Volume 39 · Issue 01 · 2023

To evaluate the efficacy of surgical resection of large medial sphenoid ridge meningioma via extended pterional approach.

From January 2012 to February 2022, 41 patients with large (diameter ≥ 4.0 cm) medial sphenoid crest meningiomas underwent tumor resection via the extended pterional approach at the Department of Neurosurgery, Affiliated Brain Hospital of Nanjing Medical University and their clinical data were retrospectively analyzed. Head CT and MRI were reexamined within 24 hours after operation, and the degree of tumor resection was evaluated by Simpson grading scale. All patients were followed up 3 to 24 months after operation by outpatient clinic or telephone, and Karnofsky performance status score (KPS) was evaluated. Head MRI was re-examined 3 to 60 months after operation to evaluate whether the tumor had recurrence or progression. Repeated-measures analysis of variance was used to compare KPS at preoperative time point, discharge, and final follow-up.

Among the 41 patients, 38 cases (92.7%) were resected with Simpson grade Ⅰ-Ⅲ, and 3 cases (7.3%) were resected with grade Ⅳ. There were 3 cases of intracranial hematoma after operation (1 case died), 2 cases of acute cerebral infarction, 3 cases of aggravated cerebral edema, 2 cases of intracranial infection, and 13 cases of neurological dysfunction. The median follow-up time of 40 patients was 36.5 months (3-60 months). During the follow-up period, the neurological function of the patients recovered well, and they basically returned to normal work and life. At the last follow-up, there were 2 cases of tumor recurrence and 4 cases of tumor progression. The KPS of 40 patients before operation, at discharge and at the last follow-up showed a gradual upward trend (78.2±8.5 points, 85.3±8.9 points, 91.4±9.6 points respectively, F=69.46, P=0.033).

Surgical resection of large medial sphenoid ridge meningiomas via extended pterional approach has relatively good therapeutic effect, fewer complications and could improve the patients′ quality of life post operation.

To preliminarily investigate the prognostic factors of diffuse intrinsic pontine gliomas (DIPGs) in children.

A retrospective analysis was conducted on the clinical data of 24 children with DIPG who were admitted to the Department of Neurosurgery, Beijing Children′s Hospital, Capital Medical University from December 2020 to February 2022. The Kaplan-Meier method was used to draw survival curves. Log-rank test was used to analyze the effects of age, gender, disease duration (≤5 weeks vs. >5 weeks), abducens nerve palsy, whether the lesion was surrounding the basilar artery and whether the tumor was enhanced, hydrocephalus and metastasis, treatment methods and Karnofsky performance status (KPS) score at the time of diagnosis (>50 vs. ≤50) on survival. Some of the above indicators (P<0.1) were included in the multivariate Cox regression model for further analysis.

All patients were followed up for 8.2 to 23.3 months. At the last follow-up, 18 patients died. The median survival time of 24 patients was 35.9 weeks (3.0-181.0 weeks), and their survival rate was 29.2% at 1 year and 4.0% at 2 years. All the 5 patients who underwent surgery died. The 5 patients′ median survival time was 12.0 weeks (5.0-77.3 weeks), and their 1-year survival rate was 20.0%, and the 2-year survival rate was 0. The median survival time of 9 patients treated with radiotherapy and chemotherapy was 45.0 weeks (11.6-101.9 weeks), and the 1-year survival rate was 55.6%, and the 2-year survival rate was 44.4%. The median survival time of 10 patients receiving palliative treatment was 29.0 weeks (3.1-181.6 weeks), 1-year survival rate was 30.0%, and 2-year survival rate was 10.0%. Log-rank test showed that shorter course of disease, lesion enhancement, lesion surrounding the basilar artery, KPS≤50 points were associated with short survival (all P<0.05), while the patient′s gender, age, treatment method, whether there was abducens nerve palsy, hydrocephalus, or tumor metastasis did not seem to affect the survival (all P>0.05). Multivariate Cox regression analysis showed that lesion enhancement (RR=181.57, 95%CI: 3.28-10 045.64, P=0.011) and shorter disease duration (RR=0.91, 95%CI: 0.84-0.99, P=0.024) were important factors for reduced survival.

Preliminary results suggest that compared with palliative care, surgery, radiotherapy or chemotherapy cannot effectively improve the prognosis of children. Children with shorter disease duration and lesions with enhancement have a worse prognosis.

