Volume 38 · Issue 07 · 2022

To investigate the feasibility and safety of intraoperative magnetic resonance imaging (iMRI) in the resection of children′s space-occupying lesions in the posterior cranial fossa and its effect on the total resection rate of the lesions.

The clinical data of 27 children who underwent iMRI-assisted resection of space-occupying lesions in the posterior fossa in the Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University from March 2019 to March 2021 were retrospectively analyzed. We documented the information including iMRI-related time-consuming, total lesion resection rate, adverse events and postoperative complications. Total resection was defined as no residual lesion on iMRI; subtotal resection was defined as residual lesion volume of ≤20% on iMRI.

All 27 patients underwent the operation and iMRI safely. The relevant total time for a single iMRI of the 27 children was 58.5±11.6 min (43-87 min). The first iMRI results of the 27 children showed that 24 (88.9%) had total resection of the lesions; three (11.1%) had subtotal resection; two of them underwent further resection, and the second iMRI showed that both lesions were completely resected. The total resection rate of lesions increased to 96.3% (26/27) after applying iMRI. Anesthesia-related adverse events occurred in 3 children during the operation, and no adverse events occurred during the iMRI scan. No intracranial infection occurred after operation; only 1 case (3.7%) had incision infection and poor healing.

It is feasible to apply iMRI in the resection of space-occupying lesions in the posterior cranial fossa in children, which can improve the total resection rate of the lesions without increasing the associated risks and complications of surgery.

To investigate the clinical characteristics and prognostic factors of different types of intracranial arachnoid cysts in children.

A retrospective analysis was conducted on the clinical data of 145 children with intracranial sylvian arachnoid cysts admitted to the Department of Pediatric Neurosurgery, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2015 to January 2020. According to the Galassi classification, those cysts were divided into Galassi type Ⅱ(78 cases) and type Ⅲ (67 cases). Among them, 56 cases underwent cyst dissection and fenestration under microscope, and 89 cases underwent neuroendoscopic cyst dissection and fenestration. Postoperative clinical and imaging follow-up was performed on the children, and the Kandenwein clinical symptom assessment method was used to evaluate the outcomes. The clinical characteristics and outcomes of different types of children were compared, and the factors affecting the prognosis of children were further analyzed by multivariate logistic regression.

All 145 cases underwent successful operation, and there were no perioperative deaths. A total of 26 children (17.9%) had surgery-related complications after surgery, including 13 cases of subdural effusion, 10 cases of subdural hematoma, 1 case of cerebrospinal fluid leakage, 2 cases of acute hydrocephalus. The follow-up time of 145 children was 60.1±15.7 months (24-83 months). The last follow-up showed favorable outcome in 125 cases (86.2%) and poor outcome in 20 cases (13.8%). There was no significant difference in age, gender, cyst location, preterm birth, or operation method between Galassi type Ⅱgroup and type Ⅲgroup (all P>0.05), while significant inter-group differences were indicated in preoperative hydrocephalus, postoperative complications, Kandenwein symptom assessment, as well as preoperative and postoperative maximum diameters of the cyst (all P<0.05). Type Ⅲ cysts were often associated with hydrocephalus before surgery, and postoperative complications were prone to occur. At the same time, the maximum diameters of type Ⅲcysts before and after surgery were both larger than those of type II cysts. Multivariate logistic regression analysis showed that Galassi type was an independent factor affecting the prognosis of children (OR=9.35, 95%CI=1.74-50.19, P=0.009).

The clinical features of Galassi type Ⅱ and Ⅲ children's intracranial sylvian arachnoid cysts are different. The overall prognosis of type Ⅲ cysts is worse than that of type Ⅱ cysts. The prognosis of children may be related to the Galassi types.

To explore the application value of frameless robot-assisted stereotactic biopsy in pediatric brainstem tumors.

A retrospective study was conducted on the clinical data of 35 children who underwent frameless robot-guided stereotactic brainstem tumor biopsy in the Department of Neurosurgery, Children′s Hospital of Fudan University from June 2018 to April 2021. Preoperative CT thin-section scan and enhanced MRI examination were performed, and the CT and MRI data were input into the SinoPlan surgical planning system, and an individualized puncture path was designed according to the location of the lesion and neuroimaging characteristics. The Mayfield head frame was installed, and the SINO surgical robot was used to plan the target and path coordinates to obtain brain tissue according to the surgical planning system, followed by histopathology and molecular genetic testing.

