Volume 38 · Issue 10 · 2022

To investigate the pathological characteristics and prognosis of H3K27M mutant midline gliomas (MGs).

The clinical data of 75 patients with H3K27M mutant MGs admitted to the Department of Neurosurgery of Guangdong Sanjiu Brain Hospital from September 2012 to December 2020 were retrospectively analyzed. The tumors were located in the brainstem in 40 cases, in the thalamus in 29 cases, in the hypothalamus in 3 cases, and in other midline sites in 3 cases. Of those, 53 underwent surgery and 22 underwent biopsy. Kaplan-Meier method was used to analyze the overall survival (OS) of patients. Univariate and multivariate Cox regression methods were used to analyze the factors affecting OS in H3K27M mutant MG patients.

Among the 75 patients, 13 patients (17.3%) were WHO grade 1 for histological classification, 20 (26.7%) were grade 2, 18 (24.0%) were grade 3, and 24 (32.0%) were grade 4. Among them, 59 cases (78.7%) were diffuse midline gliomas, and 16 cases (21.3%) were non-diffuse midline gliomas. The median follow-up time of 72 patients (3 lost to follow-up) was 12 months (0-105 months). The results of Kaplan-Meier analysis showed that the median overall survival (mOS) of 72 patients was 12.1 months, and the mOS of patients aged ≤18 years, 19-39 years and ≥40 years were 10.2 months, 15.6 months and 25.0 months, respectively. There was a statistically significant difference among the three groups (P=0.050). The mOS of patients undergoing radiotherapy or chemotherapy after surgery was longer (both P<0.05). There was no significant difference in the mOS of patients with different histopathological types and grades (all P>0.05). Multivariate Cox regression analysis showed that postoperative radiotherapy was an independent affecting factor for OS in H3K27M mutant MG patients (HR=0.36, 95%CI: 0.14-0.91, P=0.031).

H3K27M mutant MG can be diffuse or non-diffuse, with WHO histological grades 1-4. The prognosis of patients seems age-related, with poor prognosis in pediatric patients and better prognosis in middle-aged and elderly patients, regardless of histological type and histological grade. Patients can benefit from radiotherapy and chemotherapy.

To discuss the clinical, histopathological and molecular pathological characteristics of angiocentric gliomas (AGs), and to summarize the key points of diagnosis and differential diagnosis of AGs.

A retrospective analysis was conducted on the clinical data of 5 patients with AGs (accounting for 0.02% of patients with intracranial tumors treated in the same period) admitted to the Department of Neurosurgery, Beijing Tiantan Hospital Affiliated to Capital Medical University from May 2019 to December 2021. All patients underwent surgical resection. We summarized the clinical characteristics, histopathology, immunohistochemical characteristics and molecular pathological characteristics of AGs.

The median age of 5 patients was 9 years (4 to 15 years). All their onset symptoms were epileptic seizures, and the median course was 6 months(6 days to 12 months). Preoperative clinical diagnosis was low-grade glioma. The tumors of the 5 children were all located in the unilateral supratentorial cortex. MRI scans showed low or equal signal intensity areas within the mass on T1-weighted images and high signal intensity areas on T2-weighted images and fluid attenuation recovery sequencing, and none of them showed contrast enhancement. All five patients achieved complete resection. The H&E stain showed monomorphic tumor cells were arranged longitudinally along vascular axes or radially encircling blood arteries, forming rosette or sleeve-like shapes. Immunohistochemical examination revealed significant GFAP positivity in tumors. In addition to wild-type expression pattern of ATRX and p53, the AGs in all 5 patients displayed cytoplasmic dot-like EMA (epithelial membrane antigen) staining. IDH1 R132H immunolabelling showed negative results. The Ki-67 index was less than 3%. Targeted sequencing showed MYB: : QKI fusion in 4 of 5 cases. The follow-up time ranged from 6 to 35 months. At the last follow-up, all 5 patients survived.

AGs are rare, indolent tumors that mainly occur in children. Diagnosis and differential diagnosis for AGs should be based on an integrated assessment of histological, immunohisochemical and molecular pathology features.

