Risk Factors Analyses for Seizure Recurrence in Different Periods After Refractory Epilepsy Surgery: A Prospective Single-Center Study.

OBJECTIVE: To evaluate the potential risk factors associated with seizure recurrence in different periods after epilepsy surgery. METHODS: A total of 303 patients with refractory epilepsy after epilepsy surgery were included. The Kaplan-Meier method with log-rank test and univariate and multivariate Cox proportional hazards model were performed to calculate the comparison of survival curves between groups and identify the risk factors associated with seizure recurrence in different periods after surgery. RESULTS: The significant predictors of seizure recurrence were determined, including duration of epilepsy (P = 0.018), seizure types (P = 0.009), magnetic resonance imaging findings (P = 0.007), intracranial electroencephalographic recordings (P = 0.002), sides of epileptogenic zone (P = 0.025), and types of surgery (P = 0.002). Moreover, the significant predictors of seizure recurrence within 12 months after surgery were also included, such as gender (P = 0.007), duration of epilepsy (P = 0.013), intracranial electroencephalographic recordings (P = 0.003), and types of surgery (P < 0.001). Our results indicated that the variables of magnetic resonance imaging findings (P = 0.015), sides of epileptogenic zone (P = 0.004), and seizure relapse within 12 months after surgery (P < 0.001) were significantly associated with seizure recurrence in 12-36 months after surgery. Seizure relapse within 12 months after surgery (P < 0.001) was also associated with seizure recurrence >36 months after surgery. CONCLUSIONS: We reconfirmed the well-known risk factors associated with seizure recurrence and also identified the controversial variables. In addition, we found that the risk factors associated with seizure recurrence were different in different periods after epilepsy surgery.

Quantitative Study of Posterior Fossa Crowdedness in Hemifacial Spasm.

OBJECTIVE: To quantitatively study the degree of posterior fossa crowdedness (PFC) in patients with hemifacial spasm (HFS) and to further investigate whether overcrowding in posterior fossa affects the efficacy and safety of microvascular decompression. METHODS: We conducted a prospective case-control study of patients diagnosed with HFS and sex- and age-matched healthy control patients. All subjects underwent high-resolution, 3-dimensional magnetic resonance imaging, and posterior fossa crowdedness index (PFCI) and cerebrospinal fluid volume (CSFV) were measured. Patients with HFS underwent primary microvascular decompression and long-term follow-up. Associations of PFCI and other factors with operative outcomes and complications were analyzed. RESULTS: The study enrolled 153 subjects: 102 patients and 51 control subjects. Compared with control subjects, patients had a more PFC (PFCI: 83.2% vs. 80.2%; P = 0.005) and smaller posterior fossa CSFV (16,248.0 mm(3) vs. 20,054.0 mm(3); P = 0.001). The mean effective space of posterior fossa cerebrospinal fluid in patients with HFS was 11.8% smaller than in control subjects (P = 0.004). Compared with men, women showed larger PFCI (83.6% vs. 82.2%; P = 0.012) and smaller PF CSFV (16,027.5 mm(3) vs. 17,299.5 mm(3); P = 0.009). Sixty-one patients (59.8%) were spasm-free immediately postoperatively, and 95 (93.1%) were spasm-free at follow-up. Complication rates were 9.8% in the short term, and 2.9% at follow-up. Lower PFCI (odds ratio [OR] 0.63; P = 0.019) and severe indention (OR 1.41; P = 0.027) were significantly associated with better short-term outcomes. Greater PFCI (OR 2.05, P = 0.008) was associated with greater early complication incidence. CONCLUSION: Patients with HFS had more PFC. PFC potentially leads to cranial nerve and vascular structure crowding, which may increase HFS risk. PFC was significantly associated with poor short-term outcomes and greater incidence of early complications but not long-term outcomes and complications.

Endovascular coiling vs. surgical clipping for unruptured intracranial aneurysm: A meta-analysis.