Established diagnoses were made in all 35 children after stereotactic biopsy. Postoperative pathological results included 1 case (2.9%) of astrocytoma and 34 cases (97.1%) of diffuse midline glioma (31 cases with H3K27M mutation). The operation time was 79.1±25.7 min (38-121 min), and the postoperative hospital stay was 6.7±2.1 d (4-15 d). The re-examination of head CT 6 hours after operation showed that 5 cases (14.3%) had a small amount of cerebral hemorrhage without related clinical symptoms. No major hemorrhage occurred during or after operation, and there was no new neurological deficit or operation-related death.

The frameless robot-assisted stereotactic brainstem tumor biopsy has the advantages of accurate positioning, high success rate of sampling, less trauma, simple operation, and low incidence of surgery-related complications.

To compare the efficacy of concurrent chemoradiotherapy with temozolomide (TMZ) followed by adjuvant TMZ vs. that without adjuvant TMZ in the treatment of pediatric diffuse intrinsic pontine glioma (DIPG).

The clinical data of 85 children with DIPG who were treated in the Comprehensive Oncology Center, Guangdong Sanjiu Brain Hospital from January 2010 to March 2020 were retrospectively analyzed. All patients received conventional fractionated radiotherapy (total dose 50-54 Gy/27-33 f) combined with temozolomide(75 mg·m^-2·d^-1) chemotherapy. Then according to the guardians, patients received or not 6 cycles temozolomide chemotherapy one month later after concurrent chemo-radiotherapy. All patients were divided into radiotherapy + concurrent TMZ + adjuvant TMZ group (66 cases), radiotherapy + concurrent TMZ group (19 cases). The Kaplan-Meier curve was drawn to compare the difference in survival time between the two groups. According to the Common Terminology Criteria for Adverse Events Version 4.0 (CTCAE 4.0), the differences in adverse drug reactions between the two groups were evaluated.

The median follow-up time of the 85 patients was 9 months (3-28 months), and the overall median survival time was 9 months. The median survival time of the radiotherapy + concurrent TMZ + adjuvant TMZ group was 10 months, and that of the radiotherapy + concurrent TMZ group was 6 months. The log-rank test showed that the difference in survival time between the two groups was statistically significant (P=0.002). Among the 85 children, 30 (35.3%) had hematological adverse reactions, all of which were CTCAE grades 1-3. There were 24 cases (36.4%) in the radiotherapy + concurrent TMZ + adjuvant TMZ group of 66 cases, including 15 cases of grade 1, 8 cases of grade 2 and 1 case of grade 3. Among the 19 patients in the radiotherapy + concurrent TMZ group, 6 patients (31.6%) developed adverse hematologic reactions, all of which were grade 1. There was no significant difference in the rate of adverse reactions of the hematological system between the two groups (P=0.255).

Compared with concurrent chemoradiotherapy with TMZ alone, that followed by adjuvant TMZ can prolong the survival time of children with DIPG without increasing the incidence of adverse drug reactions.

To investigate the clinical features and surgical outcomes of temporal lobe tumors in children with epileptic seizures as initial symptom.

The clinical data of 27 children with temporal lobe tumors and epileptic seizures as initial symptom who underwent surgery in the Neurosurgery Department of the Children′s Hospital of Chongqing Medical University from January 2013 to January 2020 were retrospectively analyzed. The children underwent clinical follow-up after operation, and the effect of seizure control was evaluated by the Engel grading standard. According to the pathological results, the patients were divided into benign tumor group[World Health Organization (WHO) grade Ⅰ] and malignant tumor group(WHO grade Ⅱ-Ⅳ). The general data and seizure outcomes of the two groups were compared.

