Does Early Postsurgical Temozolomide Plus Concomitant Radiochemotherapy Regimen Have Any Benefit in Newly-diagnosed Glioblastoma Patients? A Multi-center, Randomized, Parallel, Open-label, Phase II Clinical Trial / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The radiochemotherapy regimen concomitantly employing temozolomide (TMZ) chemotherapy and radiotherapy (RT) 4 weeks after surgery, followed by 6 cycles of TMZ is a common treatment for glioblastoma (GBM). However, its median overall survival (OS) is only 14.6 months. This study was to explore the effectiveness and safety of early TMZ chemotherapy between surgery and chemoradiotherapy plus the standard concomitant radiochemotherapy regimen.</p><p><b>METHODS</b>A randomized, parallel group, open-label study of 99 newly diagnosed GBM patients was conducted at 10 independent Chinese neurosurgical departments from June 2008 to June 2012. Patients were treated with concomitant radiochemotherapy regimen plus early postsurgical temozolomide (early TMZ group) or standard concomitant radiochemotherapy regimen (control group). Overall response was assessed based on objective tumor assessments, administration of corticosteroid and neurological status test. Hematological, biochemical, laboratory, adverse event (AE), and neurological condition were measured for 24 months of follow-up. The primary efficacy endpoint of this study was overall survival (OS). The secondary endpoint was progression free survival (PFS).</p><p><b>RESULTS</b>The median OS time in the early TMZ group was 17.6 months, compared with 13.2 months in the control group (log-rank test P = 0.021). In addition, the OS rate in the early TMZ group was higher at 6, 12, and 18 months than in the control group, respectively (P < 0.05). The median PFS time was 8.7 months in the early TMZ group and 10.4 months in the control group (log-rank test P = 0.695). AEs occurred in 29 (55.8%) and 31(73.8%) patients respectively in early and control groups, including nausea (15.4% vs. 33.3%), vomiting (7.7% vs. 28.6%), fever (7.7% vs. 11.9%), and headache (3.8% vs. 23.8%). Only 30.8% and 33.3% were drug-related, respectively.</p><p><b>CONCLUSIONS</b>Addition of TMZ chemotherapy in the early break of the standard concomitant radiochemotherapy regimen was well tolerated and significantly improved the OS of the GBM patients, compared with standard concomitant radiochemotherapy regimen. However, a larger randomized trial is warranted to verify these results.</p>

Histopathological classification and location of consecutively operated meningiomas at a single institution in China from 2001 to 2010 / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Meningioma is one of the most common primary tumors of the central nervous system, but there are not many detailed studies on the sex, age, subtypes and locations of large series. This study was a retrospective analysis of the characteristics of meningioma cases consecutively operated on at a single institution in China from 2001 to 2010.</p><p><b>METHODS</b>This study investigated the demographic background of 7084 meningioma cases, and the subtypes and locations of the tumors. Sex and age distributions were analyzed, and the pathological subtypes were classified according to the World Health Organization (WHO) classification. The location of the meningiomas was also categorized.</p><p><b>RESULTS</b>The female:male ratio of the 7084 cases was 2.34:1. The mean age was 51.4 years (range, 11 months-86 years). The mean age of cases of WHO grade I meningioma was significantly older than that of grade II or III meningiomas (P < 0.001, Fisher's Least Significant Digit test). There was a significantly higher female:male ratio in WHO grade I meningiomas than in grade II or grade III meningiomas (2.57, 1.03 and 0.76, respectively; P < 0.001, χ(2) test). Meningothelial (n = 2061) and fibrous meningiomas (n = 3556) were the most common subtypes, comprising 79.3% of all meningiomas. All meningioma cases were classified into 23 locations in this study, with the cerebral convexity the most common site (38.33%, n = 2722). Cases with uncommon locations such as extra-cranial and sylvian fissure meningiomas were also present in this series.</p><p><b>CONCLUSIONS</b>Female predominance was found for benign meningiomas, while malignant subtypes showed male predominance. The mean age of patients with WHO grade I meningiomas was older than that of patients with higher-grade tumors. Meningothelial and fibrous meningiomas were the most common subtypes. The cerebral convexity was the most common meningioma location.</p>

