NR5A2 connects zygotic genome activation to the first lineage segregation in totipotent embryos.

Zygotic genome activation (ZGA) marks the beginning of the embryonic program for a totipotent embryo, which gives rise to the inner cell mass (ICM) where pluripotent epiblast arises, and extraembryonic trophectoderm. However, how ZGA is connected to the first lineage segregation in mammalian embryos remains elusive. Here, we investigated the role of nuclear receptor (NR) transcription factors (TFs), whose motifs are highly enriched and accessible from the 2-cell (2C) to 8-cell (8C) stages in mouse embryos. We found that NR5A2, an NR TF strongly induced upon ZGA, was required for this connection. Upon Nr5a2 knockdown or knockout, embryos developed beyond 2C normally with the zygotic genome largely activated. However, 4-8C-specific gene activation was substantially impaired and Nr5a2-deficient embryos subsequently arrested at the morula stage. Genome-wide chromatin binding analysis showed that NR5A2-bound cis-regulatory elements in both 2C and 8C embryos are strongly enriched for B1 elements where its binding motif is embedded. NR5A2 was not required for the global opening of its binding sites in 2C embryos but was essential to the opening of its 8C-specific binding sites. These 8C-specific, but not 2C-specific, binding sites are enriched near genes involved in blastocyst and stem cell regulation, and are often bound by master pluripotency TFs in blastocysts and embryonic stem cells (ESCs). Importantly, NR5A2 regulated key pluripotency genes Nanog and Pou5f1/Oct4, and primitive endoderm regulatory genes including Gata6 among many early ICM genes, as well as key trophectoderm regulatory genes including Tead4 and Gata3 at the 8C stage. By contrast, master pluripotency TFs NANOG, SOX2, and OCT4 targeted both early and late ICM genes in mouse ESCs. Taken together, these data identify NR5A2 as a key regulator in totipotent embryos that bridges ZGA to the first lineage segregation during mouse early development.

Maturation of Nephrons by Implanting hPSC-derived Kidney Progenitors Under Kidney Capsules of Unilaterally Nephrectomized Mice.

BACKGROUND: Human pluripotent stem cell (hPSC)-derived kidney organoids may contribute to disease modeling and the generation of kidney replacement tissues. However, the realization of such applications requires the induction of hPSCs into functional mature organoids. One of the key questions for this process is whether a specific vascular system exists for nephrogenesis. Our previous study showed that short-term (2 weeks) implantation of hPSC-derived organoids below the kidney capsules of unilaterally nephrectomized and immunodeficient mice resulted in the enlargement of organoids and production of vascular cells, although signs of maturation were lacking. METHODS: Organoids were induced for 15 days in vitro and then grafted below kidney capsules of the same unilaterally nephrectomized immunodeficient mouse model to examine whether medium-term (4 weeks) implantation could improve organoid maturation and vascularization, as evaluated by immunofluorescence and transmission electron microscopy. RESULTS: We demonstrated that after 2-4 weeks of implantation, renal organoids formed host-derived vascularization and matured without any exogenous vascular endothelial growth factor. Glomerular filtration barrier maturation was evidenced by glomerular basement membrane deposition, perforated glomerular endothelial cell development, and apical, basal podocyte polarization. A polarized monolayer epithelium and extensive brush border were also observed for tubular epithelial cells. CONCLUSIONS: Our results indicate that the in vivo microenvironment is important for the maturation of human kidney organoids. Stromal expansion and a reduction of nephron structures were observed following longer-term (12 weeks) implantation, suggesting effects on off-target cells during the induction process. Accordingly, induction efficiency and transplantation models should be improved in the future.

