[Microsurgical removal of olfactory groove meningiomas]

OBJECTIVE

To explore an effective method for further improving the surgical results of treatment of olfactory groove meningiomas.

METHODS

Sixty seven cases of olfactory groove meningiomas were treated by microneurosurgery, among which fifty seven were de novo cases, eight were recurrent tumors and the other two re-recurrent cases. Modified Derome approach was used in 12 cases, bilateral subfrontal approach in 28 cases, modified pterional approach in 21 cases and unilateral subfrontal approach in six cases. Tumors were resected microsurgically with radical removal of invaded dura, bone, and paranasal sinus mucosa. Reconstruction was performed in patients with skull base defect.

RESULTS

Simpson grade I removal was accomplished in 59 cases, grade II in seven cases and grade IV in one case. Among 57 patients with de novo tumor, Simpson I resection was accomplished in 54 cases. Postoperative rhinorrhea and intracranial infection occurred in one case and was cured after temporal lumbar CSF drainage and antibiotic therapy. Two patients (2.9%) died within one month after operation, i.e.one aged patient of heart failure and the other of severe hypothalamus complication. Forty seven patients (72.3%) were followed up from one to ten years with an average of five years and four months. With the exception of two cases died, among the alive 45 patients, there were only three patients with tumor recurrence, which had undergone Simpson II or IV tumor resection. No recurrence was found in cases with Simpson I tumor removal. Previous blurred vision was not improved in three patients, hemiparalysis in two patients, and the other patients recovered well, resuming previous jobs or being able to take care themselves.

CONCLUSIONS

Total tumor removal (Simpson I) should be the surgical goal for treatment of olfactory groove meningiomas, especially for de novo cases. An appropriate approach is fundamental in the effort to remove an OGM totally. Appropriate anterior skull base reconstruction with vascularized material is important and mandatory.

Polymorphisms in toll-like receptor 4 gene are associated with asthma severity but not susceptibility in a Chinese Han population

BACKGROUND AND OBJECTIVES

The toll-like receptor 4 (TLR4) gene links human innate immunity and adaptive immunity via bacterial endotoxin recognition, and plays a considerable role in the pathogenesis of asthma. The effects of the genetic variants of TLR4 on asthma are still largely unknown. This study aimed to evaluate the effects of TLR4 polymorphisms on asthma risk and asthma-related phenotypes in a Chinese Han population.

METHODS

We consecutively recruited 318 unrelated adult asthmatic patients and 352 healthy volunteers. Four tagging single nucleotide polymorphisms (SNPs) in the TLR4 gene were detected using GenomeLab SNPstream or TaqMans Genotyping. We conducted case-control and case-only studies to investigate the association between the selected tagging SNPs in TLR4 and asthma and asthma-related phenotypes.

RESULTS

We found no evidence to support a significant association between TLR4 SNPs and asthma susceptibility. However, our results revealed that the TT homozygote of rs1927914 was associated with lower forced expiratory volume in the first second (percent predicted) in asthmatic patients. An evidently positive association was found between asthma severity and both the TT genotype of rs1927914 and the GG genotype of rs10983755 and rs1927907 (P = .024, P = .009, and P = .013, respectively), indicating that the C allele of rs1927914 and the A allele of rs10983755 and rs1927907 have a protective effect on asthma severity.

CONCLUSION

TLR4 polymorphisms do not contribute to asthma susceptibility but they may influence the severity of asthma.

[Radiosurgery for cavernous sinus hemangiomas: medium- and long-term results]

OBJECTIVE

To describe the personal experiences of treating cavernous sinus hemangiomas (CSH) with gamma knife or cyberknife and evaluate the medium and long-term outcomes.

METHODS

From June 1999 to December 2008, 20 CSH patients were treated by radiosurgery (gamma knife or cyberknife). Among them, 11 had residual tumor after surgery and 9 were diagnosed by neuroradiology. All cases on magnetic resonance imaging (MRI) showed well-defined and homogeneous hyperintensity on T2-weighted images. The mean maximum diameter of tumors was 38.7 ± 9.3 mm (range: 23.0 - 60.6). The volume of tumors ranged between 4.1 - 52.6 cm(3) with a mean of (18.7 ± 12.5) cm(3). The tumor margin dose irradiated by gamma knife ranged from 9 to 16 Gy (mean 12.3 ± 2.3 Gy). The tumor margin dose irradiated by cyberknife was 20 - 21 Gy in 3 fractions. The mean follow-up period was (60 ± 32) months (range: 12 - 120).

