Three cases report of idiopathic angiosarcoma of the head and neck and literature review.

Herein, we reported 3 cases of angiosarcoma (AS) of the head and neck in old patients, and the etiology, pathogenesis, histopathology, immunohistochemistry, diagnosis, differential diagnosis and prognosis were discussion. Case 1, a male patient aged 86 years old was admitted due to purplish erythema on the head and face and progressive purplish edema in the orbit of the eye for 3 years. He was misdiagnosed with connective tissue disease in another hospital, and a second biopsy and histopathological examination confirmed the AS of the head and neck. Case 2, a male patient aged 85 years were admitted due to erythemalike hyperplasia in the left anterior head with necrosis and scar formation at the center for 2 months. He was misdiagnosed with folliculitis in another hospital, and histopathological examination confirmed the AS of the head and neck. Case 3, a male patient aged 87 years were admitted due to large erythema in the right scalp with ulcer and scar formation for 1 month, and histopathological examination confirmed the AS of the head and neck. One of them was lost to follow, one died 5 months after confirmed diagnosis, and one achieved favorable outcome after radiotherapy and received further follow up. The early clinical manifestations of the three patients were different and lacked characteristics. The disease progressed rapidly and the prognosis was poor. At present, surgery combined with postoperative radiotherapy is the preferred treatment. Through this article, the following conclusions can be obtained: erythema in the head and face of the elderly, rapid progresses and painful, pathological examinations must be performed, and changes in blood vessels and vascular endothelial cells with or without crack formation and red blood cell extravasation should be carefully observed during pathological examinations in case of misdiagnosis. It is hoped that these three cases can serve as a reminder for clinicians, for reducing misdiagnosis and miss diagnosis, choosing appropriate treatment methods, and judging their prognosis. Therefore, early diagnosis and surgical treatment are extremely important to improve the prognosis of AS patients.

[Distinguish reasons for the variety of intraoperative transcranial magnetic motor evoked potential: the anaesthesia or the operative injury].

OBJECTIVE: To find a way to discriminate operative reason from anaesthesia reason for the changes of intraoperative transcranial magnetic motor evoked potentials (MEPs). METHODS: In 26 patients under Etomidate/Fentanyl anesthesia from February 2001 to June 2004, MEPs elicited by transcranial magnetic stimulation were recorded from tibialis anterior muscles, simultaneously bispectral index (BIS) and train-of-four stimulation (TOF) were used to monitor the anesthesia depth and neuromuscular blockade respectively. MEP, BIS and measurements of TOF at different anesthesia depth and muscular relaxation were recorded synchronously, statistical analysis of this data set was done in order to find the inherent relationship between these variables. RESULTS: Under anesthesia, MEP amplitude was always positively correlated with the corresponding BIS and TOF value. A regression equation could be built, with which the MEP amplitude could be reckoned based on realtime BIS and T(1)/T(c). In case of spinal cord injury, the measured amplitude value would significantly deviate from predicted one, which suggested that the change of MEP was because of the operation, but not the anaesthesia or neuromuscular blockade. Each patient had his or her own regression equation, which was different from each other. CONCLUSIONS: The establishment of regression equation from MEPs, BIS and TOF is very useful to distinguish reasons of the changes of transcranial magnetic MEPs during surgery, and with this technique, the intraoperative MEP monitoring should be more reliable and practicable.

[The utility of neuronavigation in the microsurgery for cerebral cavernous malformations].

OBJECTIVE: To evaluate the utility of neuronavigation in the microsurgery for cerebral cavernous malformations. METHODS: In a retrospective study, 47 patients with cavernous malformations were involved from January 1995 to December 2010. Fourteen cases admitted into hospital from January 1995 to December 2002 were treated without neuronavigation (conventional group), the focus localization was based on magnetic resonance imaging (MRI) images, anatomic landmarks, and the experiences of the neurosurgeon. In the other 33 cases admitted after February 2002 to December 2010, surgeries were performed with neuronavigation using the Medtronic Stealth Station TREON or TRIA system (neuronavigation group). Excision of the cavernomas were all performed microsurgically, surrounding gliotic rim and hemosiderin stained tissue were resected in the case of epilepsy, and a few patients underwent extended hippocampal resection or multiple subpial transection. RESULTS: With the use of neuronavigation, the extent of craniotomy reduced from 5.2 cm to 3.6 cm (P < 0.01), and deeper cavernoma focuses could be treated surgically. There were no changes with regard to the mean size of the cavernomas, the mean time of surgery and hospital stay (P > 0.05), but the mean time of anaesthesia was prolonged from 164 min to 197 min (P < 0.01). Cavernomas were resected completely in all 47 cases, which was confirmed by postoperative MRI recheck. The conditions of all patients were improved or remain unchanged, and no significant differences in the clinical outcome could be evaluated between the two groups. CONCLUSIONS: Application of neuronavigation-assisted microsurgery of intracranial cavernous malformations surgery, helps reduce the surgical trauma, and has security and reliability.

