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Paroxysmal sympathetic hyperactivity (PSH) is a syndrome characterized by paroxysmal tachycardia, increased blood pressure, tachypnea, hyperthermia, profuse sweating, abnormal posture or dystonia. It occurs in diseases such as moderate to severe brain injury, cerebral hypoxia, hydrocephalus, brain tumor and encephalitis. At present, the etiology and pathogenesis are still unclear, and it is easy to be misdiagnosed as epilepsy clinically. This article reports a 43-year-old male patient with late-onset mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) confirmed by genetic testing. During hospitalization, he suddenly developed episodic involuntary limb movements, profuse sweating, tachycardia, and arterial hypertension. He was initially diagnosed with symptomatic epilepsy, but long-term electroencephalogram monitoring showed no synchronized discharge, and he was given antiepileptic drugs. The treatment was also ineffective. Brain magnetic resonance imaging revealed a new lesion in the left insular and insular operculum. Dexmedetomidine, baclofen, and gabapentin were given to suppress sympathetic nerve excitability. Drugs were effective, so the diagnosis was corrected to PSH. There is no report of MELAS complicated with PSH in the previous literature. It is speculated that it may be related to the low clinical cognition of PSH. In this case, new lesions in the insula and insular operculum appeared during the onset of PSH, suggesting that may be related to the pathogenesis of PSH.
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Objective To evaluate the efficacy and safety of Willis covered stent in the treatment of traumatic carotid cavernous fistulae (tCCF).Methods The imaging and clinical data of 7 patients with tCCF treated with Willis covered stent in Shanghai Punan Hospital from November 2015 to June 2018 were analyzed retrospectively.Results Seven Willis covered stent were used in 7 patients.Immediately after stent release,angiography showed that the fistulae completely disappeared in 6 cases.One patient had a small amount of endoleak,and there was still a small amount of endoleaks after balloon dilatation.It was not further treated.There were no operative complications.During 3-12 months follow-up,no new neurological deficits were found in all patients.Angiographic follow-up of 2 patients showed that the fistulae completely disappeared without recurrence.The internal carotid arteries were patent,no in-stent stenosis and stent displacement.Conclusions Wills covered stent can be used as a treatment for tCCF.Its efficacy is satisfactory and the safety is good.
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Objective To investigate the medium- and long-term effects and safty of Pipeline embolization device ( PED) for the treatment of large and giant intracranial anterior circulation aneurysms. Methods From December 2014 to December 2016,the data of 36 consecutive patients with large and giant aneurysm ( 36 large and giant intracranial anterior circulation aneurysms ) treated with PED in Donglei Brain Doctor Group were analyzed retrospectively. The diameter of the aneurysms was 12 -33 mm, (mean16.6±4.5mm),andthenecksizewas4-10mm(mean6.1±1.5mm).Eightaneurysmswere located in the carotid cavernous sinus segment,22 in the ophthalmic artery segment,5 in the internal carotid artery posterior communicating segment, and 1 in the M1 segment of middle cerebral artery. Seven aneurysms were only treated by PED,28 aneurysms were treated by PED in combination with coil embolization,and 1 aneurysm was treated by double PEDs. The modified Rankin scale ( mRS) score was used to evaluate the prognosis of the patients. Results (1) The clinical prognosis of the patients was followed up by telephone and outpatient department for 6-33 months. Twenty-five patients were followed up by DSA,23 aneurysms (92%) were occluded totally (Raymond gradeⅠ) and 2 (8％) were occluded near totally ( Raymond grade Ⅱ) . ( 2 ) Seven patients were treated with PED alone. Four patients were cured totally after 6 months follow-up,1 was occluded subtotally,2 were not cured;6 were cured in the last follow-up (33 months),and the other aneurysm was gradually reduced;17 of 28 patients treated with PED in combination with coils received DSA follow-up. They were followed up for 6-8 months. All the aneurysms were totally occluded ( Raymond grade Ⅰ) . 1 aneurysm was treated by 2 PEDs, DSA revealed micro-aneurysm-like development at 8 months after procedure. The aneurysms were basically occluded after 15-month follow-up. (3) MRI confirmed after operation that 10 patients had asymptomatic scattered spotted ischemic foci,4 had cerebral parenchymal hemorrhage,1 of them died,1 recovered well after treatment (mRS 1),and the other 2 were asymptomatic cerebral hemorrhage. The occupying effect of 24 cases disappeared, 8 had obvious improvement,and 3 did not have any obvious change. Conclusions The occlusion rate of the treatment of large and giant intracranial aneurysms with PED was high. The results of medium-term follow-up showed that the occlusion rate of PED in combination with coils in the treatment of aneurysms was higher than that of PED alone. The long-term follow-up results showed that the occlusion rate of patients treated with PED alone (including one or more) was gradually increased with time. The safety of the surgery needs to be further confirmed by a large sample study.
