Application of ultrasound monitoring optic nerve sheath diameter in diagnosis and treatment of adult patients with intracranial hypertension / 中国医师进修杂志

Objective:To investigate the effect of ultrasound measurement of optic nerve sheath diameter (ONSD) in adult patients with elevated intracranial pressure (ICP).Method:From June 2017 to March 2020, A total of 64 patients (32 patients with elevated ICP and 32 patients with normal ICP) were placed with invasive intracranial pressure monitoring probe in Beijing Pinggu Hospital. Their ICP and ONSD were continuously monitored. Thirty-two healthy volunteers were recruited as control group to check ONSD. The correlation between ONSD and ICP, and the changes of ICP and ONSD after osmotic therapy were observed.Results:The ONSD in ICP increased group was significantly higher than that in normal ICP group: (5.77 ± 0.3) mm vs. (5.01 ± 0.1) mm, with statistical difference ( P<0.05), and there was a positive correlation between ONSD and ICP. There was no significant difference in ONSD between normal ICP group and control group ( P>0.05). Conclusions:Ultrasound monitoring ONSD can reflect the level of ICP and evaluate the effect of osmotic therapy and the prognosis of patients. Bedside ultrasound examination of optic nerve sheath diameter could be used to judge ICP and to evaluate the curative effect of osmotic therapy, with high clinical application value.

Microneurosurgery treatment for 41 recurrent craniopharyngioma cases / 中国医师进修杂志

Objective:To investigate the method and effect of microneurosurgery in the treatment of recurrent craniopharyngioma.Methods:The clinical data of 41 recurrent craniopharyngioma patients treated by microneurosurgery in Capital Medical University Sanbo Brain Hospitalfrom January 2018 to January 2022 were retrospectively analyzed.Results:Among the 41 patients, 38 cases were treated with the frontal basal interhemispheric approach and 3 cases with the translongitudinal fissure combined with the transSylvian fissure approach. Gross total resection was performed in 34 cases (82.9%) and subtotal resection in 7 cases (17.1%). One patient (2.4%) died of pulmonary embolism during perioperative period. All patients had transient electrolyte disorder after operation, and recovered within 3 months after treatment. All patients had endocrine dysfunction. After 3 months of hormone replacement therapy, 11 patients were cured. Visual acuity decreased in 3 cases after operation, and 2 cases improved after treatment.Conclusions:Surgical treatment of recurrent craniopharyngioma is very difficult, which is a great challenge for doctors and patients. However, through the individualized evaluation of the patients and the meticulous technique of the doctors during the operation, a satisfactory effect can be achieved post the operation of recurrent craniopharyngioma.

The etiology and treatment of craniopharyngioma with aneurysm / 中国医师进修杂志

Objective:To explore the etiology and treatment of craniopharyngioma with aneurysm.Methods:Seven cases of craniopharyngioma with aneurysm from March 2014 to October 2019 treated in Sanbo Brain Hospital, Capital Medical University were retrospectively analyzed. Among the 7 patients, there were 5 males and 2 females. There were 4 cases of recurrent craniopharyngiomas, 1 case of primary tumor and 2 cases of non-recurrence tumor. Three patients with blood blister-like aneurysms were treated with microsurgical suture after craniopharyngioma resection. Among the three cases with internal carotid artery fusiform aneurysm, 1 case underwent craniopharyngioma resection after internal maxillary artery-radial artery-middle cerebral artery bypass and isolation of the aneurysm; 1 case only underwent internal maxillary artery-radial artery-middle cerebral artery bypass and isolation of the aneurysm for non-recurrence tumor; 1 case underwent craniopharyngioma resection and dynamic observation of aneurysm. One case with a cystic aneurysm of the middle cerebral artery was clipped and the craniopharyngioma did not relapse.Results:All patients had no serious postoperative complications. During the follow-up period, there was no recurrence of craniopharyngioma, no recurrence of treated aneurysms, and the stability of aneurysms was observed.Conclusions:Inflammatory stimulation of craniopharyngioma cystic fluid and operation itself are the important reasons for the occurrence of aneurysms after craniopharyngioma surgery. Choosing appropriate surgical methods can complete the removal of craniopharyngioma and the treatment of aneurysms at one time.

