Endoscopic Endonasal Transsphenoidal Approach for Third Ventriculostomy in the Management of Obstructive Hydrocephalus.

ABSTRACT: Endoscopic third ventriculostomy (ETV) is a safe and effective method for the management of obstructive hydrocephalus. Traditional approach is a transfrontal trajectory through the foramen of Monro to access and open the third ventricle floor. Though endoscopic endonasal transsphenoidal approach (EETA) for pituitary and skull base tumors has become increasingly popular, no published literature has explored its utility in performing an ETV. Here, the authors reported a successful ETV for obstructive hydrocephalus through the EETA. A 57-year-old male presenting with progressive headache and gait disturbance for 3 months was diagnosed with obstructive hydrocephalus. Brain MRI revealed an obstruction of cerebrospinal fluid (CSF) flow at the cerebral aqueduct and supratentorial hydrocephalus, accompanied with dilatation and downward herniation of the third ventricle floor. Considering the displacement of the third ventricle floor and the indication for surgery, an ETV was successfully performed through the EETA. No postoperative complication was observed. Both radiological and clinical evaluation postoperatively confirmed ETV success with decreased ventricular size, increased CSF flow across the floor of the third ventricle, and improved clinical signs. EETA is a feasible approach for ETV in selected cases of obstructive hydrocephalus. This approach provides a short trajectory to directly visualize and open the Liliequist's membrane and the displaced floor of the third ventricle, while minimizes damage to normal brain tissue. Skull base repair with nasoseptal flap ensures the success rate by preventing postoperative CSF leak and infection.

Ambulatory Surgery Protocol for Endoscopic Endonasal Resection of Pituitary Adenomas: A Prospective Single-arm Trial with Initial Implementation Experience.

Endoscopic endonasal transsphenoidal resection has been accepted as a routine therapy for pituitary adenoma, but the postoperative hospital stay is typically several days long. With the advantages of reduced cost and improved patient satisfaction, the application of ambulatory surgery (AS) has developed rapidly. However, AS was still rarely adopted in neurosurgery. Here we designed an AS treatment protocol for pituitary adenoma with the endoscopic endonasal approach (EEA), and reported our initial experiences regarding the safety and efficacy of the AS protocol. 63 patients who presented with pituitary adenoma were screened at the Department of Neurosurgery, Tangdu Hospital from July to September, 2017. A total of 20 pituitary adenoma patients who met the inclusion criteria underwent EEA surgery using this evidence-based AS protocol, which emphasized adequate assessment for eligibility, full preparation to minimize invasiveness, enhanced recovery, and active perioperative patient education. Of the 20 patients enrolled, 18 were discharged on the afternoon of the operation day with a median total length of stay (LOS) of 31 hours (range, 29-32) hours. The median LOS after surgery was 6.5 (range, 5-8) hours. Two patients were transferred from the AS protocol to conventional care due to intraoperative cerebrospinal fluid leakage (one case) and an unsatisfying post-anesthetic discharge score (one case). Complications included transient and reversible mild postoperative nausea and vomiting [visual analog scale (VAS) score <3], headache (VAS score <3) after the operation or early after discharge. No patient was readmitted. Our results supported the safety and efficacy of the AS protocol for pituitary adenoma patients undergoing EEA resection among eligible patients, and further evaluation of this protocol in controlled studies with a larger sample size is warranted.

Endoscopic Endonasal Transclival Approach to Spontaneous Hypertensive Brainstem Hemorrhage.

Surgical management of spontaneous hypertensive brainstem hemorrhage remains a challenge for neurosurgeons, especially when the hemorrhage is located the ventral brainstem. Recently endoscopic endonasal approach has been applied for resection of ventral brainstem lesions, though no published literature has explored its utility in treating brainstem hemorrhage. Here we reported a successful evacuation of severe hypertensive brainstem hemorrhage through endoscopic endonasal transclival approach. A 37 years-old male with a 5-year history of uncontrolled hypertension was brought to the Emergency Department with sudden vomiting, limb convulsions, and loss of consciousness for 2 hours. Computed tomography demonstrated a hemorrhage measuring 2.5 × 2.2 cm in the ventral midbrain and pontine. He presented with a Glasgow coma scale (GCS) score of 3 and disrupted vitals, and was intubated in the Emergency Department. Considering the ventral location of the hemorrhage and the need for emergent surgical decompression, an endoscopic endonasal approach was applied. Evacuation of the brainstem hemorrhage was achieved and his spontaneous respiration improved immediately after surgery. He was weaned off the ventilator and extubated on postoperative day 1, along with an improved GCS score of 5 (E2V1M2). At 1 month postoperatively his GCS score improved to 11 (E4V2M5) and he is currently under rehabilitation. Endoscopic endonasal approach is a feasible alternative for emergent surgery of ventrally located brainstem hemorrhage in carefully selected cases by providing direct visualization of the area and a good working angle, which facilitate evacuation of the hemorrhage with minimal damage to the brainstem.