Total tumor resection was achieved in all 27 children, of whom 18 patients underwent lesion resection and standard anterior temporal lobectomy, and 9 underwent extended lesion resection. The pathological results revealed 5 cases of oligodendroglioma (WHO grade Ⅱ), 5 cases of dysembryoplastic neuroepithelial tumor (WHO grade Ⅰ), 4 cases of pilocytic astrocytoma (WHO grade Ⅰ), 4 cases of desmoplastic infantile astrocytoma and ganglioglioma (WHO grade Ⅰ), 4 cases of ependymoma (WHO grade Ⅱ), 3 cases of meningioma (WHO grade Ⅰ), 1 case of ganglioglioma (WHO grade Ⅰ) and 1 case of anaplastic ependymoma (WHO grade Ⅲ). All 27 children were followed up after operation, and the median follow-up time was 36 months (12-96 months). At the last follow-up, there were 21 cases (77.8%) of Engel grade Ⅰ, 5 cases (18.5%) of Engel grade Ⅱ, and 1 case (3.7%) of Engel grade Ⅲ. Compared with the malignant tumor group, the children in the benign tumor group were younger (P=0.040), and there were no statistical differences between the two groups in gender, epilepsy duration, tumor growth location in the temporal lobe, or postoperative outcome of seizure control (all P>0.05). The proportions of benign tumor group and malignant tumor group reaching Engel grade Ⅰ after operation were 14/17 and 7/10 respectively.

Preliminary observation has suggested that among the children with temporal lobe tumors and epileptic seizure as initial symptom who underwent surgical treatment, oligodendrocyte tumor and dysembryoplastic neuroepithelial tumor are most common. The tumors are mostly benign and malignant tumors are mostly low-grade. After surgical resection of the tumor, the postoperative effect of seizure control seems satisfactory.

To explore the clinical characteristics, diagnosis and treatment experience as well as surgical outcomes of cranial congenital dermal sinus (CDS) in children.

A retrospective study was conducted about the clinical data of 24 children with cranial CDS admitted to the Department of Neurosurgery, Children′s Hospital of Nanjing Medical University from May 2012 to April 2021. There were 15 males and 9 females with a median age of 2 years. The lesions were located in the occipital region in 14 cases, in the temporal region in 7 cases, and in the nasal root region in 3 cases. Head CT and 3D reconstruction and (or) head MRI were performed preoperatively. All patients underwent surgical resection and were followed up regularly.

Twenty-one children underwent one-stage total resection; 3 patients underwent abscess incision and drainage first, and second-stage total resection was performed. Intraoperative findings revealed that the sinus tract terminated in the occipital periosteum in 2 cases, in the dura mater in 7 cases, in the epidural space in 11 cases, in the arachnoid in 1 case, in the occipital cistern in 1 case, and in the cerebellum in 2 cases, resulting in cerebellar abscess and hydrocephalus. The median follow-up time after operation was 58 months (6-114 months), and there was no recurrence of infection or intracranial lesions during the follow-up period.

The depth of the sinus tract in children′s skull CDS determines the severity of the disease, which can lead to brain abscesses and obstructive hydrocephalus. Surgical outcome is favorable.

To investigate the clinical characteristics and influencing factors of slit ventricle syndrome (SVS) after ventriculoperitoneal shunt (VPS) in infants and young children.

The clinical data of 497 infants and young children (≤3 years old) with hydrocephalus who were treated by VPS at the Department of Neurosurgery, the Third Affiliated Hospital of Zhengzhou University from January 2013 to December 2018 were retrospectively analyzed. According to the occurrence of SVS, the patients were divided into the SVS group and non-SVS group. Univariate analysis and multivariate logistic regression analysis (Enter) were further used to determine the clinical factors affecting the postoperative occurrence of SVS.

Of the 497 children, 28 (5.6%) were diagnosed with SVS, and the onset time [M (Q₁, Q₃)] was 3.8 (2.8, 5.5) years after surgery. Among the 28 children, the clinical manifestations were intermittent headache in 28 cases, vomiting in 22 cases, fever in 7 cases, drowsiness in 4 cases, muscle weakness in 2 cases, limb convulsion in 1 case and papilledema in 1 case. There were statistically significant differences in age, history of premature birth, etiology, severity of hydrocephalus and shunt tube type between the SVS group (n=28) and the non-SVS group (n=469) (all P<0.05). There was no significant difference in gender or surgical approach between the groups (both P>0.05). Multivariate logistic regression analysis showed that young age (OR=0.83, 95%CI: 0.70-0.99), history of premature birth (OR=4.62, 95%CI: 1.81-11.80), severe hydrocephalus (OR=6.31, 95%CI: 2.34-17.01) and the use of constant pressure shunt tube (OR=4.26, 95%CI: 1.70-10.71) were independent risk factors for SVS after VPS (all P<0.05).