Epidemiological characteristics of a 2019-nCoV outbreak caused by Omicron variant BF.7 in Shenzhen / 中华流行病学杂志

Objective: To explore the epidemiological characteristic of a COVID-19 outbreak caused by 2019-nCoV Omicron variant BF.7 and other provinces imported in Shenzhen and analyze transmission chains and characteristics. Methods: Field epidemiological survey was conducted to identify the transmission chain, analyze the generation relationship among the cases. The 2019-nCoV nucleic acid positive samples were used for gene sequencing. Results: From 8 to 23 October, 2022, a total of 196 cases of COVID-19 were reported in Shenzhen, all the cases had epidemiological links. In the cases, 100 were men and 96 were women, with a median of age, M (Q1, Q3) was 33(25, 46) years. The outbreak was caused by traverlers initial cases infected with 2019-nCoV who returned to Shenzhen after traveling outside of Guangdong Province.There were four transmission chains, including the transmission in place of residence and neighbourhood, affecting 8 persons, transmission in social activity in the evening on 7 October, affecting 65 persons, transmission in work place on 8 October, affecting 48 persons, and transmission in a building near the work place, affecting 74 persons. The median of the incubation period of the infection, M (Q1, Q3) was 1.44 (1.11, 2.17) days. The incubation period of indoor exposure less than that of the outdoor exposure, M (Q1, Q3) was 1.38 (1.06, 1.84) and 1.95 (1.22, 2.99) days, respcetively (Wald χ2=10.27, P=0.001). With the increase of case generation, the number and probability of gene mutation increased. In the same transmission chain, the proportion of having 1-3 mutation sites was high in the cases in the first generation. Conclusions: The transmission chains were clear in this epidemic. The incubation period of Omicron variant BF.7 infection was shorter, the transmission speed was faster, and the gene mutation rate was higher. It is necessary to conduct prompt response and strict disease control when epidemic occurs.

A comparative study of artificial intelligence nasal polyp classification based on whole-slide imaging and JESREC diagnostic criteria / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the types and clinical characteristics of chronic rhinosinusitis with nasal polyps (CRSwNP) based on artificial intelligence and whole-slide imaging (WSI), and to explore the consistency of the diagnostic criteria of the Japanese epidemiological survey of refractory eosinophilic chronic rhinosinusitis (JESREC) in Chinese CRSwNP patients. Methods: The data of 136 patients with CRSwNP (101 males and 35 females, aging 14 to 70 years) who underwent endoscopic sinus surgery from 2018 to 2019 in the Department of Otorhinolaryngology Head and Neck Surgery, the Third Affiliated Hospital of Sun Yat-sen University were analysed retrospectively. The preoperative clinical characteristics of patients were collected, such as visual analogue scale (VAS) of nasal symptoms, peripheral blood inflammatory cell count, total immunoglobulin E (IgE), Lund-Kennedy score and Lund-Mackay score. The proportion of inflammatory cells such as eosinophils, lymphocytes, plasma cells and neutrophils were calculated on the WSI of each patient through artificial intelligence chronic rhinosinusitis evaluation platform 2.0 (AICEP 2.0), and the specific type of nasal polyps was then obtained as eosinophilic CRSwNP (eCRSwNP) or non-eosinophilic CRSwNP (non-eCRSwNP). In addition, the JESREC diagnostic criteria was used to classify the nasal polyps, and the classification results were compared with the current gold standard for nasal polyps diagnosis (pathological diagnosis based on WSI). The accuracy, sensitivity and specificity of the diagnostic criteria of JESREC were evaluated. The data were expressed in M (Q1, Q3) and statistically analyzed by SPSS 17.0. Results: There was no significant difference between eCRSwNP and non-eCRSwNP in age distribution, gender, time of onset, total VAS score, Lund-Kennedy score or Lund-Mackay score. However, there was a significant difference in the ratio of nasal polyp inflammatory cells (eosinophils 40.5% (22.8%, 54.7%) vs 2.5% (1.0%, 5.3%), neutrophils 0.3% (0.1%, 0.7%) vs 1.3% (0.5%, 3.6%), lymphocytes 49.9% (39.3%, 65.9%) vs 82.0% (72.8%, 87.5%), plasma cells 5.1% (3.6%, 10.5%) vs 13.0% (7.4%, 16.3%), χ2 value was 9.91, 4.66, 8.28, 5.06, respectively, all P<0.05). In addition, eCRSwNP had a significantly higher level of proportion of allergic symptoms (nasal itching and sneezing), asthma, peripheral blood eosinophil and total IgE (all P<0.05). The overall accuracy, sensitivity and specificity of the JESREC diagnostic criteria was 74.3%, 81.3% and 64.3%, respectively. Conclusions: The eCRSwNP based on artificial intelligence and WSI has significant high level of allergic symptoms, asthma, peripheral blood eosinophils and total IgE, and the percentages of inflammatory cells in nasal polyps are different from that of non-eCRSwNP. The JESREC diagnostic criteria has good consistency in our research.