Imaging findings and clinical analysis of craniopharyngioma / 中国医师进修杂志

Objective:To retrospectively summarize the imaging and clinical features of craniopharyngioma in order to improve the preoperative diagnosis level.Methods:One hundred and twenty-seven patients with craniopharyngioma diagnosed by pathology in Sanbo Brain Hospital, Capital Medical University from March 2019 to June 2021 were selected and the pathological coincidence rate of imaging diagnosis were analyzed.Results:The coincidence rate of MRI diagnosis was 89.3%. The coincidence rate of CT diagnosis was 71.5%. On T 2WI and T 1WI enhanced sequences, the solid portion of the tumor may showed uneven hyperintensity, diffuse striation and spotty hyperintensity. MRI sagittal view was helpful in showing small tumors, but less sensitive to calcification than CT. MRI enhancement was very important, especially for patients with solid lesions. Conclusions:The imaging findings of craniopharyngioma are diverse. Some characteristic manifestations provide important information for the diagnosis and differential diagnosis of craniopharyngioma, which can improve the diagnostic accuracy combined with clinical data.

Application of anterior clinoid grinding in sellar region tumors and ophthalmic/superior clinoid process aneurysms of internal carotid artery / 中国医师进修杂志

Objective:To evaluate the clinical effect of anterior clinoid process grinding in the treatment of ophthalmic / superior clinoid process aneurysms and sellar tumors.Methods:The clinical data of 16 patients who underwent anterior clinoid process grinding in Sanbo Brain Hospital, Capital Medical University from January 2015 to July 2021 were analyzed retrospectively. There were 1 patient with recurrent craniopharyngioma, 1 patient with recurrent pituitary adenoma, 13 patients with aneurysms, and 1 patient with suprasellar granulosa cell tumor combined with ophthalmic aneurysm of right internal carotid artery. The Modified Rankin Scale (mRS) score was used to evaluate the situation at discharge and in the medium-and-long term.Results:Sixteen patients underwent anterior clinoidprocess grinding. At discharge and the latest follow-up, the mRS scores of the patients were 0-2. A total of 15 aneurysms were treated, and there were no symptoms of visual loss or visual field defect after operation. No cerebrospinal fluid leakage occurred in all patients.Conclusions:The grinding of anterior clinoid process can effectively and fully stretch the optic nerve and internal carotid artery, and can observe the tumor neck at the lower end of pituitary stalk and the ocular segment/superior clinoid process of internal carotid artery under direct vision. It is one of the important auxiliary methods for the treatment of sellar lesions.

Surgical treatment of spindle aneurysms in V4 segment of vertebral artery / 中国医师进修杂志

Objective To explore the surgical treatment of spindle aneurysms in V4 segment of vertebral artery. Methods The clinical data, surgical methods and prognosis of 6 patients with V4 spindle aneurysms of vertebral artery admitted from 2011 to November 2018 in Sanbo Brain Hospital were retrospectively analyzed,Results There were 4 males and 2 females aged from 45 to 65 years. Aneurysm rupture and bleeding occurred in 3 cases. Far lateral approach was used in all patients. One case was clipped with window aneurysms, 2 cases were treated with occipital artery (OA)- posterior inferior cerebellar artery (PICA) bypass, and 3 cases were treated with vertebral artery occlusion. Postoperative patients were generally in good condition. Postoperative CT arteriography confirmed that the bypass vessels were unobstructed in 2 cases. All vertebral aneurysms were treated satisfactorily and PICA arteries were preserved. Tracheotomy was performed in 5 patients (1 case was incised before operation). Three patients were removed 3 months after operation. The Glasgow Prognosis Score (GOS) was 4 points. Long-term tracheotomy was performed in 1 case, and GOS score was 3 points. Two patients died 4 months and 3 years after operation. Conclusions Craniotomy is an important method for the treatment of spindle aneurysm of V4 segment of vertebral artery. Different surgical methods should be selected according to the size of the aneurysm, the relationship between the location of the aneurysm and PICA, and the compensation of the vertebral artery.

