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Objective:To explore the mechanism,clinical features,and prognosis of trigemino-cardiac reflex (TCR) during skull base operations.Methods:A retrospective analysis was performed on 291 patients with skull base disease from Jan.2009 to Oct.2015 in Peking University First Hospital.By reviewing the patients' operative data and anaesthetic electrical record,and we picked out all the patients who suffered from TCR during the operation and analyzed their surgical procedures,clinical features,influence factors,and prognosis.TCR was defined as a drop in mean arterial blood pressure (MABP) and the heart rate (HR) of more than 20％ to the baseline values before the stimulus and coinciding with the manipulation of the trigeminal nerve.Results:In all the 291 patients receiving skull base surgery,9 patients suffering TCR for 19 times during the operation were found.These 9 cases included three acoustice schwannomas,one trigeminal schwannoma,one petroclival meningioma,one epidermoid cyst in cerebellopontine angle,one cavernous sinus cavernous hemangioma,one pituitary adenoma,and one trigeminal neuralgia.The trigger of TCR was related to manipulation,retraction,and stimulation of the trunk or branches of trigeminal nerve.The baseline heart rate was 62-119/min [mean (79.4 ± 14.6) /min] and dropped about 29.0％-66.4％ (mean 44.3％) to 22-60/min [mean (44.2 ±9.6) /min] after TCR.The baseline mean arterial blood pressure was 75-103 mmHg [mean (87.5 ±7.8) mmHg] and dropped about 23.4％-47.2％ (mean 37.3 ％) to 45-67 mmHg [mean (54.9 ± 6.3) mmHg] after TCR.During the 19 times of TCR,heart rate and blood pressure could return to baseline in a short time while stopping manipulation (8 times),using atropine (8 times,dose 0.5-1.0 mg,mean 0.69 mg),using ephedrine hydrochloride (one time,15 mg),using epinephrine (one time,1 mg),and using dopamine (one time,2 mg).TCR also could be triggered again by a second stimulation.There was no relative cardiologic complication or neurological deficit in the postoperative 24 hours.Conclusion:TCR is a short neural reflex with a drop in blood pressure and heart rate coinciding with the manipulation of the trigeminal nerve in skull base surgery.Correct recognition,intensive observation,and essential management of TCR will lead to a good prognosis.
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Objective To evaluate collateral flows using vessel encoded arterial spin labeling (VE-ASL) perfusion imaging. MethodsVE-ASL was achieved to assess the presence and function of collateral flow on patients with internal carotid artery (ICA) stenosis. The presence of the anterior and posterior collateral flow was demonstrated by flow patterns of the A1 segment and posterior communicating artery (PCoA).Distal function of collateral flow of stenotic hemisphere was categorized as adequate ( cerebral blood flow ≥10 ml · min-1·100 g-1 ) or deficient (cerebral blood flow < 10 ml · min-1· 100 g-1 ). The results were compared with magnetic resonance angiography (MRA) and intraarterial digital subtraction angiography (DSA) in crosstable by using Kappa values. The VE-ASL before and after ICA stent therapy were compared. ResultsThe Kappa values of the flow patterns of AI segment and PCoA between VE-ASL and MRA were 0. 746 and 0. 700. The Kappa value of the function of collaterals using VE-ASL and DSA was914. VE-ASL showed collateral flow via leptomeningeal anastomoses. VE-ASL changed significantly after ICA steat therapy. ConclusionVE-ASL reveals the presence and distal function of collateral flow, which helps to evaluate the efficacy of ICA steat therapy.
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@#Objective To sum up the experience of decompressive surgery for the acute massive hemispheric infarction to determine its beneficial effects.MethodsRetrospectively study 6 patients receiving early decompressive craniotomy because of deterioration after infarction.Results 5 patients survived,4 of them recovered to the good level of daily activity (Barthel index ≥60) one year after rehabilitation.One senile patient died of pulmonary infection.ConclusionThe decompressive surgery is an effective method on the survival and functionary recovery for the patients with deteriorating massive cerebral infarction.
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Objective To investigate the value of presurgical functional magnetic resonance imaging(fMRI) in identifying the eloquent brain areas and guiding the resection of cerebral tumors located in these areas.Methods A total of 10 patients(aged 51.3 years on average) with tumors near to the brain functional areas were enrolled in this study,among which 7 had weakness in the limbs,2 had convulsion,and 1 suffered from facial palsy.The preoperative Karnofsky scale of the patients was 82 on average.Before the fMRI,the patients have been confirmed as having tumors involving functional areas.They were treated by total or subtotal resection according to the anatomical relationship between activated areas and the tumor.Injuries to the activated areas should be avoided during the operation.After the treatment,the muscular strength,Karnofsky scales of the patients were tested.Postoperative MRI was carried out in all of the patients,and the results were compared with that before the operation.Results As shown by fMRI,the activated areas were compressed and dislocated by the tumor in 8 of the 10 patients.The minimal distance between the edge of the tumor and the activated spots was 0-26 mm(mean,13.6).Seven of the patients received total resection of the tumor,while the other 3 underwent subtotal resection.After the surgery,the muscular strength was improved in 7 cases;the convulsion disappeared in the 2 patients who had symptom before the treatment;and the one who had facial palsy was improved.One month after the surgery,the mean Karnofsky scale of the patients was 93.Re-examination by MRI performed one week after the operation showed that the tumor was disappeared in 7 patients,and reduced by 95% to 99% in the other three.Conclusions fMRI is valuable in the preoperative evaluation of the brain functional area near to a cerebral tumor.It can be used to guide the tumor resection while preserving the motor areas.