Infants and young children with hydrocephalus after VPS have a high incidence of SVS, and the common clinical manifestations are intermittent headache and vomiting. Children with younger age, history of premature birth, severe hydrocephalus as well as constant pressure shunts are more likely to develop SVS after VPS.

To investigate the effects of median nerve electrical stimulation (MNES) on awakening comatose children with severe traumatic brain injury and its mechanism.

From January 2019 to June 2021, 67 children with coma after severe craniocerebral injury were treated in the Department of Neurosurgery, the Affiliated Hospital of Southwest Medical University. All children received conventional treatment, and 25 of them received MNES treatment (8 h/d, a total of 2 weeks). After 1 ∶1 propensity score matching, a total of 40 cases were included for retrospective study, including 20 cases in the MNES group and 20 cases in the non-MNES group. There were no significant differences in age, gender, cause of injury, type of injury, Glasgow Coma Scale (GCS), or proportion of surgical treatment between the two groups (all P>0.05). The differences in GCS and disability rating scale (DRS) of the two groups between pre-treatment and 2 weeks post treatment were compared. All children underwent head CT cerebral perfusion imaging (CTP) and magnetic resonance spectroscopy (MRS) before and after treatment to analyze the relevant parameters of CTP in the region of interest, and to detect the changes of N-acetylaspartate (NAA) / creatine (Cr) value and choline complex (Cho) / Cr value in the thalamus using MRS.

Before and after treatment, the GCS of the MNES group was 6.0±1.2 points and 10.3±1.7 points respectively, the DRS was 18.1±2.9 points and 6.6±1.8 points respectively; the GCS of the non-MNES group was 6.1±1.3 points and 9.2±1.6 points respectively, and DRS were 17.6±2.5 points and 8.5±2.2 points respectively. The GCS and DRS in both groups were improved after treatment, and the improvement degree of the MNES group was greater than that of the non-MNES group, and the differences were statistically significant (all P<0.05). The CTP results showed that after treatment, the cerebral blood flow and cerebral blood volume in the region of interest of the brain were increased in both groups compared with those before treatment, and the average transit time and peak time of the contrast agent were decreased, the improvement degree of the MNES group was greater than that of the non-MNES group, and the differences were statistically significant (all P<0.05). The MRS results showed that, compared with before treatment, the NAA/Cr values of the thalamus in both groups increased and the Cho/Cr values decreased after treatment, the improvement in the MNES group was greater than that in the non-MNES group, and the differences were statistically significant (all P<0.05).

MNES contributes to the recovery and improvement of brain function in comatose children with severe traumatic brain injury. The mechanism may be related to the improvement of cerebral tissue blood perfusion and metabolism.

To preliminarily explore the treatment methods and clinical efficacy of pial arteriovenous fistula (pAVF) in children.

The clinical data of 5 children with pAVF admitted to the Department of Neurosurgery, Children′s Hospital of Nanjing Medical University from May 2018 to October 2019 were retrospectively analyzed. All 5 cases were diagnosed based on the whole brain digital subtraction angiography (DSA), and the fistula was located in the supratentorial area in 4 cases and in the infratentorial area in 1 case. One case supplied by a single feeding artery whose fistula was located in the superficial area was removed by microsurgery, 2 cases supplied by a single feeding artery whose fistulas were located in the deep region were embolized by coil, and the other 2 cases supplied by multiple arteries whose fistulas were located in the superficial area were embolized with coil and resected with microsurgery. Surgical complications were observed. Neurological function and imaging follow-up were performed 3 and 6 months after surgery and annually thereafter. The disappearance of the fistula was defined as cure.

Among the 5 children, 1 case had complete resection of the fistula, 2 cases had coil embolization of the feeding artery, and 2 cases had coil embolization of the main feeding artery and complete resection of the fistula. All 5 children reached the standard of cure. There were no surgery-related complications. Five children completed the follow-up of 18 to 36 months. Up to the last follow-up, none of the 5 children had headache, vomiting or neurological dysfunction, and there was no recurrence of pAVF which was indicated by cranial magnetic resonance angiography and DSA.