The research advancement of blood blister like aneurysms of the supraclinoid carotid artery / 中国医师进修杂志

Blood blister like aneurysms is very easy to rupture, especially during and after surgery. Once found, it should be treated promptly. Treatment includes direct clipping, suture artery reconstruction,aneurysm wrapping,internal carotid artery occlusion and endovascular treatment.In this article, we investigate the characteristics, clinical outcome and treatment strategy of blood blister like aneurysms of the supraclinoid carotid artery.

The correlation between Chlamydiae pneumonia and carotid atherosclerosis / 中华外科杂志

<p><b>OBJECTIVES</b>To study the correlation between Chlamydiae pneumonia and carotid atherosclerosis, and the correlation between the infection of Chlamydiae pneumonia and ischemic events.</p><p><b>METHODS</b>The study group consisted of 19 patients who underwent unilateral carotid endarterectomy surgery during the period from January 2010 to December 2011, and the atherosclerotic plaque specimens were harvested from these patients. The control group consisted of 10 patients who underwent extracranial-intracranial bypass surgery during the same period, and the normal external carotid artery specimens were got from these patients. The clinical data between the two groups had comparability. The presence of Chlamydiae pneumonia in atherosclerotic plaque and normal artery tissue were investigated by immunohistochemistry. The expression of Toll-like receptor 2 (TLR2), tumor necrosis factor-α (TNF-α) and vascular cell adhesion molecule-1 (VCAM-1) in the atherosclerotic plaque infected with Chlamydiae pneumonia were also detected. Data were analyzed using Fisher's exact test.</p><p><b>RESULT</b>Chlamydiae pneumonia was found in 9 of 19 atherosclerotic plaques, while no positive result was found in control group. The statistical analysis showed a significant difference (P = 0.011). Among the 19 patients in study group, 15 of them had ischemic events, and Chlamydiae pneumonia was found in 9 of these 15 patients; while the other 4 patients didn't have any ischemic events and no Chlamydiae pneumonia was found in them, but there was no statistical different between them (P = 0.087). Through immunohistochemistry, the expression of Chlamydiae pneumonia, TLR2, TNF-α and VCAM-1 were found in same area.</p><p><b>CONCLUSIONS</b>There is a correlation between Chlamydiae pneumonia and carotid atherosclerosis.And there might be a correlation between Chlamydiae pneumonia and cerebral ischemic events.</p>

Treatment strategy and microsurgical operation of complex cerebral arteriovenous malformations / 中华外科杂志

<p><b>OBJECTIVE</b>To study the treatment strategies and operative principles of complex cerebral arteriovenous malformation (CAVM).</p><p><b>METHODS</b>Total 27 cases of complex CAVM were microsurgically resected from June 2004 to May 2011. These account for 67.5% of CAVMs in the same time. Of the CAVM, 25 were eloquent CAVMs and 2 were non-eloquent CAVM. Among the 27 cases, the size of CAVM was large in 12 cases, median in 8, and small in 7. According to Spetzler-Martin CAVM grading, 8 cases were grade II, 5 cases were grade III, 9 cases were grade IV, and 5 cases were grade V. Pre-operative endovascular embolizations were carried out in 2 large CAVMs. All CAVMs were resected by microsurgical techniques.</p><p><b>RESULTS</b>There were 23 cases of complex CAVMs totally removed. The total resection rate was 85.2%. The residual CAVMs were found in postoperative digital subtraction angiography (DSA) in 4 cases. Three of these residual cases were treated with gamma knife. Nineteen cases recovered very well after operation. The main complications were hemianopsia in 2 cases, moderate weakness in 4 cases. Two patients in coma before operation were still comatose after operation. The follow-up period were 2 months to 6 years. Twenty-two cases were Glasgow outcome scale (GOS) 5, 3 cases were GOS 4, and 2 comatose patients were improved a little during the follow-up.</p><p><b>CONCLUSIONS</b>The microsurgical total resection of the CAVMs is the most effective method to cure the disease. With the use of microsurgical technique skillfully, mose complex CAVMs can achieve good outcomes. Preoperative embolization and radiosurgery on the residual nidus are good supplementary methods to treat the complex CAVMs.</p>