Predictive Value of Blood Eosinophil in Eosinophilic Chronic Rhinosinusitis with Nasal Polyps in Guangdong Adults / 中山大学学报(医学科学版)

@#【Objective】To investigate the predictive value of blood eosinophil in eosinophilic chronic rhinosinusitis with nasal polyps（eosCRSwNP）by analyzing the characteristics of eosCRSwNP adult patients in Guangdong Province， China.【Method】From Oct.2017 to Sep.2018，a total of 108 eosCRSwNP adult inpatients scheduled for surgery in Department of Otorhinolaryngology，Head and Neck Surgery，The Third Affiliated Hospital，Sun Yat-sen University were enrolled. They were divided into eosCRSwNP（n = 39） and non-eosCRSwNP（n = 69） group by the pathologic features. The demographic and clinical features were collected and compared.【Results】The eosCRSwNP group accounted for 36.1% while non-eosCRSwNP group accounted for 63.9% in our study. A higher prevalence of allergic rhinitis，asthma and higher blood IgE level，bilateral Lund-Mackay score of posterior ethmoid sinus，ethmoid to maxillary Lund-Mackay score ratio， peripheral blood eosinophil absolute count and percentage and peripheral blood basophil absolute count and percentage were found in eosCRSwNP patients. Only peripheral blood eosinophil absolute count and percentage were independent predictors of eosCRSwNP. The cutoff absolute value of 0.275×109/L demonstrated a sensitivity of 74.4% and a specificity of 72.5% while the cutoff relative value of 4.32% demonstrated a sensitivity of 74.4% and a specificity of 73.9%.【Conclusion】Non-eosCRSwNP was predominant in Guangdong. EosCRSwNP differs from non-eosCRSwNP in many clinical features，while peripheral blood eosinophil count and percentage were independent predictors of eosCRSwNP.

Enhanced recovery after surgery protocols in functional endoscopic sinus surgery for patients with chronic rhinosinusitis with nasal polyps: a randomized clinical trial / 中华医学杂志(英文版)

BACKGROUND@#Enhanced recovery after surgery (ERAS) protocols are a series of perioperative care to optimize preoperative preparation, prevent postoperative complications, minimize stress, and speed up recovery. This study aimed to assess the impact of ERAS protocols for functional endoscopic sinus surgery (FESS) in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).@*METHODS@#One hundred and two patients with CRSwNP undergoing FESS were randomly divided into the ERAS group and the control group. The outcomes of the Self-Rating Anxiety Scale (SAS), Visual Analogue Scale (VAS), Medical Outcomes Study Sleep Scale (MOS-SS) and Kolcaba Comfort Scale Questionnaire (GCQ) were determined in both groups. The serum levels of C-reactive protein (CRP) were compared preoperatively and 24 hours postoperatively.@*RESULTS@#The ERAS group had a significantly better SAS scores than did the control group (28 [24, 35] vs. 43 [42, 47], Z = 5.968, P  0.05); However, the CRP level in 24 hours postoperatively was significantly lower in the ERAS group than that in the control group (2.5 [1.4, 3.9] vs. 6.6 [3.8, 9.0], Z = 5.027, P  0.05), hemorrhage, aspiration and tumble, were not increased in the ERAS group compared with those in the control group. The ERAS group had a significantly shorter length of hospital stay (5 [4, 5] days vs. 8 [8,9] days, Z = 8.939, P < 0.001) and hospitalization expenses ($ 2670 [2375, 2740] vs. $3129 [3116, 3456], Z = 8.514, P < 0.001).@*CONCLUSIONS@#ERAS protocols might optimize FESS for patients with CRSwNP by reducing psychological and physical stress, shortening the length of hospital stay and lowering hospitalization expenses without increasing postoperative complications.@*TRIAL REGISTRATION@#Chinese Clinical Trial Registry, No. ChiCTR1800015791; http://www.chictr.org.cn/showproj.aspx?proj=26872.

