Volume 101 ·  Issue 23 ·  2021

China′s "Criteria and practical guidance for determination of brain death (BD)" based on medicine was launched eight years ago. After joining the writing and publishing work of "The World Brain Death Project-Determination of Brain Death/Death by Neurologic Criteria", China has accelerated the process of internationalization. For this reason, the author expressed his own opinions on the related work progress and existing problems. (1) Although the criteria of BD in different countries are different due to various national conditions, cultures, religions and laws, we can seek common ground while reserving differences, such as the unification of the minimum criteria and the choice of confirmatory tests. (2) Although there are differences in the executive force of BD evaluation among countries around the world due to whether legislation or not, all walks of life and the public can respect the development of medicine. (3) Although there are still life support and organ donation problems to be solved after the determination of BD, they will be solved one by one through medical practice. In a word, we believe that the specification of BD determination in China will continue to advance orderly and rapidly.

The incidence and mortality of lung cancer in China rank first among malignant tumors. In order to further standardize the prevention and treatment measures of lung cancer in China, improve the diagnosis and treatment level of lung cancer, improve the prognosis of patients, and provide professional evidence-based medical opinions for clinical medical staff at all levels, the Oncology Branch of Chinese Medical Association organized experts from respiratory medicine, medical oncology, thoracic surgery, radiotherapy, imaging and pathology, combined with the recommendations of international guidelines and the current status of clinical practice in China, and integrated the latest evidence-based medical evidence on lung cancer pathology, gene detection, immune molecular marker detection and treatment methods in recent years, and formulated the Guidelines for Clinical Diagnosis and Treatment of Lung Cancer (2021 Edition) of the Oncology Branch of Chinese Medical Association, aiming to provide recommendations on lung cancer screening, diagnosis, pathology, treatment and follow-up for clinicians, imaging, laboratory and rehabilitation professionals at all levels.

Brain Death Determination Criteria and Practice: Expert Supplementary Opinion (2021) is based on the second edition of China Brain Death Determination Criteria and Practice, with reference to the 2020 Global Brain Death Recommendation-Determination of Brain Death/Neurological Standard Death and combined with clinical practice. The expression form takes questions and recommendations, and the expression content not only supplements the prerequisites for brain death determination, clinical judgment and confirmation tests in more detail, but also supplements the newly emerging extracorporeal membrane oxygenation (ECMO) therapy and target temperature therapy. Brain death determination under therapy. In addition, the author emphasizes the difference between children as a special group and adults in determining brain death, especially the specific criteria and norms for determining brain death at a specific age stage, as well as the time and times of determination.

Based on the Global Brain Death Recommendation-Determination of Brain Death/Neurological Standard Death (2020), Chinese experts authored the Implementation and Management of Brain Death Determination: Expert Guidance (2021). Its main contents involve some problems encountered by clinicians in the process of determining brain death, including how to announce the results of brain death after the judgment, how to record the process of determining brain death, how to decide on system support, how to obtain religious identity, and how to abide by laws and regulations. Although these contents are not covered in the Chinese Adult Brain Death Determination Standards and Operation Standards (Second Edition) and the second edition of Chinese Child Brain Death Determination Standards and Operation Standards, clinicians need the guidance and suggestions of experts.

To investigate the use of deep learning approaches to improve the image quality of arterial spin labeling (ASL) and optimize its quantitative accuracy for cerebral blood flow (CBF).

The clinical and imaging data of 101 patients with cerebrovascular disease in Tianjin Huanhu Hospital from May 2018 to August 2019 were retrospectively collected. Patients were divided into a training set (71 cases) and a validation set (30 cases). In training set, there were 53 cases of male,18 cases of female,with age of 55.0 (41.3, 64.5), and in validation set, there were 23 cases of male,7 cases of female,with age of57.5 (49.0, 65.0). Quantitative perfusion weighted imaging was used as the reference standard, and the original ASL-CBF images were reconstructed by training a deep learning generative adversarial network (GAN). The image quality of original ASL-CBF and GAN-CBF was compared by the structural similarity index and the normalized root mean square error. Pearson correlation coefficient was used to analyze the correlation between ASL-CBF, GAN-CBF and quantitative perfusion in different cerebral vascular blood supply areas and stroke areas, and to verify the improvement effect of GAN on the image quality and quantitative accuracy of ASL.