Preoperative surgical planning for intracranial meningioma resection by virtual reality / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The Dextroscope system by Volume Interactions (Singapore) had been applied to minimally invasive neurosurgery in many units. This system enables the neurosurgeon to interact intuitively with the three-dimensional graphics in a direct manner resembling the way one communicates with the real objects. In the paper, we explored its values in pre-operation surgical planning for intracranial meningiomas resection.</p><p><b>METHODS</b>Brain computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance venography (MRV) were performed on 10 patients with parasagittal and falcine meningiomas located on central groove area; brain CT, MRI and magnetic resonance angiography (MRA) were performed on 10 patients with anterior skull base meningiomas and 10 patients with sphenoid ridge meningiomas. All these data were transferred to Dextroscope virtual reality system, and reconstructed. Then meningiomas, skull base, brain tissue, drainage vein and cerebral arteries were displayed within the system, and their anatomic relationships were evaluated. Also, the simulation operations were performed.</p><p><b>RESULTS</b>For parasagittal and falcine meningiomas, the relationships of tumor with drainage vein and superior sagittal sinus were clearly displayed in the Dextroscope system. For anterior skull base and sphenoid ridge meningiomas, the relationships of tumor with bilateral internal carotid arteries, anterior cerebral arteries, middle cerebral arteries and skull base were vividly displayed within the virtual reality system. Surgical planning and simulation operation of all cases were performed as well. The real operations of all patients were conducted according to the simulation with well outcomes.</p><p><b>CONCLUSIONS</b>According to the virtual reality planning, neurosurgeons could get more anatomic information about meningioma and its surrounding structures, especially important vessels, and choose the best approach for tumor resection, which would lead to better prognosis for patients.</p>

Neuronavigation surgery in China: reality and prospects / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>To review the history, development, and reality of neuronavigation surgery in China and to discuss the future of neuronavigation surgery.</p><p><b>DATA SOURCES</b>PubMed, the China Knowledge Resource Integrated Database, and the VIP Database for Chinese Technical Periodicals were searched for papers published from 1995 to the present with the key words "neuronavigation," functional navigation," "image-guided," and "stereotaxy." Articles were reviewed for additional citations, and some information was gathered from Web searches.</p><p><b>STUDY SELECTION</b>Articles related to neuronavigation surgery in China were selected, with special attention to application to brain tumors.</p><p><b>RESULTS</b>Since the introduction of neurosurgical navigation to China in 1997, this core technique in minimally invasive neurosurgery has seen rapid development. This development has ranged from brain structural localization to functional brain mapping, from static digital models of the brain to dynamic brain-shift compensation models, and from preoperative image-guided surgery to intraoperative real-time image-guided surgery, and from application of imported equipment and technology to use of equipment and technology that possess Chinese independent intellectual property rights.</p><p><b>CONCLUSIONS</b>The development and application of neuronavigation techniques have made neurological surgeries in China more safe, precise and effective, and less invasive, and promoted the quality of Chinese neurosurgical practice to the rank of the most advance and excellence in the world.</p>

Clinical experience of 3T intraoperative magnetic resonance imaging integrated neurosurgical suite in Shanghai Huashan Hospital / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Intraoperative magnetic resonance imaging (iMRI) dates back to the 1990s and has been successfully applied in neurosurgery but they were low-field iMRI (< 1.0T). This paper reports the clinical experience with a 3T iMRI-integrated neurosurgical suite in Huashan Hospital, Shanghai, China.</p><p><b>METHODS</b>From September 2010 through March 2012, 373 consecutive patients underwent neurological surgery under guidance with 3T iMRI. A retrospective analysis was conducted regarding clinical efficiency.</p><p><b>RESULTS</b>All surgery in the 373 patients was safe. The ratio of gross total resection for cerebral gliomas (n = 161) was increased from 55.90% to 87.58%. The ratio of benefit in extent of resection was 39.13%. One hundred and fifty eight of the 161 glioma patients accomplished follow-up at 3 months postoperatively. Twenty of 161 patients (12.42%) suffered from early motor deficit after surgery. Late motor deficit was however observed in five of 158 patients (3.16%). Twenty-one of 161 patients (13.04%) had early speech deficit and late speech deficit was only observed in six of 158 patients (3.80%). The ratio of gross total resection for pituitary adenomas (n = 49) was increased from 77.55% to 85.71%. The ratio of benefit in extent of resection was 10.2%. There were no iMRI-related adverse events even for patients who underwent awake craniotomy.</p><p><b>CONCLUSION</b>The 3T iMRI integrated neurosurgical suite provides high-quality intraoperative structural and functional imaging for real-time tumor resection control and accurate functional preservation, resulting in an improvement in maximal safe brain surgery.</p>

Superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis in treating moyamoya disease: surgical techniques, indications and midterm follow-up results / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Surgical interventions for moyamoya disease include direct and indirect revascularizations. This study aimed to evaluate the therapeutic effect of superficial temporal artery-middle cerebral artery bypass combined with an indirect revascularization procedure, encephalo-duro-myo-synangiosis, in the treatment of moyamoya disease.</p><p><b>METHODS</b>From October 2005 to November 2009, we performed this combined revascularization procedure in 111 patients with different types and stages of moyamoya disease. The superficial temporal artery, middle meningeal artery and the deep temporal artery were evaluated for individualized surgical planning in these cases. The integrity of the deep temporal artery and the middle meningeal artery network, and the pre-existing spontaneous anastomoses of the distal branches of the external carotid artery with the cortical arteries were well preserved. The mean follow-up time was 72.5 months, all clinical and radiological data were retrospectively reviewed.</p><p><b>RESULTS</b>A total of 198 stomas were performed in 122 hemispheres, all remaining patent until the last follow-up. The encephalo-duro-myo-synangiosis resulted in extensive anastomoses of the deep temporal artery (100%), the middle meningeal artery (90.9%), and the sphenopalatine artery (39.8%) with the cortical arteries, respectively. The superficial temporal artery, deep temporal artery, and the middle meningeal artery were significantly thickened in 88 patients as determined by digital subtraction angiography at follow-up. The relative cerebral blood flow increased significantly within one week after the operation. At 6 months post the operation, the relative cerebral blood flow was further increased by 15.5% from the gradual formation of anastomoses as a result of indirect revascularization. Transient ischemic attacks were effectively reduced or totally arrested. The neurological deficits significantly improved in 37 patients, with the National Institutes of Health Stroke Scale scores lowered by 2-8. There was no rehemorrhage in hemorrhagic moyamoya disease patients.</p><p><b>CONCLUSION</b>This study showed that the superficial temporal artery-middle cerebral artery bypass combined with encephalo-duro-myo-synangiosis can achieve good therapeutic effect in the treatment of moyamoya disease.</p>

Current status of cerebral glioma surgery in China / 中华医学杂志(英文版)

The treatment of gliomas is highly individualized. Surgery for gliomas is essentially for histological diagnosis, to alleviate mass effect, and most importantly, to favor longer survival expectancy. During the past two decades, many surgical techniques and adjuvants have been applied to glioma surgery in China, which lead to a rapid development in the field of cerebral glioma surgery. This article broadly and critically reviewed the existing studies on cerebral glioma surgery and to portrait the current status of glioma surgery in China. A literature search was conducted covering major innovative surgical techniques and adjuvants for glioma surgery in China. The following databases were searched: the Pubmed (January 1995 to date); China Knowledge Resource Integrated Database (January 1995 to date) and VIP Database for Chinese Technical Periodicals (January 1995 to date). A selection criterion was established to exclude duplicates and irrelevant studies. The outcome measures were extracted from included studies. A total of 3307 articles were initially searched. After excluded by abstracts and full texts, 69 studies conducted in the mainland of China were included and went through further analysis. The philosophy of surgical strategies for cerebral gliomas in China is undergoing tremendous change. Nowadays Chinese neurosurgeons pay more attention to the postoperative neurofunctional status of the patients. The aim of the glioma surgery is not only the more extensive tumor resection but also the maximal safety of intervention. The well balance of longer overall survival and higher quality of life should be judged with respect to each individual patient.

