Reconstructive Operation of Severe Orbital Hypertelorism With Computer-Assisted Precise Virtual Plan.

Orbital hypertelorism correction is still a less precise procedure, with a simple preoperative design and surgical results often depending on the operator's experience. In recent years, computer-assisted technology has been fully utilized in craniofacial surgery. This article aims to explore the clinical results of computer-assisted technology in orbital hypertelorism correction and discuss its advantages and effects on treatment. Four patients with orbital hypertelorism underwent intracranial and extracranial combined box osteotomy correction. Preoperative computed tomography scans were performed, and 3-dimensional 3D digital technology was used to measure the orbital spacing, virtually design the 3D cutting scheme, and guide the intraoperative 3D cutting to improve the accuracy of periorbital osteotomy and reduce the surgical risk. Four patients underwent successful surgery, and the average distance of the medial orbital wall was decreased from 43.6 to 23.4 mm. Computer-assisted box osteotomy shortens the operative time and provides better corrective results.

Application of neuroendoscopic surgical techniques in the assessment and treatment of cerebral ventricular infection.

Cerebral ventricular infection (CVI) is one of the most dangerous complications in neurosurgery because of its high mortality and disability rates. Few studies have examined the application of neuroendoscopic surgical techniques (NESTs) to assess and treat CVI. This multicenter, retrospective study was conducted using clinical data of 32 patients with CVI who were assessed and treated by NESTs in China. The patients included 20 men and 12 women with a mean age of 42.97 years. NESTs were used to obliterate intraventricular debris and pus, fenestrate or incise the intraventricular compartment and reconstruct cerebrospinal fluid circulation, and remove artificial material. Intraventricular irrigation with antibiotic saline was applied after neuroendoscopic surgery (NES). Secondary hydrocephalus was treated by endoscopic third ventriculostomy or a ventriculoperitoneal shunt. Neuroendoscopic findings of CVI were used to classify patients into Grade I (n = 3), Grade II (n = 13), Grade III (n = 10), and Grade IV (n = 6) CVI. The three patients with grade I CVI underwent one NES, the 23 patients with grade II/III CVI underwent two NESs, and patients with grade IV CVI underwent two (n = 3) or three (n = 3) NESs. The imaging features and grades of neuroendoscopy results were positively related to the number of neurosurgical endoscopic procedures. Two patients died of multiple organ failure and the other 30 patients fully recovered. Among the 26 patients with secondary hydrocephalus, 18 received ventriculoperitoneal shunt and 8 underwent endoscopic third ventriculostomy. There were no recurrences of CVI during the 6- to 76-month follow-up after NES. Application of NESTs is an innovative method to assess and treat CVI, and its neuroendoscopic classification provides an objective, comprehensive assessment of CVI. The study trial was approved by the Institutional Review Board of Beijing Shijitan Hospital, Capital Medical University, China.

Surgical Indications of Exploring Optic Canal and Visual Prognostic Factors in Neurosurgical Treatment of Tuberculum Sellae Meningiomas.

BACKGROUND: Tuberculum sellae meningiomas (TSMs) present a special symptom because of the adherence and compression to the optic nerve, optic artery, and the chiasm. A significant number of patients with TSMs appear visual deficits. This study aimed to investigate the surgical indications of exploring the optic canal and visual prognostic factors in the neurosurgical treatment of TSMs. METHODS: Totally 21 patients with TSM, who were operated from September 2007 to August 2011 in the Department of Neurosurgery, Tongren Hospital were enrolled in this study. Results of orbital computed tomography (CT) and magnetic resonance imaging (MRI), visual acuity, Goldmann visual field test, orbital color Doppler flow imaging (CDI) test in these patients were retrospectively analyzed. RESULTS: Visual deficit and optic canal involvement (OCI) were detected in all the 21 patients. Fourteen patients had bone proliferation within the area of the optic canal. After the operation, visual outcomes were improved in 13 patients, unchanged in 7 patients, and deteriorated in 1 patient. All the 21 patients performed orbital CDI test preoperatively, the results showed that if the peak systolic velocity (PSV) of central retinal artery (CRA) value was ≤ 8 cm/s, the visual outcome would be better. CONCLUSIONS: The surgical indications of exploring optic canal in TSM cases included: (1) The neuroimaging evidences of OCI (CT and/or MRI); (2) PSV of CRA in orbital CDI test was ≤ 8 cm/s; (3) visual acuity was below 0.1; (4) visual field deficit. The PSV of CRA in CDI test could be a prognostic factor for visual outcomes of TSMs.