BACKGROUND: With increasing use of high-resolution imaging of brain, unruptured aneurysms are more and more frequently detected. With the advances in treatment techniques, an increasing number of aneurysms are now occluded using endovascular coiling instead of conventional surgical clipping. However, the better modality for unruptured intracranial aneurysm has been poorly understood. OBJECTIVE: The objective of this meta-analysis was to compare the outcomes between endovascular coiling and surgical clipping among patients with unruptured intracranial aneurysms. METHODS: PubMed, Embase, Web of Science, CENTRAL, and SIGLE were electronically searched from January 1, 1990 to March 13, 2012 with no language restriction for randomized or nonrandomized clinical controlled trials. Article screening and data extraction were conducted in duplicate. Results were statistically pooled through Review Manager 5 and StatsDirect 2.7.9. RESULTS: Seven studies met our inclusion criteria. The pooled risk ratios (coiling vs. clipping) were 0.59 (95% CI = 0.23-1.54) for death; 0.37 (95% CI = 0.10-1.41) for bleeding; 0.78 (95% CI = 0.38-1.58) for cerebral ischemia; 0.87 (95% CI = 0.70-1.08) for occlusion of aneurysm; 0.53 (95% CI = 0.18-1.52) for independence in daily activities. The pooled rates of death, bleeding, ischemia, occlusion of aneurysm, and mRS no less than 3 were 1% (95% CI = 0-2%), 2% (95% CI = 0-5%), 8% (95% CI = 4-13%), 82% (95% CI = 64-95%), and 5% (95% CI = 1-10%) for endovascular coiling, respectively, and 1% (95% CI = 0-2%), 6% (95% CI = 3-10%), 9% (95% CI = 5-15%), 95% (95% CI = 90-98%), and 8% (95% CI = 3-14%) for surgical clipping, respectively. We failed to evaluate quality of life and cognitive outcome due to insufficient data. Both meta-regression and sensitivity analysis showed consistent results. Furthermore, Begg's test and Egger's test failed to detect publication bias. CONCLUSION: We suggest that endovascular coiling and surgical clipping bear similar risk ratios of death, bleeding, cerebral ischemia, occlusion of aneurysm, and independence in daily activities and encourage further studies on quality of life and cognitive outcome. However, albeit the results in this meta-analysis are robust, due to great clinical heterogeneity and low quality of studies, the results in this meta-analysis should be interpreted with caution.

Association of polymorphisms in the elastin gene with sporadic ruptured intracranial aneurysms and unruptured intracranial aneurysms in Chinese patients.

It has been suggested that the elastin gene is a candidate gene for the development of intracranial aneurysms (IAs). We investigated the association of single-nucleotide polymorphisms (SNPs) in the elastin gene in sporadic subarachnoid hemorrhage and in patients with unruptured aneurysms in China. We genotyped 446 (47.9%) IA patients (308 ruptured and 138 unruptured) and 485 (52.1%) control subjects for seven exonic and intronic SNPs in the elastin gene and then evaluated their allelic associations with sporadic ruptured and unruptured IAs. We found that IA is associated with two SNPs in the elastin gene: rs2071307 (odds ratio 2.87; 95% confidence interval, 2.26-3.64; p < 0.001) and rs2856728 (odds ratio 2.12; 95% confidence interval, 1.71-2.62; p < 0.001). Furthermore, the minor allele of rs2071307 (allele A) was also associated with IA rupture; 31.3% of patients with ruptured IAs were carriers of the minor allele, whereas only 23.2% of patients with unruptured IAs carried the minor allele (odds ratio 1.51; 95% confidence interval, 1.09-2.10; p = 0.013). In conclusion, our study indicates that the elastin gene may be associated with the formation of IAs, and importantly, that it may also be associated with the rupture of IAs.

The long-term outcome predictors of pure microvascular decompression for primary trigeminal neuralgia.

OBJECTIVE: The aim of this study is to provide credible and comparable evidence on the efficacy and safety of pure microvascular decompression (MVD) for primary trigeminal neuralgia (TN), and also to find out the possible prognostic factors of excellent long-term outcome after the surgery. METHODS: A prospective cohort study was conducted, involving the patients who met the diagnostic criteria of primary TN (both typical and atypical). The cohort patients underwent pure MVD, and then were followed up by independent neurologists. The possible prognostic factors were analyzed by the logistic method. RESULTS: All 154 consecutive primary TN patients (98 typical, 56 atypical) underwent pure MVD from January 2001 to November 2005. The patients were followed up for median 5.6 years (10 lost in 5 years). Respective initial and 5-year's complete pain-free without medication (Barrow Neurological Institute pain score, I) rates were 84% and 72% for total primary TN, 87% and 80% for typical TN, and 79% and 54% for atypical TN. The Kaplan-Meier survival curves of 5 years demonstrated different long-term outcomes in different groups (typical TN vs. atypical TN). The typical symptoms (odds ratio [OR], 2.776), preoperative magnetic resonance indicating vessel compression (OR, 2.950), and obvious vessel compression found during operation (OR, 3.219) were proved to have a positive effect on long-term pain relief without medication. CONCLUSIONS: This is a perspective cohort study of pure MVD, which confirms the long-term effectiveness and safety of the surgery for primary TN. Patients with typical symptoms, positive magnetic resonance findings, or obvious vessel compressions might have better long-term prognosis.

Clinical outcomes of 114 patients who underwent γ-knife radiosurgery for medically refractory idiopathic trigeminal neuralgia.