To investigate the efficacy of microsurgical resection of large olfactory groove meningiomas.

We retrospectively reviewed the clinical data of 38 patients with large olfactory groove meningioma (≥3 mm) who underwent surgical resection in the Department of Neurosurgery, the First Affiliated Hospital of Soochow University from May 2015 to May 2022. In this series, 22 cases were treated via the unilateral subfrontal approach, 13 cases via the pterional approach, and 3 cases via the lateral supraorbital approach. The postoperative efficacy and the occurrence of complications were observed.

Among the 38 patients, 10 cases (26.3%) achieved Simpson grade Ⅰ resection, 27 cases (71.1%) achieved grade Ⅱ resection, and 1 case (2.6%) achieved grade Ⅲ resection; 9 cases underwent ligation of the superior sagittal sinus. A total of 10 patients (26.3%) developed surgery-related complications. Among them, 6 cases (15.8%) had aggravated cerebral edema after operation, 2 cases had the superior sagittal sinus ligated during operation (1 case underwent decompressive craniectomy); 4 cases developed cerebral hematoma, and 1 case underwent secondary operation to remove the hematoma, 3 cases showed hematoma absorption after conservative treatment; there were 1 case of intracranial infection, 1 case of cerebrospinal fluid rhinorrhea, 2 cases of postoperative aggravation of olfactory damage, 5 cases of newly-developed olfactory damage, 2 cases of new visual impairment and 4 cases of mental symptoms. The median follow-up time of 38 patients was 31 months (2-84 months). Neither the symptoms of olfactory impairment before surgery or that developed after surgery improved; some patients′ vision, visual field, and mental symptoms improved. There was no tumor recurrence at the last follow-up. The Karnofsky performance scale (KPS) was >80 in 32 cases, 50-80 in 4 cases, and <50 in 2 cases.

Microsurgical resection of olfactory groove meningiomas via unilateral approach has a high tumor resection rate and a low incidence of serious complications. Intraoperative ligation of the superior sagittal sinus leads to a high risk of severe brain edema.

To explore the surgical effect of epidermoid cyst in the cerebellopontine angle (CPA).

The clinical data of 50 patients with epidermoid cyst in the CPA region treated in the Department of Neurosurgery of the Second Hospital of Lanzhou University from June 2014 to June 2020 were analyzed retrospectively, including 43 cases of trigeminal neuralgia, 4 cases of hemifacial spasm and 3 cases of trigeminal neuralgia complicated with hemifacial spasm. All patients underwent suboccipital retrosigmoid approach for tumor resection. The relationship between blood vessels and cranial nerves was explored during the operation, and microvascular decompression (MVD) or partial nerve dissection was performed when necessary. Telephone and outpatient follow-up were conducted 3 months after the operation and every year thereafter to follow up the patients′ neurological recovery and whether there was tumor recurrence.

All 50 patients successfully underwent tumor resection. Among them, 5 patients underwent MVD at the same time, and 1 patient underwent partial dissection of trigeminal nerve at the same time. Total tumor resection was performed in 31 cases, subtotal resection in 9 cases, and partial resection in 10 cases. After operation, the preoperative symptoms of 50 patients were relieved, and 18 patients developed new cranial nerve dysfunction. There were 3 cases of small intracranial hemorrhage, 4 cases of aseptic meningitis, 1 case of cerebrospinal fluid leakage and 1 case of perioral herpes after operation. The median follow-up time of the 50 patients was 48 months (range: 3-91 months). During the follow-up period, symptoms recurred in 3 patients, of which 2 had tumor recurrence. By the last follow-up, 17 patients had completely relieved newly-developed cranial nerve dysfunction after operation, and only 1 patient had remaining facial paralysis.

Resection of CPA epidermoid cyst via suboccipital retrosigmoid approach, combined with selective MVD or partial nerve dissection, has a good postoperative effect and fewer postoperative complications.

To investigate the surgical treatment and prognostic factors of posterior pituitary tumor (PPTs).