Preliminary observation has suggested that surgical resection, endovascular treatment or a combination of the two treatment methods could be selected according to the site of pAVF in children and its vascular architecture, which has a high cure rate, good safety, and satisfactory clinical effects.

To investigate the application effect of sub-pial resection technique in the operation of glioma in eloquent areas.

The clinical data of 62 patients with glioma in eloquent areas who underwent surgical treatment at the Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January 2019 to September 2021 were retrospectively analyzed. Sub-pial resection was performed during the operation. The extent of tumor resection, neurological function, degree of edema in the operation area, hemorrhagic and ischemic brain injury were evaluated after operation. The neurological status of the patients was followed up 3 months after the operation: the neurological dysfunction lasting for less than 3 months was defined as early neurological dysfunction, otherwise it was long-term dysfunction (divided into severe and general types according to the severity).

The operations of 62 patients were successfully completed. The pathological results indicated 46 cases (74.2%) of WHO grade Ⅱ tumors, 9 cases (14.5%) of grade Ⅲ tumors, and 7 cases (11.3%) of grade Ⅳ tumors. Postoperative assessment revealed that gross total resection was achieved in 26 cases (41.9%), near total resection in 30 cases (48.4%), and partial resection in 6 cases (9.7%). Postoperative CT or MRI showed no obvious abnormality in 54 cases (87.1%), 4 cases (6.5%) of edema, 2 cases (3.2%) of hemorrhage, and 2 cases (3.2%) of ischemia in the deep brain area. There were 15 cases (24.2%) without postoperative dysfunction, 41 cases (66.1%) with early neurological dysfunction, 2 cases (3.2%) with long-term severe dysfunction, and 4 cases (6.5%) with long-term general dysfunction.

The sub-pial resection technique used in the operation of glioma in eloquent areas can safely and effectively protect the functional cortex and the passing blood vessels, which is helpful for the maximal safe tumor resection, and the incidence of long-term severe neurological dysfunction is low.

To preliminarily explore the relationship between the changes of functional connectivity in the fronto-parietal network (FPN) and tumor grade in patients with frontal gliomas in the resting state.

A retrospective analysis was conducted on the clinical data of 44 patients with frontal glioma who underwent neurosurgery at Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University from January to December 2020. Those patients included 25 cases of high-grade glioma (HGG) and 19 cases of low-grade glioma (LGG). Twenty-one healthy controls (HC) matched with the patient′s sex and age were also included. All patients and healthy controls completed resting-state fMRI scans. Four important brain regions in the FPN were used as regions of interest, namely the left lateral prefrontal cortex (LPFC_L) and the right lateral prefrontal cortex (LPFC_R), left posterior parietal cortex (PPC_L) and right posterior parietal cortex (PPC_R). After data processing, the strength values of functional connectivity between each brain regions were obtained, and the comparison between groups and Spearman correlation analysis were carried out.

Compared with the HC group, the patients with frontal lobe glioma showed decreased functional connectivity between the LPFC_L and the PPC_L, as well as between the LPFC_R and the PPC_L (all P<0.05). There were statistically significant differences in the functional connectivity between LPFC_L and PPC_L, and between LPFC_R and PPC_L among the HGG, LGG and HC groups (all P<0.05). Compared with the HC group, the HGG group showed decreased functional connectivity between the LPFC_L and the PPC_L, as well as between the LPFC_R and the PPC_L (both P<0.05). However, there was no significant difference in the functional connectivity between those areas in the LGG group (both P>0.05). Spearman correlation analysis showed that there was no correlation between tumor volume and functional connectivity between the brain regions (all P>0.05). In addition, the correlation coefficient of functional connectivity strength values was higher in patients with frontal lobe glioma than in the HC group (P=0.009). There was a statistically significant difference in the correlation coefficient among the HGG, LGG and HC groups (P=0.036). The correlation coefficient of functional connectivity strength values was higher in the HGG group than in the HC group (P=0.044), whereas no statistical difference was found between the LGG group and the HC group (P=0.098).