To explore the factors affecting the survival prognosis of children with medulloblastoma (MB).

The clinical data of 87 children with MB admitted to the Neurosurgery Department of Beijing Children′s Hospital, Capital Medical University from December 2012 to December 2019 were retrospectively analyzed. All 87 cases underwent tumor resection, 69 cases received chemotherapy and 73 cases received radiotherapy. The overall survival (OS) of the children was analyzed by Kaplan-Meier method. Univariate log-rank test and multivariate Cox regression analysis were used to explore the influencing factors of OS in children.

Among the 87 cases of medulloblastoma, gross total resection was achieved in 75 cases, near total resection in 10, and partial resection in 2. Postoperative pathological results revealed 64 cases of classic type, 13 cases of desmoplastic/nodular type, 6 cases of large cell/anaplastic type and 4 cases of extensive nodularity type. According to the molecular typing method and out of 32 cases, there were 17 cases of Group 4, 10 cases of SHH type, 3 cases of Group 3 type and 2 cases of WNT type. Post operation, 33 cases (37.9%) were diagnosed with cerebellar mutism syndrome (CMS). The follow-up time was 1-86 months with a median of 22.5 months. The overall 7-year survival rate was 61.7%. Kaplan-Meier analysis results showed that risk hierarchy (χ²=15.80, P<0.001), preoperative tumor dissemination (χ²=13.72, P<0.001), postoperative radiotherapy (χ²=25.92, P<0.001) and postoperative chemotherapy (χ²=3.89, P=0.049) were associated with OS. Multivariate Cox regression analysis showed that postoperative radiotherapy was the only independent risk factor affecting OS (HR=-2.37, 95%CI: 0.03-0.31, P<0.001), while risk hierarchy, preoperative tumor dissemination, age, postoperative chemotherapy, or CMS were not risk factors of OS (all P>0.05).

Postoperative CMS does not affect the prognosis of MB, and postoperative radiotherapy can help improve the prognosis of MB.

To assess the efficacy of resection of pineal region meningiomas through occipital interhemispheric approach.

We retrospectively reviewed the clinical records of 10 patients with pineal region meningiomas who underwent microsurgical resection via occipital interhemispheric approach between May 2010 and November 2021 at the Department of Neurosurgery of the First Affiliated Hospital of Air Force Military Medical University. The maximum tumor diameter was 4.4±1.4 cm (2-7 cm). Among the 10 patients, there are 9 cases of falcotentorial meningiomas and 1 case of velum interpositum meningioma. According to the Bassiouni classification system, there are 4 cases of type Ⅰ, 4 cases of type Ⅱ, 1 case of type Ⅲ and 1 case of type Ⅳ. Extent of resection and postoperative complications were also assessed.

Ten patients with pineal meningioma underwent 11 surgical operations. Of the 11 operations, 9 were Simpson grade Ⅱ resection, 1 was grade Ⅰ and 1 was grade Ⅳ. Transient homonymous hemianopia occurred in 3 patients after operation and recovered in 1 week. One patient had hemiparesis, which resolved by 3 months. No patient suffered from tumor recurrence or died, with a median follow-up of 38 months (4 months to 12 years). At the last follow-up, the KPS score was ≥80 in 8 cases and 50-70 in 2 cases.

Through the occipital interhemispheric approach, the pineal region meningiomas occupying the infratentorial space can be accessed effectively by opening the tentorium or the falx cerebri. The degree of tumor resection is relatively high with few complications.

To develop and validate a machine learning model based on radiomics features extracted from contrast enhancement-T1 weighted imaging (CE-T1WI) of MR for differentiating between primary central nervous system lymphoma (PCNSL) and glioblastoma (GBM).

The clinical and imaging data of 120 patients with pathologically confirmed PCNSL or GBM admitted to the Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University from January 2020 to December 2021 were collected retrospectively. The patients were randomly divided into the training group (n=84) and test group (n=36). The tumor boundary was delineated on the preoperative CE-T1WI MR images with the 3D-Slicer software and the radiomics features were extracted using the Pyradiomics package written in Python. The t-test and LASSO regression were used to screen the best radiomics features to distinguish PCNSL and GBM in the training group and the selected features were used to construct the diagnostic model by random forest classifier. The accuracy of the model′s prediction was evaluated by drawing the receiver operating characteristic (ROC) curve and measured using the area under the ROC curve (AUC).