Preliminary application of 3.0 T intraoperative magnetic resonance imaging neuronavigation system in China / 中华外科杂志

<p><b>OBJECTIVE</b>To report the preliminary experience in clinical application of 3.0 T intraoperative magnetic resonance imaging (iMRI) neuronavigation system in China.</p><p><b>METHODS</b>From September 2010 to March 2011, a consecutive series of 122 patients with intracranial lesions underwent operations in guidance with 3.0 T iMRI. A retrospective analysis was conducted regarding clinical efficiency.</p><p><b>RESULTS</b>Among 122 procedures, the numbers of intraoperative scanning were 2 - 4 times with an average of 2.6. The qualities of images were excellent. Due to the discovery and further possibility of resection of residual tumors, the ratio of gross total resection was increased from 71.7% to 90.0% in cerebral gliomas (n = 60), while from 75.9% to 93.1% in macroadenomas (n = 29). There were 6.7% of all patients occurred postoperative paralysis, but only 3.3% of patients had persistent paralysis at 1 - 2 months follow-up. There was no iMRI-related adverse event occurred. During the same period, more than 2500 patients underwent diagnostic MRI scanning.</p><p><b>CONCLUSIONS</b>3.0 T iMRI neuronavigation system provides high-quality intraoperative structural, functional and metabolic images for real time tumor resection control and accurate functional preservation, resulting in an improvement in maximal safe brain surgery. The system is cost-effective.</p>

Awake craniotomy and intraoperative language cortical mapping for eloquent cerebral glioma resection: preliminary clinical practice in 3.0 T intraoperative magnetic resonance imaging integrated surgical suite / 中华外科杂志

<p><b>OBJECTIVES</b>To evaluate preliminary clinical experience for combining awake craniotomy and intraoperative language brain mapping within the integrated 3.0 T intraoperative magnetic resonance imaging (iMRI) suite.</p><p><b>METHODS</b>From December 2010 to April 2011, 11 right hand-dominant patients with left glioma were involved in, or adjacent to, eloquent cortex was carried out awake craniotomies with cortical stimulation within an integrated 3.0 T iMRI suite. Aphasia battery of Chinese was used to test the language function before the operation. During the procedure, after the occipital, temporal, and supraorbital nerves were blocked by the anesthesiologists, the head was fixed with a custom high-field MRI-compatible head holder. The skull and dura was opened as usual and language brain mapping was then performed. Language testing followed a set protocol: counting numbers from 1 to 50, naming objects, reading single words. Resection of the tumor was guided by neuronavigation system and continued until eloquent areas were encountered or the margin of assessment was reached. An interdissection MRI was acquired to evaluate the glioma removal in a movable MRI scanner after minimal draping. Meanwhile, adverse effects caused by electrical stimulation and iMRI were recorded. The follow-up speech tests were assessed on 7th day and 1 month at least after the operation.</p><p><b>RESULTS</b>The combined use of 3.0 T iMRI and awake craniotomy was performed safely in all patients. No adverse effects were reported. The duration of surgery was prolonged by 2 to 4 h. The patients' perception of iMRI during surgery was favorable. First-look MRI studies led to further resection attempts in 6/11 cases as well as a 3/11 increase in the number of gross-total resections. One week after surgery, baseline language function worsened in 4 cases. However, no patients had a persistent language deficit one month after surgery.</p><p><b>CONCLUSIONS</b>Awake craniotomy and direct cortical electrical stimulation can be performed safely and effectively within a 3.0 T iMRI suite. The combination of high-field iMRI and awake craniotomy may facilitate safe removal of eloquent glioma.</p>