The optimal radiation dose and target of Gamma-knife radiosurgery (GKRS) for medically refractory idiopathic trigeminal neuralgia (TN) are contentious. We investigated the effects and trigeminal nerve deficits of GKRS using two isocenters to treat a great length of the trigeminal nerve. Between January 2005 and March 2010, 129 patients with idiopathic TN underwent GKRS at the West China Hospital of Sichuan University. A maximum central dose of 80-90 Gy was delivered to the trigeminal nerve root with two isocenters via a 4mm collimator helmet. One hundred and fourteen patients were followed-up periodically by telephone interview to determine the effects, trigeminal nerve deficits and time to the onset of pain relief. The mean follow-up duration was 29.6 months. One hundred and nine patients had complete or partial pain relief and the treatment failed in five patients. Nine patients experienced a recurrence after a mean time of 12.7 months, following an initial interval of pain relief. There were no significant differences between patients with different grades of pain relief with respect to central doses. The mean time to the onset of pain relief was 3.6 weeks. The time to the onset of complete pain relief was significantly shorter than that for partial pain relief. Forty-nine patients reported mild-to-moderate facial numbness and one patient experienced paroxysmal temporalis muscle spasms two weeks after the treatment. GKRS treatment for medically refractory idiopathic TN with two isocenters resulted in an initial pain improvement in 95.6% of patients. The early response to the treatment might suggest a good outcome but, given the high incidence of nerve deficits, GKRS for TN with two isocenters is not recommended as a routine treatment protocol.

Pilot study on a fast postoperative programming approach to subthalamic nucleus stimulation in Parkinson's disease.

OBJECTIVES: T0 o evaluate the advantages and disadvantages of a fast post-operative screening method using deep brain stimulation (DBS) of the subthalamic nucleus (STN) in patients with Parkinson's disease. MATERIALS AND METHODS: Twenty-four patients implanted with electrodes for STN-DBS were divided into two groups : Group I received traditional programming and Group II was treated with the fast method. The time required for programming in each group and the treatment effects were analyzed. RESULTS: Significant postoperative improvement of the Unified Parkinson's Disease Rating Scale III was achieved in the "off medication" and "on stimulation" condition in both the groups (Group I: 51.2% vs. Group II: 54.0%, P<0.05). The average time needed for programming, however, was significantly shorter in Group II as compared to Group I (P<0.05). CONCLUSIONS: T0 he new fast method can significantly reduce the time required to find a preliminary effective STN-DBS protocol in the early postoperative phase without sacrificing clinical efficacy.

CSF fistula through the left lumbar region in adult following a ventriculoperitoneal shunt surgery: a rare case report.

A cranial spinal fluid fistula through left lumbar region following a ventriculoperitoneal (VP) shunt is an extremely rare complication. We report a 25-year-old man who presented with the leakage of clear fluid from the left lumbar region, 3 years after a VP shunt surgery. Computerized tomography scan of abdomen revealed that the distal end of the catheter penetrated into the inner layer of the wall of left lumbar region. He was managed successfully with abdominal part of shunt catheter removal from primary cervical and abdominal incision, a new abdominal part of VP shunt catheter replacement and prophylactic antibiotic.

Ruptured intracranial dermoid cyst with infarction in the basal ganglia--case report.

A 32-year-old, right-handed man presented with chronic headache persisting for the past 5 years. On admission, neurological examination revealed mild papilledema and bitemporal defects of the visual fields. Computed tomography showed a hypodense lesion in the suprasellar region. Magnetic resonance imaging revealed a 2.2 x 2.4 x 2.5-cm heterogeneously hyperintense lesion in the suprasellar region and an infarct region in the right basal ganglia on the T(1)- and T(2)-weighted images. The lesion was subtotally removed because part of the capsule was tightly adherent to important surrounding neurovascular structures. Histological analysis confirmed the diagnosis of dermoid cyst. Ruptured intracranial dermoid cyst may manifest as infarction in the basal ganglia caused by localized arterial inflammatory reaction combined with compression of the right internal carotid artery.

Giant cranionasal schwannoma.

Giant schwannomas concomitantly involving the intracranial and nasal cavities are rare. We report a 22-year-old male patient with a giant schwannoma involving the frontal skull base and extending into the nasal cavity. The patient had a 2-year history of nasal obstruction that was originally misdiagnosed as nasal polyps. A CT scan and an MRI revealed a large cranionasal tumor. Surgery was performed using a coronal incision with a bilateral frontal skull base extradural approach. The tumor originated from the anterior skull base and the dura and nasal mucosa were intact. Histopathology was consistent with a schwannoma. Schwannoma should be listed as part of the differential diagnosis of a cranionasal tumor and the surgical approach should be carefully selected to achieve total resection.

Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery.

Primitive trigeminal artery (PTA) and primitive otic artery (POA) is a very rare entity in adult life. We present a case of PTA and POA associated with a giant unruptured cavernous aneurysm in a 54-year-old woman. The PTA and the POA arose from the sac of the aneurysm directly, which greatly complicated endovascular therapy management.