Application of Intermediate Mesoderm-like Cells in Kidney Regeneration / 中国医学科学院学报

Objective To induce adipose-derived stem cells (ADSCs) to differentiate into intermediate mesoderm (IM)-like cells ,with IM-like cells for recellularizing kidney scaffolds,and then to obtain a tissue-engineering kidney with renal structures and functions through co-culture.Methods After inguinal fat pads of Wistar rats were surgically harvested,the primary ADSCs were isolated,induced,and cultured for stem cell identification. ADSCs were inducted to differentiate into IM-like cells by adding glycogen synthase kinase-3 inhibitor (CHIR99021) and fibroblast growth factor 9 (FGF9) at different stages. Seven days later,the IM-like cells were identified. The induced IM-like cells and well-prepared kidney decellularized scaffolds were co-cultured for 10 days to obtain recellularized tissue-engineered kidneys and their differentiation was identified.Results The ADSCs harvested had osteogenic and adipogenic abilities and could express the stem cell surface markers. After 7 days of induction,the positive expressions of odd-skipped related 1 and paired-box 2 were observed in IM-like cells by immunofluorescence technique. After 10 days of co-culture with kidney decellularized scaffolds,the positive expressions of Wilms'tumor 1,GATA-binding protein-3,and E-cadherin were observed by immunofluorescence technique.Conclusion ADSCs can be induced into IM-like cells,and renal cell differentiation can be observed through combining the induced IM-like cells with kidney decellularized scaffolds.

Induced Intermediate Mesoderm Combined with Decellularized Kidney Scaffolds for Functional Engineering Kidney

BACKGROUND: Chronic kidney disease is a severe threat to human health with no ideal treatment strategy. Mature mammalian kidneys have a fixed number of nephrons, and regeneration is difficult once they are damaged. For this reason, developing an efficient approach to achieve kidney regeneration is necessary. The technology of the combination of decellularized kidney scaffolds with stem cells has emerged as a new strategy; however, in previous studies, the differentiation of stem cells in decellularized scaffolds was insufficient for functional kidney regeneration, and many problems remain. METHODS: We used 0.5% sodium dodecyl sulfate (SDS) to produce rat kidney decellularized scaffolds, and induce adipose-derived stem cells (ADSCs) into intermediate mesoderm by adding Wnt agonist CHIR99021 and FGF9 in vitro. The characteristics of decellularized scaffolds and intermediate mesoderm induced from adipose–derived stem cells were identified. The scaffolds were recellularized with ADSCs and intermediate mesoderm cells through the renal artery and ureter. After cocultured for 10 days, cells adhesion and differentiation was evaluated. RESULTS: Intermediate mesoderm cells were successfully induced from ADSCs and identified by immunofluorescence and Western blotting assays (OSR1 + , PAX2 +). Immunofluorescence showed that intermediate mesoderm cells differentiated into tubular-like (E-CAD + , GATA3 +) and podocyte-like (WT1 +) cells with higher differentiation efficiency than ADSCs in the decellularized scaffolds. Comparatively, this phenomenon was not observed in induced intermediate mesoderm cells cultured in vitro. CONCLUSION: In this study, we demonstrated that intermediate mesoderm cells could be induced from ADSCs and that they could differentiate well after cocultured with decellularized scaffolds.