The resting-state functional connectivity of the FPN is decreased in patients with frontal lobe gliomas. The functional changes of the FPN are different in patients with high-grade and low-grade gliomas. The functional connectivity strength of the FPN in patients with high-grade gliomas is significantly reduced.

To investigate the clinical efficacy of neuroendoscopic resection of petroclival tumors via the far lateral infratentorial supracerebellar approach.

A retrospective analysis was performed on the clinical data of 15 patients who underwent neuroendoscopic resection of petroclival tumors via the far lateral infratentorial supracerebellar approach in the Department of Neurosurgery, Clinical Medical College of Yangzhou University from January 2020 to June 2021. Among them, 3 cases were epidermoid cysts, 5 cases were meningiomas, 6 cases were schwannoma, and 1 case was neurofibroma; 9 cases were of posterior fossa type, and 6 cases were of middle-posterior fossa straddle type. The tumor diameter ranged from 2.1 to 4.8 cm. Postoperative therapeutic effect and complications were documented.

Of the 15 patients, 10 underwent total tumor resection and 5 underwent subtotal tumor resection. During the operation, trochlear nerve injury occurred in 1 patient, and cerebellar contusion occurred in no patient. There was no intracranial infection or death after operation. The postoperative follow-up time ranged from 6 to 24 months, with an average of 12 months. One patient had limited eye movement to the inferolateral direction, and the other patients had no symptoms of newly-developed neurological deficits, and no tumor recurrence or rapid progression was found in the MRI follow-up.

Neuroendoscopic resection of petroclival tumors through the far lateral infratentorial supracerebellar approach has the advantages of less trauma and wide surgical field, and is a safe and effective surgical method for the treatment of petroclival lesions and lesions invading the middle cranial fossa.

To investigate the relationship between bilateral frontal pneumocephalus and postoperative delirium following craniotomy for intracranial tumors.

A retrospective analysis was conducted on 594 adult patients with intracranial tumors after craniotomy who were routinely monitored and treated in the Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University from March to August 2018. The patients were evaluated for delirium using the Confusion Assessment Method for the ICU (CAM-ICU) on the 1st postoperative day, and the patients were divided into a delirium group and a non-delirium group according to the occurrence of postoperative delirium. Relevant clinical data before postoperative delirium assessment and outcome data at discharge were collected. According to the diagnosis of bilateral frontal pneumocephalus based on head CT within 12 hours after operation, the patients were divided into two groups according to the presence or absence of bilateral frontal pneumocephalus: bifrontal pneumocephalus group and non-bifrontal pneumocephalus group. After univariate and multivariate logistic analyses of postoperative delirium, propensity score matching (1 ∶1) was conducted to assess the relationship between bi-frontal pneumocephalus and postoperative delirium according to the influencing factors of postoperative delirium.

Of the 594 patients, 91 (15.3%) developed postoperative delirium. Multivariate logistic regression analysis showed that bilateral frontal pneumocephalus was an independent risk factor for postoperative delirium (OR=1.94, 95%CI: 1.03-3.67, P=0.041). Of the 594 patients, 190 (32.0%) patients developed bilateral frontal pneumocephalus. Using the propensity score, 163 pairs of patients were successfully matched. Compared with the group without bilateral frontal pneumocephalus, the incidence of postoperative delirium was higher [11.7% (19/163) vs. 24.5% (40/163), P=0.003] and postoperative hospital stay was longer [M (Q₁, Q₃): 9 (8, 12) d vs. 11 (8, 14) d, P=0.016] in the bilateral frontal pneumocephalus group.

Postoperative delirium has a high incidence in patients undergoing craniotomy for intracranial tumors and is associated with poor outcomes. Bilateral frontal pneumocephalus may be an important risk factor for postoperative delirium.

To explore the feasibility of intraoperative recording of compound muscle action potential (CMAP) in deep brain stimulation (DBS) under general anesthesia and its role in the lead positioning.