A total of 1 218 imaging features were extracted by Pyradiomics package of Python software, and 3 radiomics features were screened by t-test and LASSO regression. The area under the receiver operating characteristic curve (area under the curve, AUC) of the diagnostic model constructed by random forest classifier was 0.874, and the sensitivity and specificity were 0.878 and 0.684 respectively. The AUC results of 5-fold cross-validation were 0.870, 0.881, 0.871, 0.855 and 0.898(average value: 0.870).

The machine learning model constructed based on radiomics features has a high accuracy in distinguishing PCNSL and GBM.

To investigate the application value of mixed reality technology in surgical resection for vestibular schwannomas (VS).

The clinical data of 25 patients with VS who underwent neurosurgery at the Department of Neurosurgery, the Second Hospital of Hebei Medical University from January 2021 to February 2022 were retrospectively analyzed. All patients underwent preoperative temporal bone CT, fast imaging employing steady-state acquisition with cycled phases, and diffusion tensor imaging. The 3D model was established using 3D-Slicer software, and the 3D model image was presented by mixed reality technology to predict the positional relationship between the tumor and the facial and auditory nerves, so as to develop an individualized surgical plan. Taking the results of intraoperative neurophysiological monitoring as the gold standard, the Kappa test was used to evaluate the consistency between the course of the preoperatively reconstructed facial nerve and the positioning of intraoperative neurophysiological monitoring. All 25 patients underwent surgery through the retrosigmoid approach. The facial nerve function of the patients was evaluated by House-Brackmann classification before operation and 1 week after operation.

All 25 patients successfully underwent reconstruction of the three-dimensional model of VS before operation, and the median volume of the tumor after reconstruction was 6.18 cm³ (0.73-16.86 cm³). Among them, facial nerve reconstruction was successful in 23 cases (92.0%), and reconstruction failed in 2 cases. The satisfaction rate of keyhole positioning during craniotomy was 96.0% (24/25), and there were no patients with venous sinus injury. Among the 23 patients who successfully underwent reconstruction of the facial nerve before operation, 20 cases showed completely consistency between reconstruction results and the facial nerve positioning based on the intraoperative neurophysiological monitoring, and the accuracy rate was 86.9%. The Kappa test showed that there was a strong consistency between the course of the preoperatively reconstructed facial nerve and the positioning of facial nerve based on intraoperative neuroelectrophysiological monitoring (Kappa=0.836, P<0.01). Postoperative re-examination of MRI in 25 patients showed that the tumors were completely resected. One week after operation, the House-Brackmann classification was grade Ⅰ in 6 cases, grade Ⅱ in 9 cases, grade Ⅲ in 6 cases, and grade Ⅳ in 4 cases. There was no case of cerebrospinal fluid leakage.

Preoperative reconstruction of the three-dimensional model with mixed reality technology can assist in the surgical resection of VS, which is beneficial to the protection of the facial nerve during the operation and reduction of the surgical side injury.

To investigate the clinical characteristics and surgical outcomes of spinal intramedullary arachnoid cysts.

The clinical data of 9 patients with spinal intramedullary arachnoid cysts admitted to the Department of Neurosurgery of the First Affiliated Hospital of Zhengzhou University from July 2015 to December 2020 were retrospectively analyzed. All 9 patients underwent cyst decompression and cyst wall resection via dorsomedial approach. The McCormick classification was used to evaluate the spinal cord function of the patients before operation, short-term after operation, and at the final follow-up. During the follow-up period, MRI was re-examined to observe whether the cyst recurred.

Intramedullary arachnoid cysts in the spinal cord accounted for about 3.86% (9/233) of space-occupying lesions in the spinal cord during the same period. Ages at onset ranged from 10 to 61 years, and the male to female ratio in adults was 2/5. The primary symptoms were mainly bodily pain(6/9) and limb weakness(4/9), sometimes accompanied by an acute course(4/9). Preoperative McCormick grade Ⅰ was revealed in 1 case, Ⅱ in 4 cases, and Ⅲ in 4 cases. Among the 9 patients, most of the cysts were removed in 7 cases, and partial cysts were removed in 2 cases, all of which were confirmed by pathological examination after operation. Postoperative MRI showed that the cysts were significantly shrunk. The symptoms were completely relieved in 4 cases and partially relieved in 5 cases shortly after operation, and the symptoms of 4 cases were further improved during the follow-up period. Except for 1 case lost to follow-up, the follow-up time of the other 8 patients ranged from 12 to 61 months. During the follow-up period, there was no recurrence of symptoms or no enlargement of residual cysts. At the last follow-up, the McCormick grades of the 8 patients were all grade Ⅰ.