Two anatomic variations of the vertebral artery in four patients.

In this article, we present four cases of rare anomalous aortic arch and vertebral arteries and discuss the possible embryologic etiologies. These include two cases in which the right vertebral artery originated from the right common carotid artery associated with an aberrant right subclavian artery originating from the middle of the aortic arch and two cases in which the left vertebral artery had a double origin from the left subclavian artery and aortic arch.

A delayed frontorbital abscess caused by a penetrating nonmissile foreign body (a bamboo stick).

We report an interesting case of delayed frontal abscess caused by a penetrating nonmissile foreign body, a bamboo stick in a 1.5-year-old male child. A parietal craniotomy was performed, and the brain abscess was resected along with the foreign body without any damage to the surrounding brain tissue. He also received the appropriate antibiotics. The child made a good recovery.

An Echinococcosis multilocularis presenting as a giant anterior cranial basilar tumor.

Cerebral alveolar hydatid disease is a rare subtype of Echinococcus, and prevalent in northern China and Tibetan area. In this report, we presented a giant lesion of Echinococcus multilocularis which located in anterior cranial fossa, and discussed its clinicopathological and radiological features, and strategy of treatment.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms.

OBJECT: Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. METHODS: Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. RESULTS: Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. CONCLUSIONS: Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

[Microsurgery for intracranial aneurysm:analysis of 438 cases].

OBJECTIVE: To summarize the experience of surgical therapy in a series of 438 patients with intracranial aneurysms. METHODS: A retrospective analysis was made on the clinical data of 438 patients, in terms of the perioperative management, timing of surgery, surgical skills, and The HUNT-HESS grade. RESULTS: 438 patients with 476 aneurysms underwent microsurgery, in which 450 aneurysms were clipped, 14 were wrapped, 8 were isolated,4 were cut. 32 aneurysms were ruptured (6.72%) during the operation. The relation between Hunt-Hess scale and mortality is significant postpone operation (> or =7 d) has got a better curative effect than the early. CONCLUSIONS: Microsurgical treatment is a confirmed effective method with intracranial aneurysms. The higher of HUNT-HESS grade will result to the worse clinical outcome.

The postoperative brain tumour stem cell (BTSC) niche and cancer recurrence.

Currently, surgical resection is one of only a few options for treating brain cancer. Unfortunately, postoperative tumour recurrence remains almost inevitable despite additional radiation or chemotherapy treatment following resection. Clinical observations and a growing body of experimental evidence have led to speculation that there is a population of persistent brain tumour stem cells (BTSCs)--or brain tumour initiating cells--that are difficult to completely remove surgically. Furthermore, residual BTSCs following surgery may actually be more resistant to subsequent radiation and/or chemotherapies. It remains to be determined if brain surgeries render the postoperative tissue microenvironment more favourable for the survival and growth of BTSCs, and therefore the recurrence of brain tumours.We hypothesise that BTSC-based tumour recurrence may develop within a specific niche of the aberrant tumour microenvironment. Even when the gross appearance of the primary tumour seems confined, BTSCs (albeit accounting only for a small population of tumour cells) may microscopically enter the stroma, hampering curative surgeries. This article discusses the theory that surgical resection of brain tumours generates niches recruiting BTSCs to the surgical wounds, stimulating the proliferation and invasiveness of BTSCs, and leading to tumour recurrence. Postoperative brains are marked with active wound repair in peritumoural margins, which is likely to be accompanied by increased inflammatory paracrine production, angiogenesis and reactive astrogliosis. The postoperative BTSC niche concept is consistent with the observation that brain tumour recurrence usually occurs in tissues that are proximal to the resection margin. In this article, we intend to reflect recent advances that may lead to novel strategies to eliminate postoperative brain tumour recurrence.

Intraventricular vascular malformations mimicking tumors: case reports and review of the literature.

Vascular malformations of the ventricular system are rare, and their clinical and radiologic characteristics vary depending on the location of the lesions. Many types are described, but a comprehensive summary is lacking. Herein, we add two cases to the literature and review known types of ventricular vascular malformations. One case involved a 37-year-old woman who presented with headache due to hydrocephalus. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a lesion of the foramen of Monro. The other case involved a 7-year-old boy who had dizziness and headache due to hydrocephalus. CT and MRI demonstrated a lesion of the third ventricle. In both cases, the images mimicked those of tumors with or without bleeding. As a result, the malformations were misdiagnosed, though surgical treatment was successful. In both cases, the lesions were proven to be arteriovenous malformations on pathologic evaluation. Correct diagnosis of ventricular vascular malformations is sometimes difficult but essential for good treatment planning. Their incidence is low. However, their bleeding and rebleeding rate is high, and they commonly cause hydrocephalus. Treatment should be timely and based on the type of lesion and its presentation.