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Meningomyelocele combined with squamous cell carcinoma is rare in literature. In this article,we report the clinical and treatment of a patient with meningomyelocele and squamous cell carcinoma and discuss its mechanism,clinical feature,therapy and prognosis.The patient was a 11-year-old Chinese boy.At the time of his birth he was noted to have a lumbosacral meningomyelocele,which was disrupted and the cerebral spinal fluid flew out when the child was six.The wound surface abrased and exudated repeatedly.Two months before admission,the meningomyelocele was disrupted again and the condition got worse.Inspection showed a meningomyelocele in the lower lumbar region 10 cm in diameter,consisting of a cauliflower-shaped swelling and a central crater containing black slough.The area smelled foul and was constantly draining serosanguineous fluid.Magnetic resonance imaging showed meningomyelocele associa-ted with spinal dysraphism and tethered cord syndrome.After thorough preparation,operation was undertaken.A perpendicular skin incision,which was carried down to the lumbar aponeurosis,allowed the main bulk of the tumour to be undercut and removed.The quick frozen pathological examination confirmed that it was squamous cell carcinoma.The skin and subcutaneous tissue were fruther resected and the vertebral canal explored until frozen section showed the excision edge was clear.Skin closure was achieved by a bi-pedicle advancement flap,some 10 cm wide and the secondary defect was closed with a thigh skin graft.Histological examination showed that the massive outgrowth was a well-differentiated squamous cell carcinoma.The postoperative recovery was uneventful and the wounds healed by primary intention.Although meningomyelocele combined with squamous cell carcinoma is rare in literature,the possibility of can-cerization should be considered when there is a long-term and non-healing ulcer (Marjolin ulcer) with foul smell in a meningomyelocele patient.
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Congenital bilateral perisylvian syndrome(CBPS) is rare in literature,especially in China.In this article,we report the clinical and treatment of a patient with CBPS and discuss its mechanism,clinical features and therapy.This patient was a 28-year-old man.His main clinical features were pseudobulbar palsy,cognitive deficits and intractable epilepsy.MRI shows bilateral thickening of the cortex around the sylvian fissures which were deeper than normal and polymicrogyria.The electroencephalogram demonstrated slow spike in right temporal lobe and left frontal lobe.Rhythmal 4 Hz ? waves exist in left frontal and parietal lobe.As the epilepsy was poorly controlled by antiepileptic,section of the corpus callosum was carried out.After callosotomy,there was pronounced seizure reduction and intelligence development improvement.CBPS is characterized by pseudobulbar palsy,cognitive deficits,and bilateral perisylvian abnormalities in imaging studies.If intractable epilepsy is combined,callosotomy may be effective.
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Objective To summarize and evaluate the experience and near-term outcomes of microsurgical treatment of myelomeningocele in the lumbar and sacral region in children.Methods Clinical data of 35 cases of myelomeningocele from October 2005 to November 2006 were analyzed retrospectively.The spinal cord and the cauda equine nerves were dissected microsurgically from the surrounding tissues.The duraplasty was performed and the thecal sac was reconstructed.The tight filums were released simultaneously in 8 cases and a ventriculoperitoneal shunt was placed in 10 children with severe hydrocephalus. Results The microsurgical repair was implemented and the spinal cord was released successfully in all the 35 cases.Among 10 cases of vesicorectal dysfunction,there were 3 cases of improvement of rectal sphincter functions after operation.Out of 9 cases of equinovarus,the tension of varus was decreased in 4 cases and no obvious functional improvement was observed in the rest of 5 cases.Leakage of cerebrospinal fluid from the incision occurred in 2 cases,and in the remaining cases the incision healed by first intention.The 10 cases of severe hydrocephalus were cured with ventriculoperitoneal shunting,including a delayed shunt insertion in 9 cases and a single-stage insertion in 1 case,in which a postoperative infection was encountered and a re-operation of ventriculoperitoneal shunting was given. Conclusions For children with myelomeningocele,a surgical treatment should be given as early as possible.A delayed shunt insertion 1~2 weeks after myelomeningocele repair is safe and effective.The duraplasty and optimized closure of the subcutaneous tissue are important for preventing cerebrospinal fluid leakage.
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Objective To observe the effect of transplantation of telomerase immortalized human neural progenitor cells to acute injured canine spinal cord by using MR diffusion tensor imaging (DTI).Methods Telomerase immortalized human neural progenitor cells with expression of green fluorescent protein were prepared for transplantation. Eight adult canines with left spinal cord hemisection at the level of T13 were examined by MR diffusion tensor imaging four times sequentially: prior to injury, one week after injury, one week after transplantation (two weeks after injury), and four weeks after transplantation. Results The ADC values of the injured spinal cord were (1.00?0.15)?10 -3 mm2/s, (1.65?0.45)?10 -3 mm2/s, (1.44?0.48)?10 -3 mm2/s, and (1.43?0.26) ?10 -3 mm2/s, respectively. There was statistically significant difference between the data obtained at different times (F=6.038, P=0.005). The FA values of the injured spinal cord were 0.59?0.11, 0.30?0.17, 0.36?0.25, and 0.34?0.11, respectively. There was also statistically significant difference between the data obtained at different times ( F=5.221,P=0.009). The ADC values of the intact spinal cord were (1.01?0.17)?10 -3 mm2/s, (1.32?0.06)?10 -3 mm2/s, (1.10?0.24)?10 -3 mm2/s, and (1.14?0.22) ?10 -3 mm2/s, respectively. There was no statistically significant difference between the data obtained at different times ( F=1.303,P=0.306). The FA values of the intact spinal cord were 0.60?0.09, 0.38?0.25, 0.46?0.15, and 0.50?0.21, respectively. There was also no statistically significant difference between the data obtained at different times (F=2.797,P=0.072).Conclusion DTI can provide useful information for spinal cord injury and regeneration in experimental spinal cord injury.