There were significant differences in gender, age, disease type, site and size between training set and validation set (all P>0.05). Compared with ASL-CBF, GAN-CBF had a higher structural similarity index (0.888 vs 0.801,P<0.001), and a lower normalized root mean square error (0.628 vs 0.775, P<0.001). The correlation between GAN-CBF and quantitative perfusion in different blood vessel supply areas and stroke lesion areas was improved compared with the original ASL-CBF, in which the perforating branch of the middle artery (r=0.853) and stroke lesion areas (r=0.765) were the most obvious (all P<0.001).

The generative adversarial network could improve the image quality and quantization accuracy of ASL without increasing the scanning time, and expand the clinical application value of ASL.

To explore the correlation between decreased cerebral perfusion measured from arterial spin labeling and cerebrovascular events in patients with bilateral moyamoya angiography (MMA).

Twenty-seven consecutive cases with bilateral MMA, who were admitted to the neurosurgery department of Nanjing Drum Tower Hospital from April to November 2020, were included in this retrospective study. Among them, 10 were males and 17 were females, aged 35-66 (55±9) years. These patients all presented with unilateral cerebral hemisphere cerebral infarction or cerebral hemorrhage. The Wilcoxon paired signed-rank test was used to qualitatively analyze the differences in the Arterial Transit Artifact (ATA) of the bilateral cerebral hemispheres. The mean gray value, the kurtosis and skewness of gray distribution curve of bilateral cerebral hemispheres on cerebral blood flow (CBF) images with post labeling delay (PLD) of 1.5 s and 2.5 s were quantitative calculated. The relationship between ASL and cerebrovascular event was determined using binary logistics regression analysis.

No significant difference was observed in ATA between bilateral hemispheres on CBF images with PLDs of 1.5 s and 2.5 s (P>0.05). On the CBF images with a PLD of 1.5 s, the mean gray value of the cerebral hemisphere on the lesion side (17.50±5.88) was markly lower than that on the non-lesion side (20.80±5.51) (P<0.001), the kurtosis and skewness of gray distribution were significantly different between bilateral cerebral hemispheres (P<0.05);On the CBF images with a PLD of 2.5 s, the mean gray value and the skewness of the gray distribution on the lesion side of the cerebral hemisphere were statistically different from those on the non-lesion side (P<0.05), while the difference in kurtosis was not statistically significant between bilateral cerebral hemispheres (P>0.05). Multivariate regression analysis showed that the reduction of gray value on the side of the lesion was independently associated to the occurrence of the cerebrovascular events (OR_PLD1.5=0.192, 95%CI:0.047-0.783;OR_PLD2.5=0.175, 95%CI:0.050-0.615).

The decreased perfusion detected by ASL is independently associated with cerebrovascular events in patients with MMA.

To compare the cerebral perfusion differences between the symptomatic patients and the asymptomatic patients with unilateral middle cerebral artery (MCA) severe stenosis or occlusion by using three post labeling delays (PLD) of the three-dimensional pseudo-continuous arterial spin labeling (pCASL) technique.

The clinical characteristics and ASL data of the 27 patients with severe stenosis or occlusion of unilateral MCA (18 symptomatic, 9 asymptomatic) were prospectively enrolled from April 2018 to November 2019 in the Department of Radiology of China-Japan Friendship Hospital. There were 16 males and 11 females, age range from 29 to 85 (55±13) years. According to the symptoms, they were divided into symptomatic group (18 cases) and asymptomatic group (9 cases). The parameters of cerebral blood flow (CBF), mean cerebral blood flow (mCBF), arterial transit time (ATT) and arterial cerebral blood volume (aCBV) were obtained using the Cereflow software. One-way multivariate analysis of variance (one-way MANOVA) was used to compare the differences of cerebral perfusion parameters between symptomatic group and asymptomatic group, and between the affected side and the control side in the two groups. Two-way ANOVA was used to evaluate the effects of symptoms, hemisphere (affected and control side), PLD times (1.5, 2.0 and 2.5 s) and the interaction between the two factors.