[Analysis of relevant factors affecting the visual prognosis of traumatic optic neuropathy].

OBJECTIVE: To investigate the relevant factors affecting the prognosis of traumatic optic neuropathy (TON). METHODS: A total of 685 cases (719 eyes) of TON from June 2007 to June 2012 were analyzed retrospectively. A total of 9 independent variables (X) including sex, side of TON, duration of coma, vision after trauma, fracture of optic nerve canal, fracture of big ridge of sphenoid bone, hematoma in sphenoid sinus and surgical treatment, and the dependent variable (Y) of visual prognosis were analyzed using the unconditioned Logistic regression analysis to find the risk factors for the visual prognosis of TON. RESULTS: A total of 325 eyes (45.2%) recovered out of 719 eyes. Four variables showed a significant relation with the visual recovery: duration of coma>0.5 h (X3, P<0.01), remnant vision after trauma (X4, P<0.01) and sphenoid ridge fractures (X7, P<0.01), and surgical treatment (X9, P<0.01). These factors above were also proved to be significant in Logistic regression. CONCLUSION: The duration of coma>0.5 h, no light perception after trauma, sphenoid ridge fractures are risk factors of visual recovery, while surgical treatment is the protective factor for the visual recovery after TON.

[Transnasal endoscopic management of foreign body injuries at orbital-skull base].

OBJECTIVE: To explore the feasibility and methods of transnasal endoscope for removing foreign bodies at orbital-skull base. METHODS: Retrospective analyses were performed for 8 cases of foreign body injuries at orbital-skull base at our department from January 2009 to January 2014. The foreign bodies were metallic (n = 4) and wooden (n = 4). Six cases were only within orbit while the remainder had nasal-orbital foreign bodies. The symptoms included preoperative visual loss (n = 6), visual deterioration (n = 2) and eye movement disorder (n = 5). All underwent transnasal endoscopic removal. RESULTS: Foreign bodies were totally removed. During a follow-up period of 3 months to 4 years, there was no recovery of preoperative visual loss (n = 6). Two patients with reduced vision recovered to normal after 3 months. Eye movement disorder fully recovered in 4 cases and 1 case of eye movement disorder had partial recovery. CONCLUSION: Endoscopic removal of foreign body at orbital-skull base has the advantage of mini-invasiveness and non-facial surgical scar.

Optic neuropathy induced by experimentally reduced cerebrospinal fluid pressure in monkeys.

PURPOSE: To examine the influence of experimentally reduced cerebrospinal fluid pressure (CSFP) on retinal nerve fiber layer (RNFL) thickness and neuroretinal rim area of the optic nerve head. METHODS: This experimental study included nine monkeys that underwent implantation of a lumbar-peritoneal cerebrospinal fluid (CSF) shunt. In the study group (n = 4 monkeys), the shunt was opened to achieve a CSF of approximately 40 mm H2O, while the shunt remained closed in the control group (n = 5 monkeys). At baseline and in monthly intervals thereafter, optical coherence tomographic and photographic images of the optic nerve head and RNFL were taken of all monkeys. RESULTS: Two out of four monkeys in the study group showed bilaterally a progressive reduction in RNFL thickness between 12% and 30%, reduction in neuroretinal rim area and volume, and increase in cup-to-disc area ratios. A third monkey developed a splinter-like disc hemorrhage in one eye. The fourth monkey in the study group did not develop morphologic changes during follow-up, nor did any monkey in the control group. CONCLUSIONS: Experimental and chronic reduction in CSF in monkeys was associated with the development of an optic neuropathy in some monkeys.

Small interfering RNA directed against CTMP reduces acute traumatic brain injury in a mouse model by activating Akt.