Endoscopic Approach to Remove Intra-extracranial Tumors in Various Skull Base Regions: 10-year Experience of a Single Center / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Some problems have been found in the usually adopted combined approach for the removal of intra-extracranial tumors in skull base. Herein, we described a pure endoscopic transnasal or transoral approach (ETA) for the removal of intra-extracranial tumors in various skull base regions.</p><p><b>METHODS</b>Retrospectively, clinical data, major surgical complications, pre- and postoperative images, and follow-up information of a series of 85 patients with intra-extracranial tumors in various skull base regions who were treated by surgery via ETA in our skull base center during the past 10 years were reviewed and analyzed.</p><p><b>RESULTS</b>Gross total tumor removal was achieved in 80/85 cases (94.1%) in this study. All 37 cases with tumors in anterior skull base and all 14 cases with tumors in jugular foramen received total tumor removal. Thirteen and three cases with tumors in clivus received total and subtotal tumor removal, respectively. Total and subtotal tumor removal was performed for 16 cases and 2 cases in lateral skull base, respectively. The complications in this study included: cerebrospinal fluid leakage (n = 3), meningitis (n = 3), and new cranial nerve deficits (n = 3; recovered in 3 months after surgery). In the follow-up period of 40-151 months (median: 77 months), seven patients (8.8%) out of the 80 cases of total tumor removal experienced recurrence.</p><p><b>CONCLUSIONS</b>Complete resection of intra-extracranial growing tumors in various skull base regions can be achieved via the pure ETA in one stage in selected cases. Surgical procedure for radical removal of tumors is feasible and safe.</p>

Pretreatment with baicalin attenuates hypoxia and glucose deprivation-induced injury in SH-SY5Y cells / 中国结合医学杂志

<p><b>OBJECTIVE</b>To explore the neuroprotective effects of baicalin against hypoxia and glucose deprivation-reperfusion (OGD/RO)-induced injury in SH-SY5Y cells.</p><p><b>METHODS</b>SH-SY5Y cells were divided into a control group, a OGD/RO group, which was subject to OGD/RO induction; and 3 baicalin groups subject to baicalin (1, 5, 25 μmol/L) for 2 h before induction of OGD/RO (low-, medium-, and high-dose baicalin groups). Cell viability was detected by thiazolyl blue tetrazolium bromide (MTT) assay and flow cytometric analysis was used to detect cell apoptosis. Real-time polymerase chain reaction was performed to determine the mRNA expression of caspase-3 gene. Western blot analysis was conducted to determine the expression of nuclear factor (NF)-κB and N-methyl-daspartic acid receptor-1 (NMDAR1).</p><p><b>RESULTS</b>Baicalin could significantly attenuate OGD/RO mediated apoptotic cell death in SH-SY5Y cells; the apoptosis rates in the low-, medium- and high-dose groups were 12.1%, 7.9%, and 5.4%, respectively. Western blot and real-time PCR analysis revealed that significant decrease in caspase-3 expression in the baicalin group compared with the OGD/RO group (P<0.01). Additionally, down-regulation of NF-κB and NMDAR1 was observed in the baicalin group compared with those obtained from the OGD/RO group. Compared with the low-dose baicalin group, remarkable decrease was noted in the medium- and high-dose groups (P<0.01).</p><p><b>CONCLUSION</b>Baicalin pre-treatment attenuates brain ischemia reperfusion injury by suppressing cellular apoptosis.</p>

Effect of the training scheme of microvascular anastomosis in different time courses / 中国脑血管病杂志

Objective To investigate the effect of the training scheme of microvascular anastomosis in different time courses. Methods A total of 31 neurosurgeons were trained with different training schemes of microvascular anastomosis with ultrashort time course (n = 9;4 h),medium time course (n =12;12 h),and long time course (n = 10,300 h)were selected respectively,including 22 neurosurgeons from the top three hospitals and 9 from other levels of hospitals. Before training,the average median time of working in a department of neurosurgery was 6 (range,0 to 19)years. After training,the trainees accepted the assessments,such as performing the rat common carotid artery end to end anastomosis under a surgical microscope. Their completion time,anastomosis quality score,and proportion of vascular patency after anastomosis were compared. The measurement data of normal distribution used the single factor analysis of variance. The skewed distribution used rank sum test. The comparison of count data used Fisher exact test. Results The trainees who participated in the ultrashort time course training,the time of completion of carotid end - end anastomosis was 78 ± 37 min,the anastomosis quality score was 8. 1 ± 2. 8,and 2 vessels were patent;the trainees who participated in the medium time course training,the anastomosis time was 69 ± 20 min,the anastomosis quality score was 15. 8 ± 6. 8,and 10 vessels were patent;the trainees who participated in the long time course training,the anastomosis time was 34 ± 7 min,the anastomosis quality score was 23. 5 ± 1. 3,and 10 vessels were patent. There were significant differences in the completion of anastomosis time among the 3 groups of trainees (F = 9. 50,P = 0. 001). The completion time of the long time course group was shorter than that of the medium time course group and the ultrashort time course group. There were significant differences. There were significant differences in the anastomosis quality score among the 3 groups (F = 26. 870,P = 0. 000). As for the number of the patent vessels,there were significant differences between the medium and long time course groups and the ultrashort time course group (P < 0. 01 ). Conclusion If the vascular anastomosis skills of the trainees achieve relative proficiency and stability,they need to choose the long time course training.