The CBF of the affected leptomeningeal branch and perforating branch of MCA in symptomatic group was lower than that in asymptomatic group [(36.8±10.2) ml·100 g^-1·min^-1 versus (46.6±13.9) ml·100 g^-1·min^-1, F(1, 75)=13.279, P=0.000 49; (32.3±8.3) ml·100 g^-1·min^-1 versus (36.2±7.5) ml·100 g^-1·min^-1, F (1, 75)=4.065, P=0.047], and there was no interaction between the symptom and PLD [F(2, 75) =0.061, P=0.940]. In the symptomatic group, the CBF of the leptomeningeal branch and perforating branch of MCA in affected side was lower than that in control side [(36.8±10.2) ml·100 g^-1·min^-1 versus (43.7±10.0) ml·100 g^-1·min^-1, F(1, 102)=12.559, P=0.000 59; (32.3±8.3) ml·100 g^-1·min^-1 versus (36.4±8.0) ml·100 g^-1·min^-1, F(1, 102)=6.493, P=0.012]. In the symptomatic group, the CBF of leptomeningeal branch of MCA when PLD was 2.5 s was 7.34 ml·100 g^-1·min^-1, which were higher than that when PLD of 1.5 s (95%CI: 0.72-13.9, P=0.03). There was no interaction between PLD and hemisphere [F(2, 102) =0.307, P=0.736].

The collateral circulation in the blood supply area of MCA in asymptomatic patients with severe unilateral MCA stenosis or occlusion is more abundant than that in symptomatic patients. ASL can be an effective technique for evaluating the cerebral perfusion of collateral circulation in patients with severe stenosis or occlusion of MCA.

To evaluate the diagnostic performance of the combination of arterial spin labeling (ASL) and time of flight MR angiography (TOF MRA) for intracranial arteriovenous shunt (AVS) detection.

A total of 39 patients with known or suspected with cerebrovascular malformations underwent digital subtraction angiography (DSA) and ASL/TOF MRA imaging in Department of neurosurgery and radiology and nuclear medicine, Xuanwu Hospital from May 1, 2020 to October 31, 2020 were retrospectively analyzed. Patients were divided into either acute cerebral hemorrhage group (n=13) or non-acute cerebral hemorrhage group (n=26) based on the signs of bleeding on imaging findings. According to history of treatment, those patients were divided into treated (n=11) and untreated (n=28) subgroups. The determination of the presence of AVS on images was judged by two radiologists in a blinded and randomized order fashion. The diagnostic performance of ASL or TOF MRA for AVS were evaluated in overall, acute cerebral hemorrhage subgroup and treated subgroup by using the area under receiver operating curve (AUC) with DSA as the reference standard, respectively. The κ coefficients were calculated to determine the interobserver agreement.

Among 39 patients, 29 patients were confirmed with AVS by DSA while 10 patients with no AVS. Interobserver agreement was good-excellent (κ=0.83-1.00). In patients with AVM, the detection rates for AVS of ASL or TOF MRA were 93.1% and 86.2% respectively, while the detection rates of the combination of ASL and TOF MRA were 100%. The AUC of ASL, TOF MRA and their combination for diagnosis of AVS in overall were 0.966 (95%CI: 0.909-1.00), 0.914 (95%CI: 0.825-1.00) and 0.983 (95%CI:0.943-1.00), respectively. The AUC of ASL, TOF MRA and their combination for AVS in acute cerebral hemorrhage subgroup were 1(95%CI:1.00-1.00), 0.833(95%CI:0.611-1.00), 1(95%CI:1.00-1.00), respectively.