Successful implementation of an enhanced recovery after surgery (ERAS) protocol reduces nausea and vomiting after infratentorial craniotomy for tumour resection: a randomized controlled trial.

BACKGROUND: Infratentorial craniotomy patients have a high incidence of postoperative nausea and vomiting (PONV). Enhanced Recovery After Surgery (ERAS) protocols have been shown in multiple surgical disciplines to improve outcomes, including reduced PONV. However, very few studies have described the application of ERAS to infratentorial craniotomy. The aim of this study was to examine whether our ERAS protocol for infratentorial craniotomy could improve PONV. METHODS: We implemented an evidence-based, multimodal ERAS protocol for patients undergoing infratentorial craniotomy. A total of 105 patients who underwent infratentorial craniotomy were randomized into either the ERAS group (n = 50) or the control group (n = 55). Primary outcomes were the incidence of vomiting, nausea score, and use of rescue antiemetic during the first 72 h after surgery. Secondary outcomes included postoperative anxiety level, sleep quality, and complications. RESULTS: Over the entire 72 h post-craniotomy observation period, the cumulative incidence of vomiting was significantly lower in the ERAS group than in the control group. Meanwhile, the incidence of vomiting was significantly lower in the ERAS group on postoperative days (PODs) 2 and 3. Notably, the proportion of patients with mild nausea (VAS 0-4) was higher in the ERAS group as compared to the control group on PODs 2 or 3. Additionally, the postoperative anxiety level and quality of sleep were significantly better in the ERAS group. CONCLUSION: Successful implementation of our ERAS protocol in infratentorial craniotomy patients could attenuate postoperative anxiety, improve sleep quality, and reduce the incidence of PONV, without increasing the rate of postoperative complications. TRIAL REGISTRATION: ChiCTR-INR-16009662, 27 Oct 2016, Clinical study on the development and efficacy evaluation of Enhanced Recovery After Surgery (ERAS) in Neurosurgery.

Effect of Intraoperative Lumbar Drainage on Gross Total Resection and Cerebrospinal Fluid Leak Rates in Endoscopic Transsphenoidal Surgery of Pituitary Macroadenomas.

OBJECTIVE: We sought to assess whether controlled, intraoperative lumbar drainage (LD) of cerebrospinal fluid (CSF) could facilitate resection of pituitary macroadenomas and reduce the rate of CSF leak. METHODS: A retrospective cohort study from a prospective database was conducted on 189 patients with pituitary macroadenoma who received endoscopic transsphenoidal surgery between 2013 and 2017. Patients were classified into 2 groups: 119 patients received an intraoperative LD (LD group) and 70 patients underwent routine endoscopic surgery without LD (control group). In the LD group, lumbar catheters were placed preoperatively and CSF was drained intermittently during tumor resection. The rates of gross total resection (GTR) and CSF leaks were assessed both intraoperatively and postoperatively. RESULTS: Intraoperative LD was associated with a higher rate of GTR (92.4% in the LD group vs. 78.6% in the control group, P = 0.006), especially in macroadenomas with suprasellar extension (90.3% vs. 75.0%, P = 0.012). Both intraoperative and postoperative CSF leak rates were significantly decreased in the LD group (intraoperative: 10.1% vs. 31.4%, P < 0.001; postoperative: 3.4% vs. 11.4%, P = 0.035). In functioning adenomas, a better remission rate of excess-hormone secretion was observed in the LD group compared with the controls (89.1% vs. 60.6%, P = 0.001). Patients in the LD group also had an enhanced recovery with a shorter postoperative length of stay (7 days vs. 5 days, P = 0.020). CONCLUSIONS: Intraoperative LD may assist surgeons during endoscopic transsphenoidal resection of pituitary macroadenomas by achieving a higher rate of GTR and a lower rate of perioperative CSF leaks. Validation in prospective randomized controlled studies is needed.

Neurosurgical enhanced recovery after surgery (ERAS) programme for elective craniotomies: are patients satisfied with their experiences? A quantitative and qualitative analysis.