Microsurgical removal of olfactory groove meningiomas / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To explore an effective method for further improving the surgical results of treatment of olfactory groove meningiomas.</p><p><b>METHODS</b>Sixty seven cases of olfactory groove meningiomas were treated by microneurosurgery, among which fifty seven were de novo cases, eight were recurrent tumors and the other two re-recurrent cases. Modified Derome approach was used in 12 cases, bilateral subfrontal approach in 28 cases, modified pterional approach in 21 cases and unilateral subfrontal approach in six cases. Tumors were resected microsurgically with radical removal of invaded dura, bone, and paranasal sinus mucosa. Reconstruction was performed in patients with skull base defect.</p><p><b>RESULTS</b>Simpson grade I removal was accomplished in 59 cases, grade II in seven cases and grade IV in one case. Among 57 patients with de novo tumor, Simpson I resection was accomplished in 54 cases. Postoperative rhinorrhea and intracranial infection occurred in one case and was cured after temporal lumbar CSF drainage and antibiotic therapy. Two patients (2.9%) died within one month after operation, i.e.one aged patient of heart failure and the other of severe hypothalamus complication. Forty seven patients (72.3%) were followed up from one to ten years with an average of five years and four months. With the exception of two cases died, among the alive 45 patients, there were only three patients with tumor recurrence, which had undergone Simpson II or IV tumor resection. No recurrence was found in cases with Simpson I tumor removal. Previous blurred vision was not improved in three patients, hemiparalysis in two patients, and the other patients recovered well, resuming previous jobs or being able to take care themselves.</p><p><b>CONCLUSIONS</b>Total tumor removal (Simpson I) should be the surgical goal for treatment of olfactory groove meningiomas, especially for de novo cases. An appropriate approach is fundamental in the effort to remove an OGM totally. Appropriate anterior skull base reconstruction with vascularized material is important and mandatory.</p>

Surgical treatment for the giant aneurysms of middle cerebral artery / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the surgical treatment of the giant aneurysms of middle cerebral artery.</p><p><b>METHODS</b>Clinical data, surgical methods and outcomes were analyzed in 17 giant aneurysms of middle cerebral artery treated from January 2001 to March 2008. CT scan, CTA, MRA, DSA and 3D-DSA were performed before operations so that we could comprehend the location, size, and shape of aneurysms and compensatory circulation of collateral branches to design the individualized treatment options. All patients had been surgically treated mostly by modified pterional approach, of which, direct clipping of the aneurysms was accomplished in 4 patients, aneurysms trapping or removal after trapping in 4, aneurysms excision or trapping combined with vessels reconstruction in 7, and aneurysms wrapping in 2 cases.</p><p><b>RESULTS</b>CT and MRI revealed the shape and size of aneurysms clearly, while DSA and 3D-DSA could demonstrate the aneurysm's neck and relationship with the adjacent structure. Postoperative neurological function was evaluated according to Glasgow Outcome Scale when patients were discharged. Twelve patients had excellent neurological outcomes. However 4 patients were moderately disabled and one were severely disabled. No patient was dead postoperatively.</p><p><b>CONCLUSIONS</b>It is necessary to perform elaborate imaging before operations for individualized surgical planning. The temporary occlusion of the parent artery and elimination of intra-aneurysmal thrombus are helpful to clipping the aneurysmal neck. Vessels reconstruction is a new and effective method of treating the giant aneurysms of middle cerebral artery.</p>

Clinical experience of 70 cases of cerebral arteriovenous malformations embolization with Onyx, a novel liquid embolic agent / 中华外科杂志

<p><b>OBJECTIVE</b>To report our clinical experience of using Onyx, a new liquid embolic agent, to treat cerebral arteriovenous malformations (AVMs) as well as its efficacy.</p><p><b>METHODS</b>Seventy cases were placed with 6F sheath in the femoral artery after Seldinger puncture and 6F guiding catheter was introduced into the internal carotid artery or vertebral artery, then a microcatheter was navigated into the nidus of AVMs. Slow injection of Onyx under fluoroscopic control was performed to embolize cerebral AVMs using the "plug and push" technique.</p><p><b>RESULTS</b>Thirteen AVM cases (18.6%) were totally occluded by Onyx and 5 cases of which didn't recurrence at 6-month after operation. Thirty-eight cases (54.3%) were subtotally occluded, while another 19 cases (27.1%) were partially embolized. Severe cerebral hemorrhage occurred in 4 cases, 2 of which had mild to severe hemiplegia after operation, and one died. Mild hemiplegia was also found in 1 case due to functional area embolization, and visual field deficit in 2 cases.</p><p><b>CONCLUSIONS</b>Onyx has unique and distinctive superiority in treating cerebral AVMs. Nonetheless, the correct embolization technique should be learned to achieve good clinical results and avoid complications.</p>