Surgical treatment of vertebral artery-posterior inferior cerebellar artery dissecting aneurysms / 中华外科杂志

<p><b>OBJECTIVE</b>To study an effective method for vertebral artery-posterior inferior cerebellar artery (VA-PICA) dissecting aneurysms.</p><p><b>METHODS</b>Five patients with VA-PICA dissecting aneurysms were treated surgically between December 2007 and February 2010, who were all males, aged from 40 to 55 years. Four of them presented with subarachnoid hemorrhage (SAH), 1 of them suffered from an intermittent headache on occipital area about 4 months. All the aneurysms were trapped via a far-lateral approach after revascularization of the PICAs by occipital artery-posterior inferior cerebellar artery (OA-PICA) bypass.</p><p><b>RESULTS</b>Among the 5 patients, 1 of them got a good outcome without any neurological deficit after surgery, 3 of them had postoperative lower cranial nerve palsy, 1 of them complicated with bleeding in the operative field after postoperative antithrombotic treatment, and suffered from contralateral hemiplegia after second surgery of removing hematoma. Postoperative cerebral angiographies (received by 2 patients) and CT angiographies (received by 3 patients) all showed patent bypasses and no filling of the aneurysms. During the follow-up from 2 to 29 months, 4 patients got good outcomes, 1 patient still suffered from moderate hemiplegia.</p><p><b>CONCLUSIONS</b>Trapping the aneurysms after revascularization of PICA by OA-PICA bypass should be an effective method to treat the VA-PICA dissecting aneurysms, but individualized strategies also need to be considered based on different cases.</p>

Microsurgical treatment of ophthalmic segment aneurysms of internal carotid artery: 28 cases report / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the operative modalities and outcomes of 28 cases of ophthalmic segment aneurysms of internal carotid artery.</p><p><b>METHODS</b>Twenty-eight cases of ophthalmic segment aneurysms of internal carotid artery were operated on from May 2004 to August 2009. Of all 28 cases, 20 were large or giant. Nineteen aneurysms were directly clipped or resected with internal carotid artery revascularization. Since 2006, high-flow extracranial-intracranial (EC-IC) bypass were available and performed in 9 patients of large or giant aneurysms and then the aneurysms were resected or trapped.</p><p><b>RESULTS</b>Seventeen patients underwent digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance angiography (MRA) postoperatively. The images demonstrated that 5 grafts of bypass were in patency, and 2 were occluded. Only 1 aneurysm was partially clipped and the others disappeared on imaging. The 78% of these cases had good results (GOS 4-5). One patient died after EC-IC bypass due to neck hematoma.</p><p><b>CONCLUSIONS</b>The treatment of ophthalmic segment aneurysms of internal carotid artery, especially the large and giant ones, remains a challenge for neurovascular neurosurgeon. The accessory high-flow EC-IC bypass procedures and selection of suitable aneurysm clips are very important to improve the effectiveness of the operation.</p>

The microsurgical anatomy of the suprasellar and parasellar region with reference to extend transsphenoidal approach / 中华外科杂志