OBJECTIVE: To evaluate patient satisfaction and associated predictors at discharge, as well as patient experience at 30-day follow-up, in a neurosurgical enhanced recovery after surgery (ERAS) programme. DESIGN: A single-centre, prospective, randomised controlled study. SETTING: A tertiary hospital in China. PARTICIPANTS: A total of 140 neurosurgical patients aged 18-65 years old who had a single intracranial lesion and were admitted for elective craniotomy between October 2016 and July 2017 were included. INTERVENTIONS: Patients were randomised into two groups: 70 patients received care according to a novel neurosurgical ERAS protocol (ERAS group) and 70 patients received conventional perioperative care (control group). OUTCOME MEASURES: Patient satisfaction at discharge was evaluated using a multimodal questionnaire. A secondary analysis of patient experience regarding participation in the ERAS programme was conducted using a semistructured qualitative interview via telephone at 30-day follow-up. RESULTS: The mean patient satisfaction was significantly higher in the ERAS group than in the control group at discharge (92.2±4.3 vs 86.8±7.4, p=0.0001). The most important predictors of patient satisfaction included age (OR=6.934), postoperative nausea and vomiting (PONV) Visual Analogue Scale (VAS) score (OR=0.184), absorbable skin suture (OR=0.007) and postoperative length of stay (LOS) (OR=0.765). Analysis on patient experience revealed five themes: information transfer, professional support, shared responsibility and active participation, readiness for discharge, and follow-up, all of which are closely related and represent positive and negative aspects. CONCLUSIONS: Measures that include decreasing PONV VAS score, incorporating absorbable skin suture and shortening LOS seem to increase patient satisfaction in a neurosurgical ERAS programme. Analysis of data on patient experience highlights several aspects to achieve patient-centred and high-quality care. Further studies are warranted to standardise the assessment of patient satisfaction and experience in planning, employing and appraising the ERAS programme. TRIAL REGISTRATION NUMBER: ChiCTR-INR-16009662.

A randomized controlled study of preoperative oral carbohydrate loading versus fasting in patients undergoing elective craniotomy.

OBJECT: The aim of this study was to evaluate the effect of preoperative oral carbohydrate loading versus fasting on the outcomes of patients undergoing elective craniotomy. METHODS: In a single-center randomized controlled study, 120 neurosurgical patients who were admitted for elective craniotomy were included and randomized into 2 groups: 58 patients received 400 mL of oral carbohydrate loading 2 h before surgery (intervention group), and 62 patients were fasting for 8 h prior to surgery as routine management (control group). The primary end point was glucose homeostasis. Secondary outcomes included handgrip strength, pulmonary function and postoperative complications. RESULTS: Better glucose homeostasis (5.6 ± 1.0 mmol/L vs. 6.3 ± 1.2 mmol/L, P = 0.001) was achieved in patients who received preoperative oral carbohydrate loading compared to fasting. Furthermore, patients in the intervention group had better handgrip strength (25.3 ± 7.1 kg vs. 19.9 ± 7.5 kg, P < 0.0001) and pulmonary function (in terms of peak expiratory flow rate) (315.8 ± 91.5 L/min vs. 270.0 ± 102.7 L/min, P = 0.036) compared to the controls postoperatively. The rates of postoperative surgical and non-surgical complications did not differ between the groups. Both postoperative and total hospital length of stay (LOS) reduced significantly in the intervention group (-3d, P < 0.0001 and P = 0.004). CONCLUSIONS: Oral carbohydrate loading given 2 h before surgery in patients undergoing elective craniotomy seems to improve glucose homeostasis, handgrip strength and pulmonary function as well as decrease LOS without increasing the risk of postoperative complications. Routine use of preoperative oral carbohydrate loading could be suggested in clinical settings, though further evaluation of its safety and efficacy is warranted.

Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial.

OBJECTIVEAlthough enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.METHODSA multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.RESULTSThe median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1-3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51-15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1-2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29-1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56-6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).CONCLUSIONSThis multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn).

Endoscopic Endonasal Approach to Mesencephalic Cavernous Malformations.