Resection of the intracavernous sinus tumors using a purely endoscopic endonasal approach.

Resection of the cavernous sinus (CS) lesions has been a surgical challenge because the anatomy of the CS presents a high grade of complexity. This report describes the feasibility of the purely endoscopic endonasal approach to the CS. Twenty-five patients with intracavernous sinus tumors were treated with a purely endoscopic endonasal approach. The indications, efficacy, surgical techniques, and complications of this approach were discussed. Gross total resection occurred in 19 cases (76%), subtotal resection occurred in 2 cases (8%), and partial resection occurred in 4 cases (16%) including pituitary adenoma in 10 cases (total 70%; subtotal 10%; partial 20%), meningioma in 6 cases (total 66.6%; subtotal 16.7%, partial 16.7%), schwannoma in 5 cases (100%, total 5), malignant tumor in 4 cases (total 75%; subtotal 25%). All patients experienced resolution or improvement of symptoms. No patient experienced intraoperative complication and new neurological deficit. Only 1 case of postoperative cerebrospinal fluid leakage repaired via endoscopic endonasal approach on the 14th day after the surgery. The purely endoscopic endonasal approach to the CS in appropriately evaluated patients can be used to address a wide variety of benign and malignant tumor pathology with favorable outcomes and a low incidence of complications.

Transoral endoscopic odontoidectomy to decompress the cervicomedullary junction.

STUDY DESIGN: Clinical study. OBJECTIVE: To investigate the feasibility of the transoral endoscopic odontoidectomy without occipitocervical fusion. SUMMARY OF BACKGROUND DATA: Endoscopic transnasal resection of the odontoid process is less invasive than the conventional transoral odontoidectomy. However, the endonasal approach has a much longer working distance compared with the transoral approach to the craniovertebral junction and usually the endonasal approach needs a previous occipitocervical posterior fusion. METHODS: From July 2007 to June 2010, 5 patients (3 males and 2 females, age range, 25-41 yr) with irreducible cervicomedullary junction compression were subjected to endoscopic transoral odontoidectomy without occipitocervical posterior fixation and bone fusion. RESULTS: A purely endoscopic transoral odontoidectomy for decompression of the cervicomedullary junction without the occipitocervical fusion was achieved successfully in 5 patients. None of the patients underwent tracheotomy and postoperative gastrostomy tube placement. The patients were started on liquids on the third postoperative day and advanced to a regular diet on the fourth postoperative day. There was no postoperative velopharyngeal insufficiency, cerebrospinal fluid leakage, regional infection, or meningitis. The patients were discharged in 10 to 12 days after the surgery. There were no evidence of instability at the craniovertebral junction at 12 to 47 months of follow-up and remarkable improvement in neurological function was observed in each patient. CONCLUSION: The endoscopic transoral approach may be a more direct route to C1 and the odontoid than the endoscopic endonasal approach. This approach allows complete resection odontoid to decompress the cervicomedullary junction without increasing the risk of complications such as wound infection, meningitis, and velopharyngeal insufficiency. Usually, the occipitocervical posterior fusion and tracheotomy is less necessary in this approach.