<p><b>OBJECTIVE</b>The anatomic features of transsphenoidal approach are reviewed, focusing on the microsurgical anatomy of suprasellar and parasellar structures. Pertinent microsurgical anatomy is described for neurosurgeons to successfully extend a standard transsphenoidal approach for treatment of lesions including the region of the tuberculum sellae, planum sphenoidale, supradiaphragmatic intradural space, and medial cavernous sinus.</p><p><b>METHODS</b>15 specimens (30 sides) from formalin fixed cadaveric heads and 20 adult dry skulls (40 sides) were observed. According to the need for the extend transsphenoidal approach, the sellar and parasellar region: the planum sphenoidale and the supradiaphragmatic area, medial part of cavernous sinus were studied. Special emphases were put on the relation of the cranial nerve and blood vessel structures surrounding the sellar. Meanwhile, we made the cast specimen of the blood vessel and studied the structure character of the internal carotid artery in the cavernous sinus.</p><p><b>RESULTS</b>Posterior ethmoidal could be exit as para or suprasphenoidal ethmoidal air cell. It will be important for extending the transsphenoidal approach. The mean distance between two optic canal is 15.7 +/- 3.2 mm (11.0 - 18.0 mm), the distance of internal carotid artery at tuberculum cellae level is 13.9 +/- 3.8 mm (10.0 - 17.0 mm), the mean distance between tuberculum cellae and the posterior rim of cribriform plate is 23.3 +/- 3.2 mm, the included angle between sagittal plane and optic canal is 36.3 degrees +/- 1.6 degrees , with the anatomy research data give the clue that the bone window should be made as the shape of "[see text]".</p><p><b>CONCLUSIONS</b>Expending transsphenoidal approach is suitable for medium and small lesions growing along the centre line which expand to para sellar, anterior sellar and sphenoid platform. That hypophysis has close relation with internal carotid artery during expending transsphenoidal approach to cavernous sinus increase the risk of operation. The carotid artery and abducent nerve are the easiest structures to be damaged during the operation.</p>

Microsurgical treatment of craniopharyngiomas: report of 284 patients / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Generally, total surgical removal of craniopharyngioma results in satisfactory outcome with a low recurrence rate, however, the location of the tumor and its adherence to the hypothalamic structures can make the operation difficult. The goal of the present study was to assess the outcome of craniopharyngiomas in 284 patients treated surgically.</p><p><b>METHODS</b>A total of 284 patients (151 men and 133 women) with craniopharyngioma were treated surgically by our neurosurgeons from January 1996 to March 2006. Among them, 226 (79.6%) patients were adults (15 years of age or older; mean, 35.8 +/- 10.6), 58 (20.4%) were children (14 years of age or younger; mean, 9.1 +/- 3.8). The diameter of the tumors were 2.0 - 9.0 cm (mean, 36.54 +/- 11.4). The tumors were classified into the superior (23 patients) and inferior ventricular (261) types according to the location of the tumor relative to the third ventricular floor. For the patients with craniopharyngioma of inferior ventricular type, pterional approach was used in 191 (67.3%) patients, subfrontal approach in 17 (6.0%), and translamina terminalis through frontobasal interhemispheric approach in 53 (18.7%). For those with the tumors of superior ventricular type, transcallosal approach into the anterior third ventricle was done in 10 (3.5%) patients, and the lamina terminalis approach in 13 (4.6%). Of the 284 patients, 204 (71.8%) were followed up for 0.5 to 8 years (mean, 2.1 +/- 1.8), including 162 patients received total tumor removal, and 37 underwent subtotal or partial removal.</p><p><b>RESULTS</b>Total, subtotal and partial removal of the tumors were achieved in 237 (83.5%), 34 (12.0%) and 13 (4.5%) patients, respectively. The pituitary stalk was preserved in 176 (62.0%) patients, severed in 52 (18.3%), and unidentified in 56 (19.7%). Twelve (4.2%) patients died within one month after the surgery. During the follow-up, 23 (14.1%) patients experienced tumor recurrence 1.0 - 3.5 years (mean, 1.8 +/- 1.6) after total tumor removal, and 24 (64.9%) had recurrent tumor 0.25 - 1.5 years (mean, 0.5 +/- 0.4) after subtotal or partial resection. Normal activities of daily living were regained in 63 (80%) patients, independence in 29 (14.2%), and daily life with assistance in 9 (4.4%). Four (2.0%) patients died 0.9 - 3 years (mean, 1.6 +/- 1.4) after discharge from hospital, 3 of them died of hypothalamic deficiency.</p><p><b>CONCLUSIONS</b>We can protect the hypothalamic structures and its perforating arteries by choosing surgical approaches according to the location of craniopharygioma relative to the third ventricular floor. The mortality, morbidity, and recurrence rate in patients received total resection are lower than those of patients underwent subtotal or partial resections. In addition, preservation of the pituitary stalk is critical when total tumor resection is feasible.</p>