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Objective To preliminarily discuss the technical points and clinical efficacy of the pressure cooker technique (PCT)for embolization of intracranial arteriovenous malformation (AVM). Methods From April 2015 to May 2015,7 patients with AVM were treated at the Department of Neurosurgery, Shanghai Deji Hospital. The AVMs of 2 patients were embolized with PCT. (both were Spetzler-Martin gradeⅡ). A sonic and an echelon microcatheter were implanted side by side into the same blood supply artery of an AVM. A coil + α-isobutyl cyanoacrylate (NBCA)plug was formed between the sonic microcatheter tip and the detachable point through the echelon microcatheter in order to prevent Onyx reflux when the glue was injected into a nidus via a sonic microcatheter,achieving the embolization effect of sustained,rapid and high efficient. Results Two patients achieved complete embolization immediately. The symptoms of the patients improved or disappeared within 1 month. The whole brain DSA showed the AVM of one patient did not have recurrence at 4 month after embolization. Two patients did not have any complications or sequelae at the follow-up study. Conclusion PCT can improve the efficiency of embolization. It is suitable for small, medium,superficial,non-major functional area,less feeding artery AVMs,and AVMs with less blood flow in nidus. Its safety and clinical effect still need to be observed with more samples.
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Objective To explore the feasibility of 256-slice whole-brain CT perfusion (CTP) in evaluate graft reperfusion after surgical revascularization and hemodynamic alterations before and after surgery in Moyamoya disease. Methods Twenty-five cases with Moyamoya disease were scanned on a 256-slice CT.CTP was performed pre- and post- surgical revascularization. The wolumetric CT angiographic ( CTA ) images were generated from volumetric data acquired at the arterial phase of CTP. CBF, CBV, TTP and MTT were measured in functional maps at the operated side within middle cerebral artery perfusion areas and contralateral mirroring areas. Relative CBF( rCBF), relative CBV (rCBV), relative TTP (rTTP), relative MTT (rMTT) were also obtained. Differences in perfusion CT values pre- and post operation were assessed with the paired t test or matched-pairs signed-ranks test. Data with normal distribution was present as : (x-)± s,while those with the non-normal distribution were present as M ( P25-P75 ). Results All the direct graft patencies were displayed on volumetric CTA. No significant differences were found between volumetric CTA and conventional CTA. Postoperative CBF, rCBF and rCBV values of the operated side [ 72. 86 (55.54-112. 19) ml · 100 g-1 · min-1 , 1. 31 ( 1.05-1.73), 1.45 ±0. 62] were significantly higher than those before operation [46.72(28.57-57.67) ml · 100 g-1 · min-1, 0.53(0.33-0.82), 1.01 ±0.36](Z=- 2.72, - 2. 98, t = - 2. 85, P ＜ 0. 05 ). Postoperative MTT, TTP and rTTP values of the operated side [ (3.98 ± 2. 36 ) s, ( 17.56 ± 4. 38 ) s, 1.01 ± 0. 09 ] were significantly lower than those before operation [(5.43±2.07) s,(19.40±3.87) s,1.14±0.28] (t=2.41,2.17,2.17, respectively, P＜0.05).However, no significant differences were detected for changes of CBV and rMTT after revascularization ( P ＞0. 05). Conclusion 256-slice CT has the potential value for the non-invasive assessment of both the graft patency and cerebral hemodynamics changes in moyamoya disease after surgery with administration of one contrast medium bolus in a single examination.