Combination of ASL and TOF MRA can be a non-invasive thchnique for the detection of AVS.

To explore the influence of hemodynamics, morphological and clinical characteristics on rupture risk of the dorsal and non-dorsal internal carotid artery aneurysms (ICAAs).

A total of 111 patients diagnosed with aneurysm by digital subtraction angiography (DSA) or surgery, underwent cranial CT angiography (CTA) were retrospectively collected from January 2010 to December 2016 at the Department of Diagnostic Radiology, Jinling Clinical College of Xuzhou Medical University (General Hospital of Eastern Theater Command). Among them, 41 were males and 70 were females, ranging in age from 32 to 83 (56±11) years old. The patients were divided into the ruptured group (n=54) and unruptured group (n=57) based on the hemorrhagic manifestation on non-enhanced CT images or DSA or surgery of the head. Demographics and the morphological characteristics of the aneurysms were evaluated. Hemodynamic parameters, including wall share stress, wall share stress gradient, and others were obtained in overall using computational fluid dynamics simulation technique. Characteristics were compared between the ruptured and unruptured groups. Logistic regression analysis was applied to evaluate the independent risk factors for rupture, and the hemodynamic characteristics associated with dorsal and non-dorsal aneurysms were analyzed, respectively.

Compared with the unruptured group, patients in the ruptured group were younger ((54.2±11.4) years and (58.3±9.9) years, P=0.033), mostly female (74.1% vs 52.6%, P<0.05), with a higher proportion of hypertension (46.3% vs 22.8%,P=0.009). The ruptured internal carotid artery aneurysms (ICAAs) were more frequently located at the dorsal of an arterial arch (57.4% vs 36.8%, P<0.05), and the flow of the blood was more complex, concentrated, unstable, and with a smaller impingement zone (68.5% vs 33.3%,55.6% vs 10.5%,72.2% vs 26.3% and 79.6% vs 36.8%, respectively, allP<0.05). Logistic regression demonstrated that women, hypertension, dorsal, concentrated flow pattern, and unstable flow pattern were an independent risk factors for ICAAs rupture [OR=3.551 (1.080-11.679), 3.900 (1.172-12.976), 4.966 (1.504-16.401), 51.893 (7.913-340.296) and 50.015 (8.423-296.985), respectively, all P<0.05]. The ruptured ICAAs located at non-dorsal had more concentrated, unstable, and with smaller impingement zone (P<0.05), while those at dorsal had more complex, concentrated, and unstable flow patterns, and with smaller impingement zone (allP<0.05).

Women, hypertension, dorsal concentration, and unstable flow pattern are independent risk factors for the rupture of ICAAs. The dorsal locations of ICAAs could have a higher risk of rupture.

To explore the relationship between maternal sleep time and the risk of small for gestational age (SGA), and to evaluate the role of glucose-lipid metabolism in the association.

A total of 6 821 women who was second pregnancy were recruited from pregnancies consulted at Hefei First People′s Hospital, Anhui Province Maternity & Child Health Hospital and the First Affiliated Hospital of Anhui Medical University from March 2015 to April 2019, and a face-to-face questionnaire survey was conducted to collect general demographic characteristics, dietary habits and routine lifestyles. Sleep information including bedtime, getup and sleep duration were reported by pregnant woman herself, and this survey as well as the third trimester of gestation. Pregnancy and birth outcomes were collected at delivery. A total of 5 488 mother-pairs with complete data were obtained in the final data. The non-linear relationship between chronotype and SGA risk was explored by restricted cubic spline regression model, and the role of glucose-lipid metabolism in the association between sleep midpoint and SGA was explored by using the mediating model based on bootstrap method.