Intramedullary arachnoid cysts of the spinal cord are rare clinical entities which are more common in women than in men, and patients with symptoms should be actively treated with surgery, and the clinical prognosis seems good.

To investigate the protective role of conventional motor evoked potentials (MEP) and somatosensory evoked potentials (SEP) in combination with D wave monitoring and potential reversal techniques for patients′ neurological function during spinal cord intramedullary tumor resection.

We conducted a historical control study on clinical data of 76 patients who underwent spinal cord intramedullary tumor resection at the Neurosurgery Center, Beijing Tiantan Hospital, Capital Medical University from July 2019 to December 2020 (preoperative McCormick grade Ⅰ to Ⅱ). All patients were divided into conventional monitoring group (using conventional electrophysiological techniques for interoperative monitoring, including MEP and SEP, 38 cases) and combined monitoring group (using the conventional electrophysiological techniques combined with D wave monitoring and potential reversal technique, 38 cases). Patients′ preoperative McCormick rating and its changes at 2 weeks post operation, as well as during postoperative follow-up period, postoperative intensive care duration, length of hospital stay, tumor resection rate, Short Form 36 (SF-36) score, and other indicators were compared between the two groups to examine the protective effects of different monitoring methods on patients′ neurological function.

There were no statistically significant differences between the two groups of patients in terms of gender, age, location of tumor, and initial symptoms and preoperative McCormick rating (all P>0.05), while the McCormick grade of the combined monitoring group was superior to that of the conventional monitoring group 6 months after operation (χ²=5.68, P=0.017). The McCormick grade 2 weeks after the operation did not differ between the two groups (χ²=0.26, P=0.642). No significant differences were found in postoperative intensive care duration, hospital stay, or total/subtotal tumor resection rate (all P>0.05). SF-36 scores significantly differed between the two groups at 6 month post operation (t=3.10, P=0.003). For the electrophysiological indicators used in each group, the negative and positive predictive rates of the conventional monitoring group were 86.7% and 25.0% respectively, and those of the combined monitoring group were 93.9% and 40.0% respectively.

The application of routine electrophysiological monitoring (SEP+ MEP) combined with D wave and potential reversal technology during spinal cord intramedullary tumor resection can help protect the patients′ nerve function and my play a role in predicting the nerve function.

To explore the clinical application effect of balloon-assisted blocking technique in clipping surgery for large paraclinoid aneurysms recurrent after embolization.

The clinical data of 10 patients with recurrent large paraclinoid aneurysms after embolization who were admitted to the Department of Neurosurgery of Zhongnan Hospital of Wuhan University from July 2017 to June 2020 were retrospectively analyzed. The maximum diameter of the aneurysm was 17.5±5.6 mm (11-26 mm). All 10 cases of aneurysms underwent craniotomy and clipping with balloon-assisted blocking technique, and the balloon placement and craniotomy and clipping were performed simultaneously in a one-stop hybrid operating room. Immediately after operation, digital subtraction angiography (DSA) was performed to observe the clipping condition of the aneurysm and the patency of the parent artery. During the follow-up period, DSA examination was performed to evaluate the occlusion and recurrence of the aneurysm; the modified Rankin scale (mRS) was used to evaluate the outcomes of the patients.

In all 10 cases of aneurysm, a balloon was successfully placed and the neck of the aneurysm was blocked, and the residual coil and thrombus at the neck of the aneurysm were safely removed, and the aneurysm was successfully shaped and clipped. Immediately after the operation, DSA examination showed that all 10 cases of aneurysms were completely occluded, and there were no residual aneurysms, parent artery stenosis, or large vessel embolism, and no death cases occurred. There were 7 cases with mRS score of 0 and 3 cases with mRS score of 1 at discharge. No delayed visual impairment occurred in any of the patients. The follow-up time of 10 patients was 29.7±8.5 months (13-48 months). DSA reexamination at 6 months after operation showed that the aneurysm was completely occluded in all patients, and there was no residual aneurysm or recurrence. At the last follow-up, the mRS score was 0 in 9 cases and 1 in 1 case.