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Objective To evaluate the clinical results of Willis covered stent implantation and coil embolization in the treatment of cranial internal carotid artery (CICA) aneurysm. Methods Eighty-nine patients with CICA aneurysms were selected for treatment with Willis covered stents (n = 43, group A) or coil embolization (n =46, group B) according to the patients'will. Data on the technical success, initial procedure time and in-hospital interval, initial and final angiographic results, mortality, morbidity, and final clinical outcomes were collected and analyzed for the two groups at 6 months post-procedure. Results Endovascular covered stent placement and coil embolization were technically successful in all patients,except for one patient in group A. The initial angiographic results showed complete occlusion in 34 patients of group A (81%, 95% CI: 69%, 93% ) and 24 patients of group B (52%, 95% CI: 37%, 67% ) ( P ＜0. 05). The final angiographic results indicated complete occlusion in 39 patients of group A (39/41,95%,95% CI: 88%, 102% ) and 22 patients of group B (22/45,49%, 95% CI: 34%, 64% ,P ＜0. 01 ). The average procedure time was(103 ± 13)min in group A and (143 + 39) min in group B (P＜0. 01). No significant differences were seen between the two groups in technique success, mortality, morbidity, or final clinical outcomes. Conclusion In this nonrandomized, prospective trial, CICA aneurysm treatment with covered stents yielded midterm angiographic results that were superior to those of coil embolization.
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Objective To compare the efficacy and cost of surgical clipping and endovascular embolization in the treatment of anterior and posterior communicating artery aneurysm and to conduct cost-effectiveness analysis. Methods The data of treatment outcomes and costs in patients with anterior or posterior communicating artery aneurysms admitted to Huashan hospital from 2002 to 2006 were analyzed using a retrospective cohort study. Results A total of 302 patients were included in the study. They were divided into surgical clipping group (n = 150; 65 males, age [48. 11 ±9. 94] years), interventional treatment group (n = 152;75 males, age [52. 56 ± 11. 09] year). The age of the former was lower than that of the latter (t = -3. 670, P =0. 000). There was no significant difference in preoperative clinical conditions (such as location of aneurysms and Hunt-Hess grade) between the two groups. The good outcome rate in the interventional treatment group was significantly higher than that in the surgical clipping group (84. 87% vs. 74. 67%, χ2 = 4. 875, P = 0. 027). There was no significant difference in hospital mortality (5. 33% vs. 3. 94%,χ2 =0. 328, P =0. 567) and complication rate (26.67% vs. 19. 74% , χ2 =2.036, P =0.154) between the surgical clipping group and the interventional treatment group, but the intraoperative aneurysm rupture (10. 67% vs. 3. 95%, χ2 =5.047, P =0.028) and the incidence of postoperative intracranial infection (6/144 vs. 0/152, χ2 = 6.203, P =0.014) in the surgical clipping group were higher than those in the interventional treatment group. The length of hospital stay in the interventional treatment group was significantly shorter than that in the surgical clipping group ([10. 0 ± 7. 0] dvs. [23.0 ± 11. 0] d, Z = -10. 35, P ＜0.001). The median cost of treatment was 95 327.63 %,yuan in the interventional treatment group, and the interquartile range (IQR) was 26 312. 98 yuan; it was significantly higher than the surgical clipping group (median 30 072. 01 yuan, IQR 11 178. 54 yuan) (Z = -14.449, P＜0.001). Compared with the surgical clipping group, while the mRS score improved in the interventional treatment group 0. 10, the cost was about 66 438 yuan, so that the surgical clipping was more cost-effective. Conclusions The efficacy of the intervention treatment of anterior and posterior communicating artery aneurysms is better than that of the surgical clipping The mortality and total complication rate are almost the same with the surgical clipping Thehospital stay is shorter, but the cost of treatment is higher. From an economic point of view, the surgical clipping is more cost-effective.