The incidence of SGA was 8.4% (459/5 488) in eligible pregnant women. Compared with the pregnant women who went to bed before 21∶00, the risk of SGA of women who went to bed after 23∶00 am (OR=1.54, 95%CI: 1.01-2.34) was significantly higher in the multivariate logistic regression model. Additionally, the risk of SGA in pregnant women who got up after 8∶00 am was significantly higher than those women who got up before 8 o′clock (OR=1.31, 95%CI:1.05-1.62). However, the significant association between sleep duration and SGA was not found. In the restricted cubic spline regression, the risk of SGA was significantly increased from the specific midpoint of 02∶45 am (P<0.05). Moreover, mediation model showed that the negative effect of late sleep in the second trimester on SGA may be partially explained through glucose-lipid metabolism(allP<0.05).

Maternal sleep status at the second trimester of gestation may be more susceptible to SGA. Lately sleep midpoint may be a potential independent risk factor for increased risk of SGA, and furtherly affect the occurrence of SGA by changing the level of glucose and lipid metabolism.

To evaluate the value of soluble thrombomodulin (sTM) in evaluating endothelial injury in patients with kidney disease.

One hundred and thirty-three patients who first visited the Department of Nephrology of Beijing hospital for various reasons from September 2020 to January 2021 and 130 healthy people were collected and divided into groups according to age, gender, primary disease, complications and so on. The differences of sTM and serum creatinine in patients with different diseases and renal disease stages were analyzed.

For patients with chronic kidney disease (CKD), sTM increased significantly with the decrease of renal function. The level of sTM in patients with CKD stage 1-5 was (0.013±0.007), (0.019±0.010), (0.022±0.008), (0.027±0.008), (0.033±0.006)TU/L, respectively (F=21.005,P<0.05). There was no significant difference in the level of sTM between patients with non-CKD urinary tract infection (0.013±0.009) TU/L and patients with stage 1 CKD (t=1.023, P>0.05). No matter whether the patients were complicated with infection or cardiovascular disease, there was no significant difference in sTM level under the condition of serum creatinine matching (allP>0.05). In 4 patients with acute renal injury, serum creatinine returned to normal after active treatment, but sTM did not decrease significantly. Correlation analysis showed that there was a positive correlation between sTM and serum creatinine (r=0.697, P<0.01).

sTM can evaluate the renal function damage of patients with CKD more early, and the level of sTM in patients with renal disease is more related to the degree of endothelial damage.

To investigate the influence of the preoperative factors on the segmental range of motion (ROM) during long-term follow-up after artificial cervical disc replacement (ACDR), so as to further improve the selection of surgical indications for ACDR.

Retrospective analysis was performed on 71 patients with cervical degenerative diseases who underwent single-segment Bryan ACDR in Beijing Jishuitan Hosptial from December 2003 to December 2008, and a 10-year clinical follow-up was conducted. Among the patients, 44 were males and 27 were females, with a mean age of (45±8) years at operation. The mean follow-up time was (129±14) months. Preoperative and follow-up imaging evaluation including measurement of the segmental range of motion (ROM) by cervical X-ray, and preoperative height of intervertebral space was measured by cervical lateral X-ray. According to CT and coronal reconstruction, the grade of paravertebral ossification (PO) was assessed. Clinical symptoms assessment including the Japanese Orthopaedic Association scoring (JOA), the Neck Disability Index (NDI) evaluation was performed preoperatively. Multivariate logistic regression analysis was used to analyze the influencing factors of the range of motion of the surgical segment during follow-up. The best cut-off value was calculated by receiver operating characteristic (ROC) curve.

The preoperative and follow-up ROM at the operated segment was 9.7°±4.5° and 8.7°±5.4°, respectively (P>0.05). Univariate analysis revealed that the postoperative segmental ROM was not significantly correlated with the factors including the surgical level, gender, age, and preoperative clinical diagnosis (1: Radiculopathy; 2: Myelopathy; 3: Mixed type), preoperative segmental ROM, preoperative JOA score and preoperative NDI score (allP>0.05), and was significantly correlated with imaging diagnosis (1: cervical disc herniation; 2: degenerative cervical stenosis), preoperative PO grade (bothP<0.05). The multi-factor analysis showed that preoperative segmental ROM (OR=1.228, 95%CI:1.012-1.489, P<0.05) and PO grade (OR=0.190, 95%CI: 0.085-0.424, P<0.05) had significance in the overall test, but imaging diagnosis had no significance in the overall test (P>0.05). The optimal cutoff value of preoperative segmental ROM and PO grade was 9.185° and grade 2.5 assessed by ROC curve, and the area under the ROC curve was 0.86 and 0.72, respectively.