[Microsurgical management of tuberculum sellae meningiomas].

OBJECTIVE: To explore the approach and efficacy of microsurgery for tuberculum sellae meningiomas. METHODS: The clinical data of 56 patients with tuberculum sellae meningiomas treated at our department from 1991 - 2009 were analyzed retrospectively. There were 20 males and 36 females with an age range of 32 - 65 years old (mean: 46). All patients underwent microsurgery through pterional, unilateral subfrontal, orbitozygomatic or supraorbital keyhole approach. RESULTS: Among these patients, there were total resection (n = 51) and subtotal resection (n = 5). Postoperatively, 53 patients recovered well, 2 had a mild disability, 1 suffered a severe disability and there was no mortality. CONCLUSION: Most cases of tuberculum sellae meningiomas can be removed safely and totally. Several approaches may be employed to achieve the best outcomes. Microsurgery can markedly boost the total resection rate of tuberculum salle meningiomas and lower the postoperative complications and mortality.

[The utility of transcranial magnetic motor evoked potential monitoring during spinal surgery].

OBJECTIVE: To evaluate the practicability and validity of transcranial magnetic motor evoked potential monitoring (TMS-MEP) during spinal surgery. METHODS: From February 2001 to June 2004, 37 patients undergoing spinal surgery were involved, anaesthesia was maintained with volatile anesthetics in 11 operations and etomidate in 26. Analgesia was provided with fentanyl, and non-depolarizing muscle relaxant was given intermittently. MEPs elicited with transcranial magnetic stimulations were recorded from tibialis anterior muscles, simultaneously bispectral index (BIS) and train-of-four stimulation (TOF) were used to monitor the anesthesia depth and neuromuscular blockade respectively. The variety of MEP and its effect on surgical operation at different anesthesia depth and muscular relaxation were observed, and the muscle strength of the patients before and after operation were compared. RESULTS: The 11 cases anesthetized with isoflurane or enflurane gave no response to TMS, the other 26 cases in which anaesthesia was maintained with etomidate and fentanyl gave satisfactory TMS-MEPs, but with significantly attenuated amplitudes and prolonged latencies (P < 0.05). Intraoperative MEP showed a grossly unchanged waveform, and its amplitude and latency had little fluctuation when anaesthesia and neuromuscular blockade maintained stable. When T(1) value of TOF at 40% - 60%, a steady MEP could be acquired and the muscular contraction after TMS should not interfere the operation.Seven of 26 cases had a MEP amplitude drop up to 50% or more during the operation, the surgical team was notified to avoid further spinal injury, at last only 1 case had a worsen muscle power after operation. CONCLUSIONS: Myogenic TMS-MEP is a valid and practicable technique for intraoperative monitoring, and the etomidate + fentanyl technique is adequate for its anesthesia. BIS and TOF monitoring are helpful to maintain the steadiness of the anesthesia and MEPs, which is very important for monitoring the changes of the MEPs.

[Microsurgical management of anterior clinoidal meningiomas].

OBJECTIVE: To explore the method and efficacy of microsurgery for anterior clinoidal meningiomas. METHODS: The clinical data of 53 patients with anterior clinoidal meningiomas treated from 1991-2009 were analyzed retrospectively. There were 15 males and 38 females. The age range was 33 - 65.5 years old (mean: 45.5). All patients underwent microsurgery through pterional, extended pterional, frontotemporal, frontotemporal and orbitozygomatic approaches. RESULTS: Of 53 patients, total, subtotal and partial resections were performed in 38, 10 and 5 cases respectively. Postoperatively, 48 patients recovered well, 4 had mild disability, 1 severe disability and no dead case. CONCLUSION: Most anterior clinoidal meningiomas can be removed safely and effectively. Several approaches may be used to achieve the best results. Microsurgical operation can offer a great aid in an effective resection of anterior clinoidal meningiomas and reduce the postoperative complications and mortality. Postoperative radiotherapy should be carried out for the residual tumor invading cavernous sinus or internal carotid artery.