The clinical data of 47 patients with PPTs who underwent surgical treatment in the Neurosurgery Department of Beijing Tiantan Hospital, Capital Medical University from January 2012 to June 2022 were retrospectively analyzed. Different surgical approaches were adopted according to the tumor size, location, and whether it invaded the cavernous sinus. Among them, 32 patients underwent transsphenoidal approach and 15 underwent craniotomy. The Kaplan-Meier method was used to analyze the progression-free survival (PFS) of the patients, and the univariate and multivariate Cox regression analyses were further used to determine the clinical factors affecting the prognosis of the patients.

Among the 47 patients with PPTs, 29 (61.7%) had total tumor resection and 18 (38.3%) had subtotal tumor resection. The median intraoperative blood loss was 200 ml (100-775 ml). The pathological diagnosis was confirmed after operation, including 30 cases of pituitary cell tumor, 6 cases of spindle cell oncocytoma, 6 cases of granulosa cell tumor, and 5 cases of mixed posterior pituitary tumor. The median follow-up time of the 47 patients was 12 months (3-102 months), and at the last follow-up, 45 patients survived, 2 died, and 21 had tumor recurrence. The results of Kaplan-Meier analysis showed that the overall median PFS of 47 patients was 10.0 months. Among them, the median PFS of patients with total tumor resection was 12.0 months, and the median PFS of patients with incomplete tumor resection was 8.5 months. The difference in PFS between patients with various resection degrees was statistically significant (P<0.05). Multivariate Cox regression analysis showed that intraoperative blood loss (HR=1.62, 95%CI: 1.17-2.24) and the extent of tumor resection were independent factors affecting PFS . Among them, total tumor resection (HR=0.34, 95%CI: 0.12-0.94) was a protective factor for PFS (all P<0.05).

Patients with large intraoperative blood loss and incomplete tumor resection are prone to postoperative recurrence.

To investigate the effects of pituitary stalk preservation on pituitary endocrinological functions after endoscopic endonasal resection for craniopharyngiomas.

The clinical data of 117 patients with craniopharyngiomas who underwent endoscopic endonasal resection at the Department of Neurosurgery, Huashan Hospital, Fudan University from September 2014 to August 2019 were retrospectively analyzed. Intraoperative pituitary stalk preservation or sacrifice was determined by reviewing operative records, videos and postoperative MRI scans. Intraoperative monitoring of variations in volume status was performed for evaluation of perioperative endocrine function of posterior pituitary. Patients were followed up with a special focus on the postoperative functions of pituitary axes.

The pituitary stalk was preserved in 76.9% (90/117) of all cases. Total urine output, hourly urine output and immediate postoperative serum sodium level in stalk sacrifice group (27 cases) were not significantly different from those in stalk preservation group (90 cases)(all P>0.05). All 117 patients were followed up with a median of 11.0 months (range: 5.5-23.5 months). The endocrine outcomes were more favorable when the pituitary stalk was preserved regarding the rate of hypogonadism [70.8% (51/72) vs. 95.2% (20/21), P=0.021] and posterior pituitary dysfunction[41.1% (37/90) vs. 74.1% (20/27), P=0.003] than stalk sacrifice group. No significant differences were found regarding the rate of postoperative hypoadrenalism [68.9% (62/90) vs. 81.5% (22/27), P=0.202] or hypothyroidism [70.0% (63/90) vs. 85.2% (23/27), P=0.117]. Compared with those in patients with stalk sacrifice, surgically induced new-onset hypogonadism (10/23 vs. 4/4, P=0.038) and function loss of posterior pituitary (20/65 vs. 10/15, P=0.010) were significantly lower in patients with stalk preservation. For patients who had preoperative hypopituitarism, there was no significant difference in the rates of function loss of all pituitary axes between patients with and those without stalk preservation(all P>0.05).

Pituitary stalk preservation is helpful for the preservation of function of hypothalamus pituitary-gonad axis and posterior pituitary.

To evaluate the treatment strategy and clinical efficacy of endovascular treatment of moderate to severe stenosis of the initiation segment of the internal carotid artery (ICA) combined with distal aneurysm in one stage.