ACDR surgery can achieve satisfactory long-term effects for patients with nerve root type, spinal cord type and mixed type cervical degenerative diseases, and effectively retain the overall ROM of the cervical spine and the ROM of replacement segments. Patients with good preoperative segmental ROM and lower PO levels have a greater chance of obtaining good segmental ROM in the long-term postoperatively.

A 48-year-old woman with exophthalmos and enlarged lymph nodes was reported. Imaging showed sialadenitis and serum IgG₄The level was significantly increased, and the lymph node biopsy showed a large amount of IgG₄Positive plasma cell infiltration, proposed IgG₄Related diseases. Nine years after the onset of the disease, the patient developed a breast mass, and the extranodal marginal zone lymphoma was diagnosed by surgical pathology. The patient was complicated with eosinophilia at the later stage of the disease, and showed heart failure, bronchial asthma, rash and other target organ damage manifestations. After glucocorticoid treatment, the above symptoms of the patient were significantly improved. This case suggests that for clinically suspected IgG₄Patients with related diseases should be alert to the risk of lymphoma and eosinophilia with target organ damage.

Brain tissue is extremely sensitive to local ischemia and hypoxia, and its tolerance is poor. It is very important to evaluate cerebral perfusion and collateral circulation in ischemic cerebrovascular disease as early as possible. Arterial spin-labeled imaging (ASL) technology uses water molecules from arterial blood as natural endogenous diffusion tracers to obtain perfusion information of blood flow through brain tissue. With the advent of some ASL extension technologies, making imaging faster and more accurate. This article reviews the techniques related to extension of ASL, the application of ASL in cerebral perfusion display, ischemic penumbra assessment, collateral circulation assessment, treatment adjustment and prognosis assessment in ischemic cerebrovascular disease.

Internal carotid artery stenosis has a higher risk of stroke. At present, many studies have focused on plaque vulnerability: plaque structure and composition, but few studies have analyzed intracerebral hemodynamic changes as a risk factor for stroke in patients with internal carotid artery stenosis. The study used magnetic resonance contrast-enhanced angiography, carotid plaque imaging, and arterial spin labeling (ASL) to distinguish between asymptomatic and symptomatic patients with carotid stenosis. The enrolled patients with carotid stenosis were derived from two prospective studies (ECST-2, SHIP) in which ASL and carotid plaque imaging were acquired on the same 3T magnetic resonance imaging (MRI) between 2014 and 2018. Enrolled patients were divided into symptomatic and asymptomatic groups according to clinical assessment of recent transient ischemic attack or stroke. Without the knowledge of clinical symptoms, the degree of stenosis of carotid plaque, plaque surface structure and intraplaque hemorrhage (IPH), collateral branches of Willis ring, and the presence and severity of superior arterial passage artifacts (ATAs) in ASL images were analyzed. A total of 44 patients were enrolled in the study. Sixteen of the 28 patients with more than 70% carotid stenosis were shown to have ATAs, and ATAs was associated with absence of the anterior communicating artery. There was no significant correlation between cerebral ischemic symptoms and the degree of stenosis, IPH and plaque surface structure. Patients with ATAs are more likely to develop symptoms than those without ATAs. Cerebral ischemic symptoms were also associated with ATAs severity. Therefore, it is concluded that ATAs is the only factor associated with ischemic symptoms in patients with recent carotid stenosis, and the degree of carotid stenosis, plaque ulcers and IPH are not associated with cerebral ischemic symptoms.