[Effects of gap junction blocking on the oxygen partial pressure in acupoints of the bladder meridian].

OBJECTIVE: To explore the relation between gap junction and meridian phenomenon. METHODS: The oxygen partial pressure in acupoints [see text for formula] and in their corresponding non-acupoints of the Bladder Meridian was observed with the needle-type tissue oxygen tension sensor in the gap junction blocking goats by 1-Heptanol injection and the Connexin 43 (Cx43) gene knockout mice. RESULTS: (1) The oxygen partial pressure in acupoints of Bladder Meridian on goats was higher than that in non-acupoints after 1-Heptanol injection with significant differences between them (both P < 0.01). (2) The oxygen partial pressure in acupoints of Bladder Meridian on goats increased significantly after injecting 1-Heptanol as compare with that either injecting normal saline or injecting nothing with significant differences between them (all P < 0.01). (3) The oxygen partial pressure in acupoints of the Bladder Meridian was significantly higher than that in the non-acupoint controls in Cx43 wild type (WT) mice (all P < 0.01). In Cx43 heterozygote (HT) mice, the oxygen partial pressure between acupoints and non-acupoint controls showed no significant differences (all P > 0.05). (4) In acupoints, the oxygen partial pressure in Cx43 WT mice was significantly higher than that in Cx43 HT mice (all P < 0.05), while in the corresponding non-acupoints, this difference had no statistically significant (all P > 0.05). CONCLUSION: Gap junction maybe the essential factor in signal transduction of acupuncture.

[Microsurgical treatment of spinal cavernous malformation].

OBJECTIVE: To investigate the characteristics of clinical manifestations, diagnostic imaging, pathology, and microsurgical treatment of spinal cavernous malformation. METHODS: The clinical data of 28 patients with spinal cavernous malformation undergoing total resection through posterior approach during 1991-2006, all receiving MRI examination and 22 also receiving spinal DSA examination, were analyzed. RESULTS: Among the 28 cases, 8 lesions were located in the cervical segment of the spinal cord; 12 lesions in the cervical-thoracic segment; 4 lesions in the thoracic segment; 2 in the lumbar segment, and 2 in the thoraco-lumbar segment. The MRI images looked like mulberry; a black ring around the cavernoma was indicated. The spinal cord tissues around the lesion were obviously stained by the deposited hemosiderin. Follow-up of 3 months to 6 year showed no recurrence. CONCLUSION: MRI is the most reliable method for diagnosis of spinal cavernous malformation and surgical resection is the best treatment method. The key of success is meticulous surgical techniques. DSA helps differentiate spinal cavernous malformation from other arterio-venous malformations.

[Treatment of spinal cord hemangioblastoma by microoperations combined with embolization].

OBJECTIVE: To investigate the effects of microoperations combined with embolization in treatment of spinal cord hemangioblastoma. METHODS: Thirty-six patients with spinal cord hemangioblastoma, 21 males and 15 females, aged 24.2 (12-48), underwent MRI and digital abstraction angiography. Twelve of them underwent pure microsurgical treatment and 24 of them underwent operation combined with remobilization. RESULTS: MRI showed clear boundary mass, and DSA showed round or oval high density images with clear boundary and definite supplying artery. 30 cases had their tumors totally removed; and 6 cases had their tumors subtotally removed. Complete functional recovery was seen in 27 of the 36 patients (67%). Four patients resumed their self-care ability,and 4 still needed someone's help. CONCLUSION: Embolization lowers the blood supply of the spinal cord hemangioblastoma, elevates the cure rate, and enlarges the indication of spinal cord hemangioblastoma operation.

[Effect of Ca2+ complexation on oxygen partial pressure in the Bladder Meridian in goats].

