=0.008) and KPS during follow-up (P=0.002) were improved.

Resection of tumors in the ventral foramen magnum and foramen jugular region by the far lateral suboccipital approach is feasible with controllable adverse reactions, and can lead to a good outcome.

To observe the application effect of spinal canal reconstruction with micro-titanium plate internal fixation in children undergoing congenital spinal canal tumor resection.

This study retrospectively analyzed the clinical data of 46 children with congenital spinal tumors treated by spinal canal reconstruction technique with micro-titanium plate internal fixation during tumor resection in the Department of Neurosurgery, Children′s Hospital Affiliated with Zhengzhou University from January 2013 to December 2016. Outpatient follow-up was performed at 1, 3, 6 and 12 months after discharge, and annual review was conducted since the second year post operation. Three-dimensional spiral CT reconstruction and MRI were performed during the review. Clinical symptoms were assessed using the modified McCormick grading standard to assess the efficacy. Spinal stability was assessed by the White-Panjabi criterion, and spinal instability was defined as the score of at least 5. The transverse and anteroposterior diameters of the spinal canal of cervical, thoracic and lumbar vertebrae were measured before and after surgery, and were compared before and after surgery to evaluate whether spinal canal stenosis occurred.

In 46 cases, there were 2-7 segments of free lamina, with an average of 4.0±1.1 segments. A total of 184 spinal canal segments were operated on, including 61 cervical vertebra segments, 91 thoracic vertebra segments and 32 lumbar vertebra segments. The operation time was 60-130 min, with an average of 102.4±15.2 min. There were no postoperative complications such as infection, cerebrospinal fluid leakage, spinal cord or nerve root injury. The follow-up time of 46 cases was 12-36 months, with an average of 24.7±5.3 months. One year after operation, there were 30 cases of modified McCormick grade Ⅰ, 12 cases of grade Ⅱ, 3 cases of grade Ⅲ, and 1 case of grade Ⅳ. The grading results were improved compared with those before operation, and the difference was statistically significant (P=0.009). None of the patients had spinal instability at the last follow-up. There were no statistically significant differences in transverse diameters or anteroposterior diameter of the spinal canal in 184 segments between before and after surgery (all P>0.05).

Children with spinal canal reconstruction using micro-titanium plate internal fixation during intraspinal congenital tumor resection seem to report improved clinical symptoms, few complications and good postoperative spinal stability.

To investigate the clinical efficacy of microsurgical treatment of intracranial arteriovenous malformations (AVMs).

The clinical data of 51 patients with AVMs admitted to the Cerebrovascular Disease Treatment Center of the Affiliated Nanjing Brain Hospital, Nanjing Medical University from March 2017 to September 2020 were retrospectively analyzed. The patients′ AVMs were located in the cerebral hemisphere in 36 cases, the cerebellum in 9 cases, and deep supratentorial area in 6 cases. Spetzler-Martin grading was used to evaluate the AVMs before operation, which indicated that there were 5 cases of grade Ⅰ, 16 cases of grade Ⅱ, 18 cases of grade Ⅲ, 10 cases of grade Ⅳ, and 2 cases of grade V. All 51 AVM patients were treated with microsurgery, of which 19 were treated with endovascular embolization combined with microsurgery, and 32 were treated with microsurgery alone. After surgery, the Glasgow Outcome Scale (GOS) was used to evaluate the neurological status of the patients. MRI, CT angiography (CTA) or digital subtraction angiography (DSA) was used to evaluate the degree of resection and recurrence of the lesions.

All 51 malformed vascular masses were completely resected, and no residual lesions were found in postoperative MRI, CTA or DSA. Thirty-seven patients (72.5%) had improved initial symptoms, 1 patient (2.0%) developed new symptoms and neurological dysfunction, and 1 patient (2.0%) died during hospitalization. At discharge, there were 34 cases of GOS grade Ⅴ, 12 cases of grade Ⅳ, and 4 cases of grade Ⅲ. The follow-up time of 50 patients was 24.8±2.5 months (3-42 months). There was no death or rebleeding during the period. No recurrence was found in MRI, CTA or DSA, and anatomical cure was achieved. At the last follow-up, there were 36 cases of GOS grade Ⅴ, 10 cases of grade Ⅳ, and 4 cases of grade Ⅲ. The proportion of favorable outcomes (GOS ≥ grade Ⅳ) was 92.0% (46/50).

Microsurgical treatment of AVM can not only help achieve a high total resection rate, but also improve clinical symptoms and reduce the incidence of complications.