Anatomical study of endoscope-assisted far lateral keyhole approach to the ventral craniocervical region with neuronavigational guidance / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Image-guided neurosurgery, endoscopic-assisted neurosurgery and the keyhole approach are three important parts of minimally invasive neurosurgery and have played a significant role in treating skull base lesions. This study aimed to investigate the potential usefulness of coupling of the endoscope with the far lateral keyhole approach and image guidance at the ventral craniocervical junction in a cadaver model.</p><p><b>METHODS</b>We simulated far lateral keyhole approach bilaterally in five cadaveric head specimens (10 cranial hemispheres). Computed tomography-based image guidance was used for intraoperative navigation and for quantitative measurements. Skull base structures were observed using both an operating microscope and a rigid endoscope. The jugular tubercle and one-third of the occipital condyle were then drilled, and all specimens were observed under the microscope again. We measured and compared the exposure of the petroclivus area provided by the endoscope and by the operating microscope. Statistical analysis was performed by analysis of variance followed by the Student-Newman-Keuls test.</p><p><b>RESULTS</b>With endoscope assistance and image guidance, it was possible to observe the deep ventral craniocervical junction structures through three nerve gaps (among facial-acoustical nerves and the lower cranial nerves) and structures normally obstructed by the jugular tubercle and occipital condyle in the far lateral keyhole approach. The surgical area exposed in the petroclival region was significantly improved using the 0° endoscope (1147.80 mm(2)) compared with the operating microscope ((756.28 ± 50.73) mm(2)). The far lateral retrocondylar keyhole approach, using both 0° and 30° endoscopes, provided an exposure area ((1147.80 ± 159.57) mm(2) and (1409.94 ± 155.18) mm(2), respectively) greater than that of the far lateral transcondylar transtubercular keyhole approach ((1066.26 ± 165.06) mm(2)) (P < 0.05).</p><p><b>CONCLUSIONS</b>With the aid of the endoscope and image guidance, it is possible to approach the ventral craniocervical junction with the far lateral keyhole approach. The use of an angled-lens endoscope can significantly improve the exposure of the petroclival region without drilling the jugular tubercle and occipital condyle.</p>

Early experience of resection of meningiomas in anterior skull base with intra-extracranial extension via a pure endoscopic endonasal approach / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>The early experience of treating anterior skull base meningiomas with intra-extracranial extension via pure endoscopic endonasal approach (EEA) was presented, the safety, feasibility and preliminary treatment outcomes were investigated.</p><p><b>METHODS</b>Eight patients with intra-extradural meningiomas who were admitted from October 2006 to October 2010 were operated on via EEA in one stage in Xuanwu hospital. In this study, the operative technique was described, the degree of resection, complications and the early clinical outcomes were discussed.</p><p><b>RESULTS</b>The complete resection of meningiomas with intra-extracranial extension was achieved in all patients using EEA in one stage. Preoperative visual symptoms were improved or resolved in all cases who presented with preoperative visual complaints. No patient in our series experienced a new neurological deficit after surgery or recurrence and death related meningiomas in the follow-up period (33-75 months). One patient experienced postoperative cerebrospinal fluid leak, delayed meningitis and secondary hydrocephalus which responded to therapy. After treatment, the patient was cure.</p><p><b>CONCLUSION</b>Our limited experience indicates that EEA is feasible and safe for the complete resection of anterior skull base meningiomas with intra- and extracranial extension in one stage in selected cases.</p>

Anatomy of the petrous apex as related to the endoscopic endonasal approach.

The endoscopic endonasal approach (EEA) has been reported to be an efficient approach for treating lesions of the petrous apex. However, there have been only limited anatomic studies for the EEA. Furthermore, most of the relevant distances for EEA cannot be measured easily on a cadaveric skull. Two fresh adult cadaver heads and five formalin-fixed adult cadaver heads were dissected using the EEA to identify groups of landmarks for safe guidance during this approach. The distances between these landmarks were then measured by CT angiography by using three-dimensional software. The EEA to the petrous apex can be divided into five phases. In each phase, a group of landmarks, rather than a single landmark, can be identified easily for guiding the next phase of the approach. There was no significant difference between males and females in any of the distances reported in the present study. The EEA can be performed to manage a petrous apex lesion more safely by referring to multiple landmarks and the distances between them.

Endoscopic endonasal management of trigeminal schwannomas extending into the infratemporal fossa.