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Extracranial-intracranial arterial bypass, an elegant procedure, was first performed and developed gradually by M. Gazi Yasargil. It has been used in the management of ischemic cerebrovascular disease, moyamoya disease, intracranial aneurysms and brain tumors.This article focuses on its application in the ischemic cerebrovascular disease, and reviews it from the aspects of cerebral hemodynamics of ischemic cerebrovascular disease, indications for arterial bypass, preoperative evaluation, operating modes, intraoperative assessment,complications, postoperative care and prognosis.
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CT perfusion (CTP) has provide a novel approach for the diagnosis of ischemic cerebrovascular diseases. The evaluation indices include cerebral blood flow, cerebral blood volume, time to peak, and mean transmit time. These semi-quantitative indices used for evaluating cerebral blood perfusion have very important significance for the guidance of choosing the best treatment protocol and efficacy observation. CTP is mainly used in acute ischemic stroke to identify penumbra and infarct, as well as predicting hemorrhagic transformation in combination with other means and choosing thrombolytic candidates. In addition, CTP is also used to assess cerebrovascular reserve capacity in patients with chronic ischemic diseases and diagnose cerebral vasospasm in patients with subarachnoid hemorrhage and their efficacy evaluation.
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There has been no consensus on the efficacy of extracranial-intracranial arterial bypass (EIAB) for ischemic cerebrovascular disease. As an important factor in the pathophysiologic mechanisms of ischemic cerebrovascular disease, the changes of cerebral hemodynamics have received attention. The article expounds the clinical significance of EIAB from the point of view of cerebral hemodynamics, particularly presents its preoperative assessment, operative procedures, and efficacy criterion.
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<p><b>OBJECTIVE</b>To investigate the biomechanical characters of human dura and its substitutes and to establish guidelines for selection of optimal repair materials for reconstruction of skull base defects.</p><p><b>METHODS</b>A measurement of creep properties of human dura and its substitutes were conducted using biomechanical tests. The dynamic changes of biomechanical properties of canine dura obtained from skull base defects were observed as well.</p><p><b>RESULTS</b>The creep properties of human dura presented a linear-relationship between initial strain and stress, and the creep strain increased slowly with time. The creep compliance formula for human dura and its substitutes was as follows: J (t) = J(0) + Kf (t). The initial compliance of canine dura in skull base defects was reduced by 35%, 46% and 50%, respectively 1, 3 and 6 months after surgery.</p><p><b>CONCLUSION</b>The optimal material for the repair of skull base defects can be estimated using creep compliance analysis. The less the compliance, the better the property of anti-protrusion. Fresh human dura is the least compliant and then in increasing order are lyophilized human dura, fresh human pericranium, Terylene and silicon membranes. The pattern of biomechanical characteristics of the dura mater at skull base defects shows that the strain ability of the dura mater decreases distinctly for 1 - 3 months and then remains almost unchanged for 3 - 6 months after surgery.</p>
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Animals , Dogs , Humans , Biomechanical Phenomena , Dura Mater , Physiology , Skull Base , General SurgeryABSTRACT
<p><b>OBJECTIVE</b>To clarify whether it is necessary to reconstruct bone defects at the anterior skull base.</p><p><b>METHODS</b>A long-term follow-up study of 50 patients with anterior skull-base defects in which the dura was reconstructed without bone grafts was conducted. CT and MRI examinations were taken periodically after surgery.</p><p><b>RESULTS</b>The ordinates of the bone defects averaged 3.5 cm (range, 2 - 6 cm), and the abscissas averaged 2.8 cm (range, 2 - 5 cm). The abscissas of the bone defects measured 2 - 3 cm in 38 patients, 3 - 4 cm in 10 patients, and 4 - 5 cm in 2 patients. The follow-up ranged from 3 months to 5 years (average, 2 years).</p><p><b>CONCLUSIONS</b>At normal intracranial pressure, if the dura mater is repaired properly at the skull-base defects and reinforced with a pedicled pericranial flap, encephalomeningocele and cerebrospinal fluid (CSF) leakage can be prevented. It may not be necessary to make free bone grafts when the size of the cranial base bone defect is smaller than 4 cm.</p>