We retrospectively analyzed the clinical data of 18 patients with moderate and severe stenosis (19 stenoses) combined with distal aneurysms (21 aneurysms) in the initiation segment of ICA treated with endovascular treatment in one stage in the Department of Neurosurgery, the First Affiliated Hospital of Nanjing Medical University from January 2017 to October 2020. All patients were prioritized for treatment of ICA stenosis, and intraoperative angiographic evaluation was followed by contemporaneous treatment of aneurysms. We observed the postoperative treatment effect and complications of the patients.

A total of 21 aneurysms and 19 carotid stenoses were successfully treated in 18 patients. Immediate postoperative angiography showed that the residual stenosis rates of 19 ICA stenoses were all <40%. Among the 21 aneurysms, embolization of Raymond grade Ⅰ was achieved in 12, grade Ⅱ in 7, and grade Ⅲ in 2. Except for 1 patient who had transient right upper limb muscle weakness (grade Ⅲ) on the 1st postoperative day and returned to normal on the 3rd day, the other patients had no symptoms of newly-developed neurological deficits. Postoperative follow-up lasted for 4 to 36 months (median: 12 months). At the last follow-up, the mRS was 0 in 10 cases, 1 point in 6 cases, 2 points in 1 case, and 3 points in 1 case. Thirteen patients were followed up by digital subtraction angiography, and the residual stenosis rates of 13 ICA initial segments were all less than 40%, and no in-stent stenosis occurred. Among the 14 aneurysms, embolization of Raymond grade Ⅰ was reported in 13 and grade Ⅱ in 1.

The clinical efficacy of endovascular treatment of moderate to severe stenosis of the initiation segment of the ICA combined with distal aneurysm in one stage seems good, and the complication incidence is low.

To preliminarily explore the application of microcatheter shaping method based on CFD (computational fluid dynamics) simulation of cerebral blood flow lines in endovascular treatment of proximal posterior aneurysms of anterior cerebral artery A1 and to evaluate its safety and effectiveness.

A retrospective analysis was conducted on the clinical data of 8 patients with unruptured posterior anterior cerebral artery A1 aneurysms who were admitted to the Cerebrovascular Division of Interventional Therapy Center, Zhengzhou University People′s Hospital from January 2019 to September 2021. All 8 patients underwent 3D-DSA before surgery. A1 ∶1 transparent resin hollow aneurysm model was printed according to the 3D-DSA data, and the aneurysm blood flow lines were simulated by CFD and microcatheter shaping was performed according to the flow lines. The accuracy of microcatheter shaping was verified by aneurysm model in vitro. Then endovascular treatment was performed, the tip position, success rate and stability of the microcatheter were analyzed. The embolization results of were evaluated based on the Raymond grading system. Postoperative neurological function was assessed by modified Rankin Scale (mRS) score.

All microcatheters were placed successfully with good stability in 8 patients, which was shown by in vitro test. Microcatheters were anchored in position for one time in 7 cases. The remaining 1 case underwent the remodeling for the second time due to vascular tortuosity and achieved good anchoring. During the operation, the catheter tip was stable in all patients with good support. No catheter prolapse, aneurysm rupture or surgical complications occurred in those patients. DSA immediately after surgery showed complete embolization of aneurysms in 7 cases (Raymond grade Ⅰ) and minimal residual aneurysm neck in 1 case (Raymond grade Ⅱ). The follow-up time of 8 patients was 3-12 months, including 7 patients with mRS of 0 and 1 patient with mRS of 1. Six patients were followed up by DSA, which showed that 5 patients achieved complete aneurysm embolization (Raymond grade Ⅰ) and 1 patient had residual neck (Raymond grade Ⅱ).

The microcatheter shaping based on CFD simulation of cerebral blood flow line not only has a high success rate in place, but also has good stability and support force, which could reduce the difficulty and risk of surgery, thus reducing complications and improving the embolization effect of aneurysm.

To investigate the clinical outcomes of microsurgical clipping of different types of ruptured internal carotid artery (ICA) bifurcation aneurysms via frontolateral keyhole approach.