Extracranial trigeminal schwannomas extending into the infratemporal fossa are rare. The traditional surgical approaches to the infratemporal fossa are associated with complications, such as facial nerve dysfunction, hearing loss, dental malocclusion and cosmetic problems. We report eight patients (four males, four females, age range=31-62 years) who were treated between 2004 and 2009 for extracranial trigeminal schwannomas extending into the infratemporal fossa. Schwannomas were surgically removed using a purely endoscopic endonasal approach. The maximum diameters of the tumours ranged from 30 mm to 70 mm and all tumours were completely removed. There were no intraoperative or postoperative complications in this series. There were no recurrences during the follow-up period which ranged from 10 to 74 months (mean=30 months). The purely endoscopic endonasal approach may provide a minimally invasive and safe approach to remove extracranial trigeminal schwannomas extending into the infratemporal fossa. Radical resection was associated with an excellent long-term outcome in this series.

Surgery for jugular foramen schwannomas via a pure endoscopic transoral approach / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To report a new approach, endoscopic transoral approach for the resection of jugular foramen schwannoma.</p><p><b>METHODS</b>Nine patients with jugular foramen schwannoma (three males and six females, ranging in age from 15 to 61 years old) were treated by direct surgery via a pure endoscopic transoral approach to the jugular foramen. Eight patients complained of hypoglossal nerve palsy with hemiatrophy of the tongue; six cases complained of vagus nerve palsy. Three cases complained of glossopharyngeal nerve palsy, one case complained of facial nerve palsy and hearing loss.</p><p><b>RESULTS</b>The nerves in this area were preserved and radical intracapsular removal of the tumor was performed via endoscopic transoral approach in the nine cases. Tumor removal, as assessed by intraoperative endoscopic inspection, postoperative magnetic resonance imaging and clinical evaluation, revealed all tumors were completely removed. One patient suffered from temporary swallowing difficulties and temporary right vagus palsy 1 day after surgery. There were no others intraoperative and postoperative complications. All patients were followed up for 4 - 29 months, no recurrences were occurred in all these patients and the muscle bulk, motor and the pre-postoperative swallowing function, the vagus palsy, the facial nerve palsy and hearing loss had improved in these patients.</p><p><b>CONCLUSION</b>The endoscopic transoral approach and intracapsular removal of the tumor provided for successful minimally invasive surgery in the jugular foramen schwannomas.</p>

Transclival cerebrospinal fluid rhinorrhea as the initial presenting symptom of a tiny intradural chordoma.

We report a patient with a tiny intradural clival chordoma, which was identified following presentation with cerebrospinal fluid (CSF) rhinorrhea as the initial symptom. The transclival dural defect and the intradural tumor were successfully localized by both radiological investigation and intraoperative endoscopic inspection. The tumor was totally resected and the CSF fistula was repaired by an endoscopic endonasal approach. The diagnosis, possible mechanisms and management of this rare condition are discussed. The role of endoscopy in identifying and treating the clival CSF rhinorrhea is emphasized. To our knowledge, this is the first report of a clival fistula secondary to a tiny intradural chordoma.

Endoscopic endonasal surgery of trigeminal schwannoma extending into the infratemporal fossa / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility of removing extracranial trigeminal schwannomas located in the infratemporal fossa by using a purely endoscopic endonasal approach.</p><p><b>METHODS</b>From November 2004 to July 2009, 8 patients with extracranial trigeminal schwannomas located in the infratemporal fossa (4 male patients and 4 female patients, age ranged 31 - 62 years) were surgically treated by using a purely endoscopic endonasal approach.</p><p><b>RESULTS</b>The maximum diameters of the tumors ranged from 3 to 7 cm. All tumors were completely removed. The operation time was 40 to 120 min, blood loss was 300 to 1500 ml. The clinical symptoms of some patients were relieved or improved. There were no intraoperative and postoperative complications, no deaths in this series. No relapse happened during the follow-up.</p><p><b>CONCLUSIONS</b>The purely endoscopic endonasal approach may provide a minimally invasive and safe approach to remove extracranial trigeminal schwannomas extending into the infratemporal fossa. Radical resection is associated with an excellent long-term outcome in this series.</p>