OBJECTIVE: Protein kinase B (PKB/Akt), which is phosphorylated and activated by upstream activators, exerts critical neuroprotective effects by phosphorylating downstream targets after traumatic brain injury (TBI). Studies on the regulation of Akt will be crucial for our understanding of neuronal survival. The goal of this study is to investigate the effects of carboxyl-terminal modulator protein (CTMP) on phosphorylation of Akt and neurological function in a mouse model of TBI. METHODS: Traumatic brain injury in mice was performed by a controlled cortical impact device. The expression of Akt, phospho-Akt, and CTMP was examined in the injured cortices by immunohistochemistry and Western blot analysis. To determine the effects of CTMP, small interfering RNAs (siRNAs) directed against CTMP were injected in mice with TBI, and the expression of phosphorylated Akt and neurological function were evaluated. RESULTS: Phospho-Akt significantly increased at 4 hours post-TBI in the nucleus (P < 0.01) and remained at high levels until 72 hours after TBI, as shown by Western blot analysis. In the cytosol, the expression of phospho-Akt reached its peak at 4 hours post-TBI, but decreased markedly at 24 hours and maintained below pre-TBI levels until 72 hours post-TBI. Interestingly, the expression of CTMP significantly increased 4 hours after TBI (P < 0.01) and sustained those levels until 72 hours without dramatic changes. Treatment with CTMP siRNA effectively augmented the phosphorylation of Akt and significantly improved the neurological functional recovery up to 28 days post-TBI. CONCLUSION: We conclude that Akt is phosphorylated and translocated to nucleus after TBI to exert neuroprotective effects. However, CTMP is simultaneously triggered to inhibit the phosphorylation of Akt. Inhibition of CTMP by siRNA improves the recovery of neurological functions after TBI.

Noninvasive intracranial pressure estimation by orbital subarachnoid space measurement: the Beijing Intracranial and Intraocular Pressure (iCOP) study.

INTRODUCTION: The orbital subarachnoid space surrounding the optic nerve is continuous with the circulation system for cerebrospinal fluid (CSF) and can be visualized by using magnetic resonance imaging (MRI). We hypothesized that the orbital subarachnoid space width (OSASW) is correlated with and can serve as a surrogate for intracranial pressure (ICP). Our aim was to develop a method for a noninvasive measurement of the intracranial CSF-pressure (CSF-P) based on MRI-assisted OSASW. METHODS: The prospective observational comparative study included neurology patients who underwent lumbar CSF-P measurement and 3.0-Tesla orbital magnetic resonance imaging (MRI) for other clinical reasons. The width of the orbital subarachnoid space (OSASW) around the optic nerve was measured with MRI at 3, 9, and 15 mm behind the globe. The study population was randomly divided into a training group and a test group. After adjusting for body mass index (BMI) and mean arterial blood pressure (MABP), algorithms for the associations between CSF-P and OSASW were calculated in the training group. The algorithms were subsequently verified in the test group. Main outcome measures were the width of the orbital subarachnoid space (OSASW) and the lumbar cerebrospinal fluid pressure (CSF-P). RESULTS: Seventy-two patients were included in the study. In the training group, the algorithms for the associations between CSF-P and OSASW were as follows: (a) CSF-P = 9.31 × OSASW (at 3 mm) + 0.48 × BMI + 0.14 × MABP-19.94; (b) CSF-P = 16.95 × OSASW (at 9 mm) + 0.39 × BMI + 0.14 × MABP-20.90; and (c) CSF-P = 17.54 × OSASW (at 15 mm) + 0.47 × BMI + 0.13 × MABP-21.52. Applying these algorithms in the independent test group, the measured lumbar CSF-P (13.6 ± 5.1 mm Hg) did not differ significantly from the calculated MRI-derived CSF-P (OSASW at 3 mm: 12.7 ± 4.2 mm Hg (P = 0.07); at 9 mm: 13.4 ± 5.1 mm Hg (P = 0.35); and at 15 mm: 14.0 ± 4.9 mm Hg (P = 0.87)). Intraclass correlation coefficients (ICCs) were higher for the CSF-P assessment based on OSASW at 9 mm and at 15 mm behind the globe (all ICCs, 0.87) than for OSASW measurements at 3 mm (ICC, 0.80). CONCLUSIONS: In patients with normal, moderately decreased or elevated ICP, MRI-assisted measurement of the OSASW appears to be useful for the noninvasive quantitative estimation of ICP, if BMI and MABP as contributing parameters are taken into account. TRIAL REGISTRATION: Clinical trial registered with the Chinese Clinical Trial Registry: ChiCTR-OCC-11001271.