A retrospective analysis was performed on the clinical data of 30 patients with Parkinson′s disease (PD) who received DBS of bilateral subthalamic nucleus (STN) under general anesthesia at the Department of Neurosurgery, Qilu Hospital of Shandong University from January 2016 to December 2019 (referred to as the general anesthesia group) and 30 PD patients undergoing bilateral STN-DBS under local anesthesia combined with general anesthesia (referred to as local + general anesthesia group) during the same period of time. In the general anesthesia group, bilateral orbicularis oris muscles, thenar muscle, and flexor hallucis brevis muscle were selected to record the CMAP waves during the operation. The patients in the local + general anesthesia group received intraoperative electrical stimulation in an awake state, and the presence of pyramidal tract reactions was recorded. The threshold voltage, the electrode position verified by the fusion of postoperative CT and preoperative MRI images, and the improvement rates of Unified Parkinson′s Disease Rating Scale part Ⅲ (UPDRS-Ⅲ) score in the two groups in the medication-off period at 3 months after operation were compared.

There was no significant difference between general anesthesia group and local + general anesthesia group in the patent′s age, course of disease and UPDRS-Ⅲ score in preoperative medication-off period (all P>0.05). Difference in sex between the two groups were significant(P<0.05). (1) Typical CMAPs were recorded in 30 patients in the general anesthesia group when they were given intraoperative electrical stimulation. (2) There were differences in the induction rate of CMAP among the three groups (P<0.05), which was the highest for the orbicularis oris muscle (60/60), followed by the thenar muscle (35/60), and no CMAP was recorded in the flexor hallucis brevis muscle. (3) Three patients in the general anesthesia group and four patients in the local anesthesia + general anesthesia group underwent electrode position adjustment. There was no significant difference in the voltage threshold between the two groups of patients without electrode position adjustment (P>0.05). (4) The postoperative CT and preoperative MRI fusion results of the two groups showed that the electrode position was satisfactory, and there was no significant difference in the distance between the outer edge of side reaction contact and the inner edge of the internal capsule bilaterally in the general anesthesia group and the local anesthesia + general anesthesia group (P>0.05). (5) There was no significant difference in the improvement rate of UPDRS-Ⅲ between the two groups at 3 months after operation (both P>0.05).

Recording CMAP during electrical stimulation in the surgery of DBS under general anesthesia is a safe, feasible and effective technique. The CMAP of the face and upper extremities is easier to record. The threshold value can be used to provide bases for estimation of the distance between the electrode and the internal capsule and possible intraoperative adjustment of the lead position, which helps the surgeon improve the accuracy of electrode placement under general anesthesia and avoid the occurrence of the pyramid tract side effects.

To alleviate the early brain injury in mice after subarachnoid hemorrhage (SAH) by regulating the function of dural lymphatics (DL), and to explore the possibility of DL as a therapeutic target after SAH.

SAH model of C57BL/6J mice was induced by puncture of internal carotid artery. The sham operation group, SAH model group (SAH group) and vascular endothelial growth factor (VEGF) C intervention group (recombinant VEGF-C colloid intervention was followed by SAH model induction) were established. The morphological changes of DL after 10 days of recombinant VEGF-C colloid intervention were observed by immunofluorescence staining and compared with the colloid group (without recombinant VEGF-C). We evaluated the functional changes of DL by Evans blue drainage assay, and then cerebral blood perfusion, brain water content and neurological function injury (based on the Garcia score) of the three groups of mice after SAH were compared. Finally the expression of apoptotic protein caspase-3 in each group was determined by using Western blot method.

Compared with the colloid group, the DL in the VEGF-C intervention group generated more lymphatic branches and the mean lumen diameter of lymphatic vessels was significantly increased (24.8±4.8 μm vs. 31.2±3.9 μm, P<0.01). The Evans blue color in the deep cervical lymph nodes in the VEGF-C group was significantly darker than that in the colloid group. Compared with the SAH group, the recovery of cortical blood perfusion in the VEGF-C intervention group was more significant, the brain water content was lower [(76.7±1.6)% vs. (81.2±1.1)%, P<0.01], and the neurological function was less impaired [Garcia score: 10.7±1.3 points vs. 14.0±0.9 points, P<0.01). Meanwhile, the expression level of apoptosis protein caspase-3 in brain tissue was lower (0.559±0.034 vs. 0.712±0.036, P<0.01).

Regulating the DL function can effectively reduce the early brain injury after SAH in mice.