Increased protein and mRNA expression of endostatin in the ischemic brain tissue of rabbits after middle cerebral artery occlusion / 神经科学通报·英文版

<p><b>OBJECTIVE</b>To explore the changes of endostatin (a strong anti-angiogenesis factor) and vascular endothelial growth factor (VEGF) in the brain tissues of rabbits following cerebral ischemia induced by middle cerebral artery occlusion (MCAO).</p><p><b>METHODS</b>Twenty-four New Zealand white rabbits were randomly divided into 5 groups: control (n = 5), sham-operation (n = 4), 2-hour ischemia (n = 5), 24-hour ischemia (n = 5), and 48-hour ischemia (n = 5). The expression of VEGF and endostatin were measured by enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry, respectively. In situ hybridization was used to characterize the expression of mRNA for the endostatin.</p><p><b>RESULTS</b>Both the protein (at least 50%, P < 0.01) and mRNA (at least 70%, P < 0.05) of endostatin increased significantly in the ischemic brain tissues after MCAO compared with the control group. VEGF increased at least 270% in the brain after cerebral ischemia (P < 0.05).</p><p><b>CONCLUSION</b>Cerebral ischemia leads to an up-regulation of endostatin in the brain, which is not associated with the increase of VEGF in the brain. The increase of endostatin may serve as a deleterious mechanism for ischemic injury through blocking angiogenesis.</p>

Application of virtual reality technique in preoperative planning of neurosurgery / 中华显微外科杂志

Objective To evaluate the usefulness of virtual reality technique in preoperative planning of neurosurgery.Methods Multiple medical imaging data including magnetic resonance imaging,magntic rsonanc angiograph,magnetic resonance venography and computed tomography collected from 26 patients who suffered craniocerebral diseases,were transfered to Dextroscope system.A stereoscopic 3-D object displayed after merging,extracting,dissecting the data with the Radiodexter software in virtual reality environment.A suite of 3-D tools accessible inside the Dextroscope workspace enabled users to obtain measurement and simu- lated intraoperative viewpoint about the lesion and adjacent anatomic structure.A preoperative plan was de- fined and compared with real operation.Results 3-D stereoscopic virtual reality images of 26 cases were re- constructed successfully,and of coincidence with real situation in operations.Conclusion VR technique in Dextroscope system can integrat multiple medical imaging data quickly,intuitively and overall,offer a compre- hensive information about the lesions and related local anatomy,give a hand to optimizing the operative project and might be possible potentially to increase the safety of operation and the resecting rate of the lesion.

Keyhole approach surgery for petroclival meningioma / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>In China, the feasibility of keyhole approach in surgical treatment of petroclival meningioma has not been well evaluated. This report summarized our experience in 25 patients with petroclival meningioma who had been treated with keyhole approach surgery.</p><p><b>METHODS</b>From July 2000 to July 2005, 25 patients with petroclival meningioma were subjected to resection via subtemporal, retrosigmoid or combined keyhole approaches. The extent of tumor resection was evaluated by MRI 3 months after surgery, and postoperative complications were investigated.</p><p><b>RESULTS</b>The maximum diameter of tumors ranged from 2 to 7 cm (mean, 4.5 cm). Gross total resection (GTR) was achieved in 14 patients, giving a GTR rate of 56%. Subtotal resection (STR) was carried out in 8 patients and partial resection in 3. Thirteen patients kept normal neurological status, whereas others suffered from cranial nerve deficits (VII, VII, III and lower CN). One patient died in the postoperative period.</p><p><b>CONCLUSIONS</b>Keyhole approach surgery, especially the combined keyhole approach is suitable for the treatment of petroclival meningioma. It provides easy and quick access to the supra- and infratentorial juxta-clival region without drilling of the petrous bone. Complications related to the approach can be minimized.</p>

Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate clinical strategy and effect of early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm.</p><p><b>METHODS</b>Seventy-five patients presenting with anterior circulating aneurysmal subarachnoid hemorrhage (SAH) underwent early-mid-phase (within 3 days or 3-10 days) microsurgical clipping at Huashan Hospital between January 2001 and August 2004. Glasgow outcome scale (GOS) was conducted to evaluate patients' outcomes.</p><p><b>RESULTS</b>Of 81 intracranial aneurysms, 77 lesions were clipped successfully, and 4 were wrapped. Good outcome was achieved in 53 cases, mild disability in 9 cases, severe disability in 7 cases, persistent vegetative state in 3 cases, and 3 patients (4%) died after surgery. The difference of GOS was statistically significant between patients in Hunt and Hess Grade I-III and Grade IV-V. However, there was no significant difference between early surgery and metaphase surgery.</p><p><b>CONCLUSIONS</b>Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm is considered the feasible opinion.</p>

Upregulated gene expression of local brain-derived neurotrophic factor and nerve growth factor after intracisternal administration of marrow stromal cells in rats with traumatic brain injury / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To examine the effects of rat marrow stromal cells (rMSCs) on gene expression of local brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) after injection of rMSCs into Cistern Magnum of adult rats subjected to traumatic brain injury (TBI).</p><p><b>METHODS</b>A modified Feeney's TBI model was created in 48 adult rats. rMSCs were harvested from 3-month-old rats, and injected into Cistern Magnum in 24 rats subjected to TBI (Group cell transplantation). Saline was given through Cistern Magnum to another 24 rats subjected to TBI (Group saline control). Animals were sacrificed 1, 2 and 3 weeks after intervention, and special brain tissue blocks were dissected for total RNA extraction from each block. BDNF and NGF mRNA were reverse-transcribed into cDNA and further expanded by polymerase chain reaction (PCR). The expression of target genes was evaluated using semi-quantitative methods.</p><p><b>RESULTS</b>Group cell transplantation had higher BDNF and NGF gene expressions than Group saline control during a period of less than 3 weeks (P<0.05).</p><p><b>CONCLUSIONS</b>rMSCs transplantation via Cistern Magnum in rats subjected to traumatic brain injury can enhance expressions of local brain NGF and BDNF to a certain extent.</p>

Prospective comparison of functional magnetic resonance imaging and intraoperative motor evoked potential monitoring for cortical mapping of primary motor areas / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the relation between the preoperative functional magnetic resonance imaging (fMRI) with blood oxygen level dependent (BOLD) technique and intraoperative motor evoked potential (MEP) monitoring for cortical mapping of primary motor cortex in patients with tumors near the central area. And to determine whether non-invasive preoperative fMRI can provide results equivalent to those achieved with the invasive neurosurgical "gold standard".</p><p><b>METHODS</b>A prospective study of 16 patients with various pathological tumors of the central area was conducted. Preoperative fMRI scans using the BOLD contrast technique in each patient were performed. An activation scan was achieved by using a motor task paradigm, which consisted of simple flexion-extension finger movements and finger-to-thumb touching in a repeating pattern. The anatomical structure was delineated by the T(1)-weighted three-dimensional fast spoiled gradient recalled sequence (3D/FSPGR) immediately afterward. The BOLD images were overlaid on the T(1)-weighted 3D/FSPGR images, and then co-registered to the neuronavigation system. The fMRI activations were documented by using a neuronavigation system in sequence, and compared to standardized intraoperative MEP monitoring, which included direct cortical electrical stimulation (DCES) or transcranial cortical electrical stimulation (TCES) or their combination. The compound muscle action potentials of forearm flexor and hand muscle responses were recorded during either TCES or DCES. Two techniques were compared to determine the accuracy for cortical mapping of primary motor areas with fMRI.</p><p><b>RESULTS</b>Overall, the intraoperative MEP monitoring showed good correlation with fMRI activation in 92.3% of cases. The coincidence rate, however, was 100.0% between TCES and fMRI, and 66.7% between DCES and fMRI respectively. There was no statistically difference between two cortical mapping techniques, chi-square test of paired comparison of enumeration data, P < 0.01.</p><p><b>CONCLUSION</b>BOLD fMRI was a high sensitive and reliable technique to locate the position of the primary motor areas and their spatial relation with adjacent tumor, especially for the presurgical planning in patients with central area brain tumor.</p>