BACKGROUND: Symptomatic cavernous malformations involving the brainstem are difficult to access by conventional approaches, which often require dramatic brain retraction to gain adequate operative corridor. Here, we present a successful endoscopic endonasal transclival approach for resection of a hemorrhagic, symptomatic mesencephalic cavernous malformation. CASE DESCRIPTION: A 20-year-old woman presented with acute onset of headache, nausea, and vomiting. Computed tomography scan revealed a ventral midbrain hemorrhage. On day 3 of admission, the patient developed left-sided hemiparesis, restriction of medial and lateral left-eye movements, and loss of left pupillary light reflex. Subsequent magnetic resonance imaging demonstrated an increase of the midbrain lesion to 1.2 cm × 1.7 cm. Diffusion tensor imaging showed compression and lateral displacement of the right corticospinal tract near the thalamus and cerebral peduncle. Given the patient's clinical presentation and the findings on imaging, we suspected a mesencephalic cavernous malformation. CONCLUSIONS: The patient underwent an endoscopic endonasal transclival resection of a ventral midline mesencephalon cavernous malformation. A dark red lesion was directly visualized under the endoscope. After a small cortiectomy, the pial and perforator vessels were dissected, and dark-brown blood was drained from the cavernoma cavity. Using a biopsy forceps and with careful attention to the cavernoma borders, the lesion was removed and hemostasis was achieved. Pathologic examination confirmed cavernous malformation. One week after the operation, magnetic resonance imaging demonstrated total resection of the lesion. A 3-month follow-up revealed improved neurologic symptoms with minimal surgical morbidity.

Critical roles of chemokine receptor CCR5 in regulating glioblastoma proliferation and invasion.

Glioblastoma (GBM) is the most prevalent malignant primary brain tumor in adults and exhibits a spectrum of aberrantly aggressive phenotype. Tumor cell proliferation and invasion are critically regulated by chemokines and their receptors. Recent studies have shown that the chemokine CCL5 and its receptor CCR5 play important roles in tumor invasion and metastasis. Nonetheless, the roles of the CCR5 in GBM still remain unclear. The present study provides the evidence that the chemokine receptor CCR5 is highly expressed and associated with poor prognosis in human GBM. Mechanistically, CCL5-CCR5 mediates activation of Akt, and subsequently induces proliferation and invasive responses in U87 and U251 cells. Moreover, down-regulation of CCR5 significantly inhibited the growth of glioma in U87 tumor xenograft mouse model. Finally, high CCR5 expression in GBM is correlated with increased p-Akt expression in patient samples. Together, these findings suggest that the CCR5 is a critical molecular event associated with gliomagenesis.

Exogenous hydrogen sulfide exhibits anti-cancer effects though p38 MAPK signaling pathway in C6 glioma cells.

It has been documented that H2S, in some types of cancer, promotes tumor proliferation, whereas, in the other types, it inhibits the tumor cell growth. In the present study, we investigated the anti-cancer effects and relevant mechanisms of NaHS in C6 glioma cells. C6 cells were subjected to different concentrations of NaHS, then cell viability and morphological changes were examined by MTT assay and Hoechst staining. The protein expression of Caspase-3, Bcl-2, Bax, p38 MAPK (mitogen-activated protein kinase), and p53 was measured by Western blotting. This work demonstrated that NaHS could reduce cell number and induce apoptosis of C6 gliomas cells. The protein expression of Caspase-3 and Bax was up-regulated, while the protein expression of Bcl-2 was down-regulated. Additionally, p38 MAPK and p53 were activated in response to NaHS. Moreover, p38 MAPK inhibitor, SB203580, counteracted the inhibitory effect of NaHS on C6 glioma cells. These data suggest that NaHS can effectively reduce cell number of C6 cells by triggering the apoptosis via Caspase-dependent pathway. p38 MAPK and p53 play an important role in NaHS-induced apoptosis in C6 cells. These findings imply that administration of NaHS may represent a new strategy for the treatment of glioma.

[Inhibition of glucoraphenin enzymolysis in Raphani Semen by processing].

OBJECTIVE: To explore material basis of the pharmacological differences between the roasting and pro-roasting Raphani Semen. METHOD: The two new sulfur-containing compounds (A209 and B221) were found changed after processing in the water decoction. The common precursor-C3 of A209 and B211 and the precursor of C3 were seperated and purified. Their transforming relationship was proved. RESULT: The result showed that glucosinolates could decompose into sulforaphane and transform into A209 and B221 further in the boiling process. CONCLUSION: This study provides some experimental evidences for revealing the mechanism of Raphani Semen processing.

Two novel sulfur compounds from the seeds of Raphanus sativus L.

The seeds of Raphanus sativus L., known as Lai-fu-zi in traditional Chinese Medicine, are always roasted before clinical use for avoiding nausea. During an investigation of the chemical difference between roasted and pre-roasted products, two novel sulfur-containing compounds, which mainly existed in the pre-roasted products, were isolated. Their structures and absolute configurations were established by spectroscopic and X-ray diffraction analysis.