OBJECTIVE: To explore the relationship between energy metabolism and meridian phenomenon. Methods Ten Boer hybridism goats mitigated under chlorpromazine (0.85 mg/kg, intramuscular injection) were subjected to the present study. Changes of oxygen partial pressure (PO2) in "Ganshu" (BL 18), "Dachangshu" (BL 25) and "Guanyuanshu" (BL 26) of Bladder Meridian and in 3 non-acupoints (3 cm apart from BL18, BL25 and BL26 separately on the unilateral side) were recorded by using a needle-type tissue oxygen tension sensor before and following local injection of EDTA-Na2 (200 microL, 0.05 kg/mol, for complexing Ca2+) and 0.9% saline. RESULTS: (1) Compared with the corresponding non-acupoints, Ca2+ potentials in BL18, BL25 and BL26 were all significantly higher (P < 0.05, 0.01). (2) In comparison with the corresponding non-acupoints, the values of tissue PO2 of BL18 and BL26 were significantly higher (P < 0.01). (3) After injection of EDTA-Na2, PO2 values in both BL18, BL26, and their respective non-acupoints increased significantly in comparison with those of either injection of saline or their respective basal values (P < 0.01, 0.05). Compared with those of their corresponding non-acupoints PO2 values in both BL18 and BL26 increased markedly (P < 0.01). CONCLUSION: Ca2+ potential of the Bladder Meridian was significantly higher than that of non-acupoints, and after complexing Ca2+, PO2 in acupoints and non-acupoints increased markedly, suggesting that Ca2+ may play an important role in meridian signaling and production of acupuncture effect.

[Treatment of multisegmental intramedullary cervical spinal cord ependymomas].

OBJECTIVE: To discuss the possibility of microneurosurgery techniques in the treatment of multisegmental intramedullary cervical spinal cord ependymomas. METHODS: The clinical data of 26 cases of multisegmental intramedullary cervical spinal cord ependymomas patients was reviewed and analyzed. RESULTS: There were 14 cases of cervical spinal cord ependymomas, 12 cases of cervical and thoracic spinal cord ependymomas. 4.5 spinal cord segments were involved in average. Incompletely inferior paraplegia was in 18 cases, incompletely high paraplegia in 8 cases, dyspnea in 6 cases, sphincter dysfunction in 10 cases. MRI detected syringomyelia formation in 24 cases. Vertebral lamina reposition were done in 20 cases. Muscle strength recovered in 21 cases, no change in 4 cases, aggravated in 1 case. All cases had total resection and 1 cases vertebral had instability in MRI. CONCLUSIONS: Total resection of intramedullary cervical spinal cord ependymomas can be achieved by microneurosurgery. Most of the symptoms can be released after microsurgical treatment. After multisegmental laminotomy, the vertebral plate reposition should be done to ensure the stability.

[Management of elderly patients with symptomatic vertebrobasilar insufficiency].

OBJECTIVE: To evaluate the feasibility, safety and short-term efficacy of stent-assisted angioplasty and/or drug therapy for elderly patients with symptomatic vertebrobasilar insufficiency. METHODS: Elderly patients (> or = 60 years old) with symptomatic vertebrobasilar stenosis (> or = 50%) demonstrated by cerebral angiography were treated with drug therapy and some with endovascular stenting further from April 2001 to June 2006. The clinical, imaging, intervention and follow-up data were collected and analyzed. RESULTS: Eighty-one elderly patients were chosen for study, including 68 males and 13 females. The mean age is 70 years (60 - 87 years); stroke rate of 4.9% (4/81) and stroke-related mortality rate of 2.5% (2/81) were found in this group during hospitalization and follow-up (mean 28.1 months), and symptoms resolved or improved clinically in 66 (81.5%). Fifty-two balloon expandable stents were placed in 48 (59.3%) patients of this group with a technical success rate of 98.1% and the mean degree of stenosis was reduced from (82.4 +/- 13.1)% to (6.4 +/- 3.2)% (t = 22.4, P = 0.00). CONCLUSIONS: Appropriate management including endovascular stenting and/or drug therapy may improve short-term outcomes of elderly patients with symptomatic vertebrobasilar insufficiency; meanwhile, stent-assisted angioplasty is technically feasible and relatively safe.

[Effect of acupuncture on pH values of acupoints in the goat].

OBJECTIVE: To study effect of acupuncture on pH values of acupoints and non-acupoints. METHODS: The pH values of acupoints and non-acupoints were determined with pH sense needles at the same time and separately in the goat. RESULTS: (1) The pH value of the acupoints and non-acupoints decreased when acupuncture was separately at acupoints and non-acupoints with the pH value of the acupoint decreased more significantly; (2) there was no significant difference in decreasing amplitudes of the pH values between the acupoint and non-acupoint when acupuncture was simultaneously given at acupoints and non-acupoints. CONCLUSION: Acupuncture can more significantly strengthen metabolism of acupoints; when acupuncture was simultaneously given at acupoints and non-acupoints, local metabolism is influenced each other.