Activation of Akt/GSK-3beta/beta-catenin signaling pathway is involved in survival of neurons after traumatic brain injury in rats.

OBJECTIVE: Apoptotic cell death is an important factor influencing the prognosis after traumatic brain injury (TBI). Akt/GSK-3beta/beta-catenin signaling plays a critical role in the apoptosis of neurons in several models of neurodegeneration. The goal of this study was to determine if the mechanism of cell survival mediated by the Akt/GSK-3beta/beta-catenin pathway is involved in a rat model of TBI. METHODS: TBI was performed by a controlled cortical impact device. Expression of Akt, phospho-Akt, GSK-3beta, phospho-GSK-3beta, beta-catenin, phospho-beta-catenin were examined by immunohistochemistry and Western blot analysis. Double immunofluorenscent staining was used to observe the neuronal expression of the aforementioned subtrates. Terminal deoxynucleotidyl transferase-mediated uridine 5'-triphosphate-biotin nick end-labeling (TUNEL) staining was performed to identify apoptosis. RESULTS: Western blot analysis showed that phospho-Akt significantly increased at 4 hours post-TBI, but decreased after 72 hours post-TBI. Phospho-GSK-3beta - phosphorylated by phospho-Akt - slightly increased at 4 hours post-TBI and peaked at 72 hours post-TBI. These changes in Phospho-GSK-3beta expression were accompanied by a marked increase in expression of phospho-beta-catenin at 4 hours post-TBI which was sustained until 7 days post-TBI. Double staining of phospho-Akt and NeuN revealed the colocalization of phospho-Akt positive cells and neuronal cells. In addition, double staining of phospho-Akt and TUNEL showed no colocalization of phospho-Akt cells and TUNEL-positive cells. CONCLUSION: Phosphorylation of Akt (Ser473) and GSK3beta (Ser9) was accelerated in the injured cortex, and involved in the neuronal survival after TBI. Moreover, neuroprotection of beta-catenin against ischemia was partly mediated by enhanced and persistent activation of the Akt/GSK3beta signaling pathway.

Craniotomy with endoscopic assistance in the treatment of nasopharygeal fibroangioma.

BACKGROUND: Nasopharygeal fibroangioma (NPF) can be approached through lateral rhinotomy, the middle skull fossa approach and the transcranial-facial combined approach. It is complicated and thus results in more insults, and when adopted, the total resection rate of tumor is still low. The nasal endoscope is minimally invasive, the dead angles of a craniotomy, such as sphenoid sinus, maxillary sinus, and nasopharynx are easily approached by an endoscope. Lateral rhinotomy have to make facial incision and affects maxillary bone development. We combined the craniotomy and endoscopic approach intending to take advantages of the two approaches. METHODS: Twelve NPF patients who underwent craniotomy with endoscopic assistance from March 2002 to July 2008 at the Beijing Tongren Hospital were selected. All patients were male. Their ages ranged from 11 to 33 years. The main symptoms were visual deterioration, exophthalmos, nasal obstruction, epistaxis and pharynx nasalis neoplasm. The diagnosis was based on CT, MRI and digital subtraction angiography (DSA). All patients had intracranial encroachment and all underwent DSA and embolism treatment were taken before surgery. Seven patients had a pterional craniotomy, five had a frontal-temporal-orbital-zygomatic craniotomy. Most of the tumor was resected piecemeal, then removed through the sphenoidal sinus. Finally, using an endoscope in the nasal cavity, tumor in nasal cavity was resected and removed through the sphenoidal sinus, observing the dead angle of the craniotomy and confirming that sinus drainage was unobstructed. RESULTS: The tumor was removed completely in 11 patients and partially resected in one patient because of hemorrhage. One patient had an infection after the operation and one patient had cerebrospinal rhinorrhea 3 years after surgery that was remediated by endoscopic repair. CONCLUSION: Craniotomy with endoscopic assistance in the treatment of NPF was minimally invasive, safe and efficient, and avoided facial incision.