A retrospective analysis was conducted on the clinical data of 28 patients with different types of ruptured internal carotid artery (ICA) bifurcation aneurysms (31 aneurysms in total) who were admitted to the Department of Neurosurgery, Lianyungang Hospital Affiliated to Xuzhou Medical University from January 2015 to December 2019. Based on the location of the aneurysmal neck, the aneurysms were categorized into three types as follows: aneurysms above the ICA bifurcation in 5 cases, aneurysms below the ICA bifurcation in 13 cases, aneurysms located at involved angles in 10 cases. Among the 10 cases with aneurysms located at involved angles, there were aneurysms at the ICA-ACA (anterior cerebral artery) angle in 1 case, at the ICA-MCA (middle cerebral artery) angle in 1 case, and at the ACA-MCA angle in 8 cases. All patients underwent microsurgical clipping via frontolateral keyhole approach. Different methods of clipping of ICA bifurcation aneurysms were used based on the different types of aneurysms. After clipping, indocyanine green fluorescence angiography was performed to assess the conditions of aneurysm, parent artery and branch vessels. The occurrence of perioperative complications was observed. The patients were followed up for 9 to 12 months after surgery. The follow-up methods included the Glasgow Outcome Scale (GOS) to evaluate the clinical outcomes of the patients, and the imaging evaluation was used to determine recurrence or residue of aneurysms subtraction angiography.

The aneurysm was successfully clipped in all 28 patients. During the operation, it was found that the anterior choroidal artery was not visualized in 1 case (caused by misclipping) and there was 1 case of residual aneurysm. For both cases, aneurysm clips were adjusted and no abnormality was found in indocyanine green fluorescence angiography. Postoperative CT showed infarction of the lenticulostriate artery in 2 cases, and the clinical manifestation was hemiplegia of the contralateral limb. One case showed brain swelling, midline structure shift of <1 cm, and no obvious compression of the brain stem. All 3 cases underwent conservative treatment and their symptoms improved after treatment. No newly-developed infarction or hydrocephalus occurred during the follow-up period. The aneurysms did not remain or recur. At the last follow-up, 25 cases were GOS grade Ⅴ, 2 cases were grade Ⅳ, and 1 case was grade Ⅲ.

The surgery via frontolateral keyhole approach is a safe and effective treatment for ICA bifurcation aneurysms with few complications and favorable outcomes.

To preliminarily observe the efficacy of flow diverting device (FD) combined with coil embolization in the treatment of vertebral artery hemorrhagic dissecting aneurysm.

The clinical and imaging data of 7 patients with vertebral artery hemorrhagic dissecting aneurysm treated by FD combined with coil embolization in the Cerebrovascular Division of Interventional Therapy Center, Zhengzhou University People′s Hospital from June 2017 to March 2022 were retrospectively analyzed. Clinical and imaging follow-up was performed 6 months after surgery. The modified Rankin scale (mRS) was used to evaluate the clinical outcome of the patients; the O′Kelly-Marotta (OKM) classification was used to evaluate the aneurysm occlusion.

The surgical procedure was smoothly performed in all 7 patients, and the FD was successfully released and adhered well. No neurological complications occurred during the perioperative period. Immediate postoperative angiography showed that the aneurysm reached OKM grade D in 4 cases (complete occlusion), C grade in 1 case (residual aneurysm neck), and B grade in 2 cases (partial residual aneurysm). Six months after the operation, all 7 patients were followed up clinically, and there were no new neurological symptoms, and the mRS was all 0 points. Four cases were followed up by imaging, the aneurysm was completely occluded, the parent artery was unobstructed, and there was no stenosis in the FD.

Preliminary observation suggests that the application of FD combined with coil embolization in the treatment of vertebral artery hemorrhagic dissecting aneurysm has a high technical success rate and good clinical efficacy and safety.

To observe the therapeutic effect of mechanical thrombectomy transradial access for acute intracranial large vascular occlusion.