To explore the feasibility of microinjection method to construct the brain organoids and glioblastoma co-culture system, and to evaluate its effect and sensitivity to temozolomide (TMZ) treatment.

GBM tissue samples and adjacent tissues were obtained from patients undergoing surgical treatment in the Neurosurgery Department of Xiangya Hospital, Central South University. The brain organoid model was constructed by human induced pluripotent cell line labeled with green fluorescent protein (GFP) after 24 days of culture. The expression of different protein markers was detected by immunofluorescence staining to evaluate whether the model was successfully established. We established a three-dimensional brain organoids and glioblastoma co-culture system by injecting tumor cells derived from patient-derived tumor cells or U-251 MG into cerebral organoids, in which tumor cells were labeled with red fluorescent dye. The proliferation and infiltration of GBM cells in cerebral organoids were observed by immunofluorescence staining and H-E staining. The expression of matrix metalloproteinases (MMPs), GFAP and BrdU of tumor cells in GBM fusion brain organ was detected by immunofluorescence staining, and the morphological and structural changes were observed by H-E staining. Ten μmol/L TMZ was added into the co-culture system and GBM organoids separately for 48 h, and the expression of Caspase-3 in the two models was detected by immunofluorescence staining.

(1) After 24 days of organoid culture, a tissue-like structure with clear buds and stratified edges was formed. Immunofluorescence staining showed positive staining results for FOXG1, N-cadherin, Auts2, Frizzled 9, GFAP, and TUJ1, which were protein markers of forebrain, ventriculoid structure, prefrontal cortex, hippocampus, astrocyte, and neuron cells, respectively. (2) Transplanted GBM cells rapidly expanded within cerebral organoids and invaded into neural tissue. Compared with brain organoids, the expressions of MMP2 and MMP13 in GBM fused organoid tumor cells were significantly increased, while the expressions of Fibronectin, MMP3, and MMP9 were significantly decreased with statistical significance (all P<0.05). There was no significant difference in MMP10 expression (P>0.05). The expressions of BrdU and GFAP were increased (all P<0.05). (3) Compared with GBM organoids, GBM organoid-derived cells in cerebral organoids exhibited resistance to TMZ treatment with a lower expression of Caspase-3.

The GBM-fused brain organoid model can be successfully constructed by microinjection method. The sensitivity to TMZ of tumor tissue in this model is lower than that of GBM organoids.

To investigate the effect of nicotinamide (NA) on polyadenylation of diphosphate-ribose polymerase 1 (PARP-1)-mediated cell death in a rat model of early brain injury after subarachnoid hemorrhage (SAH) and its possible mechanisms.

The rat SAH model was established by internal carotid artery puncture. The male rats were randomly divided into a sham operation group (sham group), a SAH model group (SAH group), and a SAH model + NA group (SAH + NA group) (n=40 in each group). The effects of NA on the expression of PARP-1 and apoptosis-inducing factor (AIF) after SAH were detected by protein immunoblotting and immunofluorescence staining. The effect of NA on the expression of adenine dinucleotide (NAD+ ) was detected by enzyme-linked immunosorbent assay (ELISA). The neurological function score was used to evaluate the effect of NA on craniocerebral injury after SAH. To observe the effect of NA on the blood-brain barrier after SAH, we measured the brain water content, Evans blue exudation and the relative expressions of tight junction protein (ZO-1) and Occludin.

Immunofluorescence staining showed that the expression of AIF in SAH group was increased and shifted into the nucleus. Compared with the sham group, the expression of PARP-1 in SAH group was increased and co-localized with neurons (NeuN). The results of ELISA showed that the contents of NAD+ in Sham, SAH and SAH+ NA groups were (89.31±3.58)%, (57.61±2.19)% and (83.48±2.84)% respectively (F=30.57, P<0.01). Western blotting showed that the expression levels of PARP-1, PAR and AIF in the sham, SAH and SAH+ NA groups were significantly different (all P<0.01). The expression levels of PARP-1, PAR and AIF in SAH+ NA group were lower than those in SAH group (all P<0.01). The differences in neurological scores, brain water content and Evans blue exudation among the sham, SAH and SAH+ NA groups were statistically significant (F values were 36.58, 56.91 and 48.14 respectively, all P<0.05). The relative expression levels of ZO-1 and Occludin in the sham group, SAH group and SAH+ NA group were significantly different (F values were 60.81 and 30.15 respectively, both P<0.01).

In the rat SAH model, PARP-1-mediated cell death pathway can aggravate the early brain injury in SAH, and NA inhibition of PARP-1 expression can reduce the early brain injury after SAH.