Sphenoid wing meningioma en plaque: report of 37 cases.

BACKGROUND: Sphenoid wing meningioma en plaque is a special morphological subgroup of intracranial meningiomas, defined by a carpet-like, soft tissue component that infiltrates the dura and invades the sphenoid wing and orbit associated with a significant hyperostosis. This report summarized our experiences in 37 patients with sphenoid wing meningioma en plaque who had been treated with transcranio-orbital approach surgery. METHODS: A retrospective study was made on clinical manifestations, neuroradiological features, and operative techniques in 37 patients undergoing transcranio-orbital approach from Sep. 1998 to Apr. 2009. Patients ages: 16 years to 67 years, 45.5 years in average; sex: 15 males, 22 females. Chief complaints were progressive proptosis and visual acuity deficits. All patients were operated on using a fronto-temporal approach with orbital decompression. The extent of tumor resection and postoperative complications were investigated. RESULTS: Simpson grade II resection was achieved in 9 patients, Simpson grade III in 22 patients and Simpson grade IV in 6 patients. Pathological examination showed 27 (73%) patients were meningothelial meningiomas. After surgery, proptosis improved in all patients, visual acuity improved in 18 patients (69%). Temporary ophthalmoplegia was found in 8 patients, cerebrospinal fluid leak was found in 1 patient. Duration of follow up was from 3 months to 9 years, tumor recurred in 7 patients, and 5 patients underwent second surgery, including two trans-nasal endoscopic surgeries to resect sphenoid sinus-involved tumor. There were no operation-related deaths or other significant complications. CONCLUSIONS: Sphenoid wing meningioma en plaque, mainly meningothelial meningiomas, are more likely to produce adjacent hyperostosis and have characteristic radiological appearances. All the hyperostosis bone of the great wing of sphenoid bone should be removed to prevent recurrence. Extensive tumor removal with bony decompression at the orbital apex can produce satisfactory cosmetic and functional outcome. Close co-operation between the neurosurgeons and the ophthalmologists is important.

[Neurosurgical therapy of transorbital intracranial foreign bodies: review of 28 cases].

OBJECTIVE: To discuss the benefits and complications of the neurosurgical therapy in transorbital intracranial foreign bodies. METHODS: The clinical data of 28 cases of transorbital intracranial foreign bodies, metallic in 13 cases, vegetal 5 cases, and vitreous, plastic and other kinds in 10 cases, were analyzed retrospectively. Optic nerve injury was found in 13 cases, orbital apex syndrome in 11 cases; CSF rhinorrhea in 13 cases, CSF orbital leak in 3 cases, and hemiplegia in 2 cases. All the patients underwent head CT scan, and orbital horizontal and coronal CT scan. The patients with metallic foreign bodies had DSA exams, and the non-metallic cases had MRA scans. 22 cases had orbital-frontal craniotomy and foreign body resection, and 6 cases had direct foreign body extraction. All the cases received antibiotic and nerve nutritional therapy postoperatively. RESULT: The cases in which the foreign bodies came from the orbital roof into the skull recovered well postoperatively; and the cases in which the foreign bodies came from the superior orbital fissure into the skull showed hemiplegia (n = 2) or orbital apex syndrome (n = 6) postoperatively. CONCLUSION: Transorbital intracranial foreign body should be diagnosed in early stage to avoid missed diagnosis. Omission should be avoided during resection of the foreign body. The relationship between the foreign body and internal carotid artery should be examined carefully before the extraction. Direct extraction of foreign body causes less injury, and patients' condition should be followed up.

[Clinical study of lacrimal gland tumor involving anterior and middle cranial fossae].