A retrospective analysis was conducted on the clinical data of 15 patients with acute intracranial large-vessel occlusion at the Department of Neurosurgery, Wuxi Second Hospital Affiliated to Nanjing Medical University from June 2016 to December 2020. Those patients underwent mechanical thrombectomy transradial access after failed transfemoral access. We observed the establishment of surgical channels transradial access, the immediate postoperative vascular recanalization [modified thrombolysis in cerebral infarction (mTICI) ≥ 2b for recanalization] and surgery-related complications. Patients′ outcomes were assessed using the modified Rankin scale score (mRS) 90 days postoperatively (0-2 points for good outcomes prognosis and 3-6 for poor outcomes).

All 15 patients underwent successful establishment of a surgical channel transradial access. Among them, 14 patients completed mechanical thrombectomy, and the blood vessels achieved successful recanalization, and 1 patient failed in recanalization due to thrombosis escape to the distal blood vessels. None of the patients developed surgery-related complications. After 90 days of follow-up, none of the patients died, of which 5 patients had a good outcome and 10 patients had a poor outcome.

Mechanical thrombectomy transradial access for the treatment of acute intracranial large vessel occlusion has a high success rate and low risk, which is an important remedy after the failure of the transfemoral access.

To observe the clinical effect of endovascular treatment of tentorial dural arteriovenous fistula (TDAVF).

The clinical data of 28 patients with TDAVF admitted to the Department of Neurosurgery of the First Affiliated Hospital of Xinjiang Medical University from March 2015 to June 2021 were retrospectively analyzed. Eight patients were diagnosed as subarachnoid hemorrhage prior to operation. Among them, 9 cases underwent embolization with Glubran glue through arterial approach, 17 cases underwent embolization with Onyx glue, and 2 cases underwent embolization with Onyx glue through arterial approach combined with transvenous balloon-assisted embolization. The therapeutic effect and operation-related complications were documented.

Among the 28 patients, 22 had complete embolization, 2 had subtotal embolization, 1 had partial embolization, and 3 had failed embolization. There was 1 case of subacute infarction of the right cerebellar hemisphere due to the Glubran glue reflux. The follow-up time was 5 months to 6 years, and the median follow-up time was 34 months. The symptoms of 19 patients were significantly improved, including 13 patients who were cured (symptoms disappeared) and 6 patients whose symptoms improved, and the symptoms of the remaining 9 patients did not change significantly compared with those before surgery. No recurrence was found in the 15 patients who underwent DSA follow-up.

Endovascular treatment of TDAVF has relatively favorable therapeutic effect and few surgical risks.

To systematically compare the efficacy of subperiosteal drainage (SPD) and subdural drainage (SDD) in patients with chronic subdural hematoma (CSDH) during burr hole drainage.

PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CNKI, Wanfang, VIP and China Biomedical Literature Database were systematically searched for relevant literatures on SPD and SDD in the treatment of CSDH. The publication date of the searched literature was until March 2021. The primary outcome measure extracted from the SPD group and SDD group was hematoma recurrence, and the secondary outcome measures were brain parenchyma injury, intracranial infection, death, and postoperative epilepsy. Cochran Q test and I² value were used to evaluate the study heterogeneity. If the degree of heterogeneity was high, the random effect model was used to combine the effect values. Otherwise, the fixed effect model was used to combine the effect values. A funnel plot and Egger′s test were used to assess whether the study was subject to publication bias.

Finally, 10 articles were included (3 345 cases in total, 1 602 cases in SPD group and 1 743 cases in SDD group), which included 2 randomized controlled, 2 non-randomized controlled studies and 6 cohort studies. Meta-analysis results showed that there were no significant differences in the recurrence rate of hematoma (RR=0.90, 95%CI: 0.65-1.26, P=0.55), the incidence of intracranial infection (RR=0.88, 95%CI: 0.47-1.65, P=0.70), mortality (RR=0.85, 95%CI: 0.71-1.03, P=0.10), or postoperative epilepsy incidence (RR=0.91, 95%CI: 0.52-1.58, P=0.73) between the SPD and SDD groups. However, the incidence of brain parenchyma injury in the SPD group was lower than that in the SDD group (RR=0.14, 95%CI: 0.05-0.40, P<0.01).

Compared with SDD, the risk of brain parenchymal injury seems to be lower when SPD is selected in CSDH during burr hole drainage.