For large paraclinoid aneurysms that recur after embolization, surgical clipping with balloon-assisted blocking technique has a high success rate, fewer postoperative complications, and good prognosis, which seems to be a safe and effective hybrid surgery method.

To analyze the efficacy and complications of selective posterior rhizotomy (SPR) combined with replacement laminoplasty (RL) for the treatment of spastic cerebral palsy (SCP).

The clinical data of 785 children with SCP who underwent SPR+ RL at the Department of Functional Neurosurgery of Beijing Children′s Hospital, Capital Medical University from September 2015 to June 2020 were retrospectively analyzed. Postoperative rehabilitation was routinely administered. Follow-up was performed from 6 months to 3 years after surgery. Efficacy evaluation criteria were gross motor function measure (GMFM) and modified Ashworth spasticity scale (MAS). Postoperative complications were summarized.

The spasticity and limb motor function of 785 children were improved to varying degrees after operation. The GMFM scores at preoperative and last follow-up were 34.9±5.2 and 58.9±8.0 respectively, and the MAS scores were 4.8±0.4 and 2.9±0.5 respectively, and the differences were statistically significant (both P<0.05). Short-term postoperative complications included low-grade fever (3.18%, 25/785), moderate to high fever (4.08%, 32/785), headache (1.91%, 15/785), and acute urinary retention (0.38%, 3/785), abdominal distension or difficulty in defecation (4.08%, 32/785), poor healing of superficial incision (3.18%, 25/785), deep incision infection (1.02%, 8/785), cerebrospinal fluid leakage (0.25%, 2/785), limb sensory disturbance (7.77%, 61/785); postoperative long-term complications included low back pain (2.04%, 16/785), intermittent lower extremity weakness (0.64%, 5/785), spinal deformity (0.38%, 3/785) and defecation disorder (0.13%, 1/785). After symptomatic treatment of various complications, the outcomes were satisfactory.

SPR+ RL combined with rehabilitation can improve spasticity and limb motor function in children with SCP. The incidence of postoperative complications is low, and various complications could be treated with satisfactory outcomes.

To explore the related factors affecting the surgical outcome in patients with Chiari malformation type Ⅰ (CM-Ⅰ).

The clinical data of 77 CM-Ⅰ patients admitted to the Department of Neurosurgery of the Second Hospital of Lanzhou University from January 2017 to December 2020 were retrospectively analyzed. Twenty-five cases were treated with posterior cranial fossa bony decompression and expanded dural angioplasty, and 52 cases were treated with posterior approach fixation. The Chicago Chiari outcome scale (CCOS) was used to evaluate the short-term efficacy (at discharge), long-term efficacy (≥3 months after surgery), and the improvement of curative effect(improvement of long-term efficacy over short-term efficacy). The influencing factors of CM-Ⅰ operation efficacy were analyzed by univariate analysis and multiple linear regression model.

The CCOS scores at discharge varied in patients with different first symptom(P=0.008). Patients without limb weakness, abnormal sphincter function, cerebellar ataxia, unsteady walking or scoliosis before operation, and those with low national nosocomial infection surveillance risk index(NNIS) scores had higher CCOS scores at discharge, and the differences were statistically significant (all P<0.05). Patients with preoperative occipital pain, American Society of Anesthesiologists (ASA) anesthesia class Ⅰ, and those without platybasia had higher CCOS scores ≥3 months after operation, and the differences were statistically significant (all P<0.05). Patients aged 18 to 40 years old, with preoperative limb weakness, combined with atlantoaxial dislocation, atlanto-occipital fusion, without platybasia and treated with posterior approach fixation had more improvement in terms of the CCOS score, and the differences were statistically significant (all P<0.05). Preoperative limb weakness and scoliosis were the influencing factors of short-term efficacy after CM-Ⅰ surgery (both P<0.05). ASA preoperative anesthesia risk classification was the influencing factor of long-term efficacy after CM-Ⅰ surgery (P=0.047). Preoperative limb weakness and platybasia were the influencing factors for the improvement of curative effect of CM-Ⅰ (both P<0.05).

CM-Ⅰ patients without limb weakness or scoliosis before surgery have better short-term postoperative outcomes. Patients with lower ASA preoperative anesthesia risk classification have better postoperative long-term outcomes. CM-Ⅰ patients with preoperative limb weakness and without platybasia have better improvement of curative effect.