OBJECTIVE: To investigate the clinical manifestations of lacrimal gland tumor involving the anterior and middle cranial fossae and the effect of transcranial-orbital approach in treatment of such tumor. METHODS: A retrospective study was conducted on the clinical data of 23 cases lacrimal gland tumor involving the anterior and middle cranial fossae confirmed by radiological examination, including 11 cases of adenoid cystic carcinoma, 6 cases of pleomorphic adenocarcinoma (malignant mixed tumor), 2 cases of adenocarcinoma, 1 case of squamous cell carcinoma, 1 case of ductal carcinoma, 1 case of mucoepidermoid carcinoma, and 1 case of benign mixed tumor, 15 males and 8 females, aged 42.5 (2 - 76), with a case history of 43 months (2 months to 27 years), with the chief complaints of progressive proptosis, disgenesia of the eye ball, and orbit pain, all undergoing transcranial-orbital operation from August 1998 to February. 2006. Follow up was conducted for 1 month to 7 years. RESULTS: Postoperatively, ophthalmoplegia was found in 4 cases, and blindness in 1 case. There was no operative death or other significant complication. Recurrence of tumor occurred in 4 cases, and 1 case died from distant metastasis of adenocarcinoma. CONCLUSIONS: Malignant lacrimal gland tumors, mainly adenoid cystic carcinomas, incline to involve the anterior and middle cranial fossae. Adequate orbital apex decompression and exposure of the tumor can result from suitable transcranial-orbital approach. However, complete surgical excision is difficult, and the tumor has a tendency to recur post-operatively. Suitable treatment strategy should by combination of operation with irradiation or chemotherapy. Prognosis is poor.

[Endoscopic decompression of optic canal].

OBJECTIVE: To evaluate the effectiveness of endoscope in the treatment of optic nerve injury. METHODS: Thirteen patients with fracture at the inner and lower walls of optical canal underwent endoscopic decompression. The posterior 1/3 of the middle concha, the posterior ethmoid sinus and sphenoid sinus were opened, chips of bone and old hematocele were scavenged, and the optic ring of the optic canal was polished; however, the sheath of the optic nerve remained intact. In 2 cases with the dura broken at the cranial part of optic nerve, the broken site was covered with mucosa of middle concha, and the sphenoid sinus and the middle nasal meatus were covered with oil ribbon gauze. Three days after the operation, the ribbon gauze was pulled put, however, if cerebro-spinal fluid leakage was suspected, the ribbon gauze was pulled out 7-10 days after. After the operation the visual acuity improvement reaching one grade or more and improvement of visual field were defined as effective. RESULTS: Five of the 6 patients without light perception before the operation showed improvement in visual acuity. The other 7 patients with residual visual acuity all recovered to different extents. CONCLUSION: A mini-invasive surgery, decompression of optic canal with endoscope is effective in decompressing optic nerve, decreasing the injury of optic nerve, and the patients recover quickly after operation.

[Surgical treatment of fibrous dysplasia of the skull with neuro-navagation].

OBJECTIVE: To evaluate the role and effect of neuro-navagation in the surgical treatment of fibrous dysplasia of the skull and to discuss the indication and advantages of transcranial optic nerve decompression are discussed. METHODS: Fifteen patients with fibrous dysplasia of skull, 6 males and 9 females, aged 10.3 (5 approximately 21), were surgically treated by transcranial approach. The location of lesion, symptoms and signs, CT characteristics, surgical approaches, and outcomes were analyzed. The postoperative outcomes of visual acuity were grouped into 5 categories: blindness, light perception, hand motion, counting fingers, and recognizing acuity chart. Improvement of visual acuity of one grade or more or increase of 0.1 by acuity chart, and improvement of visual field were defined as effective. RESULTS: Fibrous dysplasia of skull in children most often involved the frontal, sphenoid, and ethmoid bones and resulted in stenosis of optic canal and superior optic fissure. The most common symptoms were decreased vision, proptosis and facial asymmetry. 13 patients underwent decompression of optic canal in lateral side, and two patients in both side. All the cases had pathological diagnosis of Fibrous dysplasia of the skull. After 3-to-25-month follow-up, improvement was found in 11 eyes (65%), and no improvement was found in 6 eyes (35%). Decreased vision was not seen. CONCLUSION: Transcranial optic nerve decompression is an effective treatment for decreased vision induced by Fibrous dysplasia of the skull.