Changes of hypothalamus-pituitary hormones in patients after total removal of craniopharyngiomas / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>This paper aimed to elucidate the changes of hypothalamus-pituitary hormones in patients after total removal of craniopharyngiomas.</p><p><b>METHODS</b>A total of 40 patients with craniopharyngiomas received surgery. The levels of triiodothyronine (T3), thyroxine (T4), thyrotropic hormone (TSH), antidiuretic hormone (ADH), and adrenocorticotropin (ACTH) were measured in the 40 patients before surgery and one week after surgery respectively.</p><p><b>RESULTS</b>Twenty-eight patients (70%) had hypothyroidism before surgery, but 38 (95%) had hypothyroidism after surgery (P < 0.01). Twenty-three patients (57.5%) had diabetes insipidus (DI) before surgery and 38 (95%) had DI after surgery (P < 0.001). The pre- and post-operative levels of ADH were (2.49 +/- 0.30) pg/ml and (2.80 +/- 0.29) pg/ml respectively (P > 0.05), whereas those of ACTH were (23.97 +/- 2.69) pg/ml and (15.60 +/- 1.91) pg/ml respectively (P < 0.05).</p><p><b>CONCLUSIONS</b>Hormone deficits after total removal of craniopharyngioma appear to be the common complication of surgery. Hypothyroidism and diabetes insipidus are more frequent after surgery than before surgery. Thyroxine and glucocorticoids should be administered routinely after total removal of craniopharyngioma.</p>

Microsurgical resection of the recurrent craniopharyngiomas / 中华外科杂志

<p><b>OBJECTIVE</b>To study the effective method of microsurgical resection of the recurrent craniopharyngiomas.</p><p><b>METHODS</b>Microsurgical resection underwent in 40 cases with the recurrent craniopharyngiomas that accounted for 24 men and 16 women with mean age 35.1 year old. Visual deterioration was mainly complained in 25 patents, headache of symptoms in 9 patients, defect of visual field in 2 patients, amenorrhea in 2 patients, hyposexuality in one patient and diabetes insipidus in the one. Average history was 2.9 years. The superior sellar tumors on MR imaging grew in 19 cases, the superior-inferior sellar mass in 9 cases, intra-sellar in 5 cases and the tumors into the third ventricle in 7 cases. The huge calcification tumors were found in 5 cases, cystic tumors in 21 cases, and solid tumors 2 cases. Hydrocephalus presented in 12 cases. Evolution of tumor residuum was revealed in 31 cases after initial surgery and recurrent tumor after completing total removal of the tumor in 9 cases. The pterional approach was employed in 33 cases. The longitudinal fissure to the corpus callus approach in 2 cases was available for resection of the third ventricular tumor through the fornix column and septum pellucidum spaces.</p><p><b>RESULTS</b>In 33 cases with the pterional approaches, total removal of the tumors were completed in 22 cases, subtotal removal of tumors in 9 cases, and partial removal in 2 cases. In 5 cases with subfrontal approach, 4 patients the total removal of tumors obtained in 4 cases and one subtotal removal of tumor in one. Of 2 cases with the longitudinal fissure to the corpus callus approaches, one case was achieved with the total removal of tumor and the other with subtotal removal of tumor. The pituitary stalk was preserved in 8 cases, the pituitary stalk was severed in 9 cases and the pituitary stalk was not identified in 23 cases when surgery. 17 patients experienced diabetes insipidus and 12 patients had the hypothalamic hypofunction after surgery. One death occurred from the hypothalamic hypofunction 35 day after surgery. By follow-up from 3 months to 3 years, 22 patients returned normal life, 11 patients can carry out their self-life, and 6 patients need care.</p><p><b>CONCLUSIONS</b>The desirable removal of recurrent craniopharyngioma could be completed in the majority of patients although the reoperation of the tumors was performed very difficulty owing to the tumor adhesive to the surrounding hypothalamic structures.</p>