Cerebral revascularization in treatment of intractable aneurysms / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the effectiveness of cerebral revascularization in the treatment of intractable aneurysms and to discuss the indications, surgical techniques, and the outcome of the revascularization.</p><p><b>METHODS</b>During the recent 4-year period, 9 radical artery grafts were performed in patients with intractable or giant internal carotid artery (ICA) aneurysms. The indications for cerebral revascularization included parent vessel occlusion during the treatment of the intractable aneurysms with poor collateral circulation or the young patients. Modified techniques were taken to use the main trunk of superficial temporal artery (STA) as donor, while M3 branches near the bifurcation of the M2 segment of the middle cerebral artery (MCA) were chosen as the recipient arteries. STA-Radial artery (RA)-MCA bypass was followed by parent vessel occlusion via chronic cervical ICA ligation or balloon occlusion.</p><p><b>RESULTS</b>Postoperative angiography demonstrated the patency of the grafts in eight cases. The procedure of the parent vessels occlusion was uneventful in these patients. Follow-up showed the patients were in excellent conditions after successful treatment of aneurysms. Significantly delayed filling of the graft was revealed in one patient, who could not tolerate balloon occlusion test and occlusion of parent artery failed.</p><p><b>CONCLUSIONS</b>Extracranial-to-intracranial bypass followed by parent vessel occlusion is a safe and effective method to treat intractable ICA aneurysms. Radical artery as graft can offer high-flow revascularization with less complications. Combined surgical and endovascular treatment might be the future direction for the treatment of the difficult aneurysms.</p>

Diagnosis and treatment of tentorial dural arteriovenous fistulae / 中华外科杂志

<p><b>OBJECTIVE</b>Tentorial dural arteriovenous fistulae are uncommon but life-threatened lesions. We present our experience of 5 cases with tentorial dural arteriovenous fistulae, review the relevant literature and present the rationale of our current management strategy.</p><p><b>METHODS</b>The data of five patients with tentorial DAVF treated in Huashan Hospital between June 2002 and May 2003 were reviewed retrospectively, including their ill history, neuroimagings, operation records and follow-up data.</p><p><b>RESULTS</b>There were 3 females and 2 males with age from 25 to 52 years (average, 42.6 years). Clinical manifestations were acute subarachnoid hemorrhage in 2 cases, progressing neurological deficits in 3 cases. MRI and DSA were major diagnostic and follow-up modalities. Borden classification type II was in 1 case, type III in 4 cases. According to DAVF location, tentorial marginal type were in 3 cases, tentorial lateral type 1 case, tentorial medial type 1 case. Two patients had transarterial embolization preoperatively. All patients underwent craniotomy with the coagulation of the nidus and tentorium, disconnection of leptomeningeal venous drainage. The surgical approaches were via trans-anterior-petrous approach in 3 cases, transpterional subdural approach 1 case, transoccipital and transtentorial approach 1 case. All patients had clinical improvement, there was no surgical mortality and morbidity. Postoperative DSA confirmed obliteration of DAVF in 3 cases, MRI demonstrated the thrombosis of venous aneurysm and the disappearance of previous brainstem edema, partial thrombosis of venous aneurysm in 1 case. Follow-up study ranging from 1 to 2 year showed no recurrence and all patients resume their full activities.</p><p><b>CONCLUSIONS</b>Tentorial DAVF is an aggressive vascular lesion, causing subarachnoid hemorrhage and progressive neurological deficits. Prompt diagnosis and definite treatment for tentorial DAVF are mandatory. Obliteration of the nidus and/or leptomeningeal venous drainage should be the goal of treatment. Microsurgical procedures with/without endovascular intervention are the best choice of treatment.</p>