RESULTS

Follow-up imaging showed tumor volume decreased over 90% (n = 5), tumor regressed over 50% in volume (n = 9) and no change in tumor volume (n = 1). One patient with large tumor (irradiated 10 Gy) was operated by open surgery at 5 months after gamma knife. Four giant tumors decreased over 50% in volume after cyberknife. Neurologically, none of these patients showed any deterioration. And 16 patients demonstrated an obvious improvement after radiosurgery. At the last follow-up, there were no complications related to radiosurgery.

CONCLUSION

Radiosurgery (Gamma knife or cyberknife) is a safe and effective modality for small- and medium-sized CSH. Fractionated Cyberknife proves to be an effective treatment for large or giant CSH. Thus radiosurgery will be an alternative option to surgery.

Virtual reality presurgical planning for cerebral gliomas adjacent to motor pathways in an integrated 3-D stereoscopic visualization of structural MRI and DTI tractography

OBJECTIVE

Resection of gliomas invading primary motor cortex and subcortical motor pathway is difficult in both surgical decision-making and functional outcome prediction. In this study, magnetic resonance (MR) diffusion tensor imaging (DTI) data were used to perform tractography to visualize pyramidal tract (PT) along its whole length in a stereoscopic virtual reality (VR) environment. The potential value of its clinical application was evaluated.

METHODS

Both three-dimensional (3-D) magnetic resonance imaging (MRI) and DTI datasets were obtained from 45 eligible patients with suspected cerebral gliomas and then transferred to the VR system (Dextroscope; Volume Interactions Pte. Ltd., Singapore). The cortex and tumor were segmented and reconstructed via MRI, respectively, while the tractographic PTs were reconstructed via DTI. All those were presented in a stereoscopic 3-D display synchronously, for the purpose of patient-specific presurgical planning and surgical simulation in each case. The relationship between increasing amplitude of the number of effective fibers of PT (EPT) at affected sides and the patients' Karnofsky Performance Scale (KPS) at 6 months was addressed out.

RESULTS

In VR presurgical planning for gliomas, surgery was aided by stereoscopic 3-D visualizing the relative position of the PTs and a tumor. There was no significant difference between pre- and postsurgical EPT in this population. A positive relationship was proved between EPT increasing amplitude and 6-month KPS.

CONCLUSIONS

3-D stereoscopic visualization of tractography in this VR environment enhances the operators to well understand the anatomic information of intra-axial tumor contours and adjacent PT, results in surgical trajectory optimization initially, and maximal safe tumor resection finally. In accordance to the EPT increasing amplitude, surgeon can predict the long-term motor functional outcome.

Modified grading system for clinical outcome of intracranial non-germinomatous malignant germ cell tumors

This study investigated the clinical outcome of intracranial non-germinomatous malignant germ cell tumors (NGMGCTs). All histologically proven cases of NGMGCTs treated in Shanghai Huashan Hospital, Fudan University were reviewed. A total of 39 cases were analyzed. There were 15 mixed germ cell tumors, 15 immature teratomas, 7 embryonal carcinomas and 2 yolk sac tumors. Patients were treated surgically first, followed by radiotherapy and/or chemotherapy. Some patients also received gamma knife surgery. The common 5-year survival rate was 36.8%. According to Matsutani's grading system, the 5-year actuarial survival rate for patients in the intermediate and poor prognosis groups were 45.8 and 14.3%, respectively. Individual analysis of each type of tumor showed that the median survival time of embryonal carcinoma was 27 months, which is very close to that of the intermediate group (28 months). We therefore classified embryonal carcinoma into the intermediate group where the 5-year actuarial survival rate for patients in the new intermediate prognosis group was 42.6%. Further analysis of immature teratoma cases found that the 5-year survival rate of patients with immature teratoma who received gamma knife surgery is 100%. This rate exhibited a significant difference (P=0.0049) compared to that of patients who did not undergo gamma knife surgery. In conclusion, we consider surgery as the first choice of treatment although for different histologis, the type of the tumor should be treated separately.

Polymorphisms in the toll-like receptor 2 subfamily and risk of asthma: a case-control analysis in a Chinese population

BACKGROUND AND OBJECTIVE

Cell activation through toll-like receptors (TLRs) has robust bipolar effects on host immunity and the pathogenesis of asthma. The TLR2 subfamily is a pivotal member of the TLR family. We sought to determine whether mutations in TLR2 subfamily genes affect the risk of asthma.

METHODS

A total of 318 asthmatic patients and 352 nonasthmatic controls were recruited. Eight single-nucleotide polymorphisms in TLR2 subfamily genes were detected using GenomeLab SNPstream (Beckman Coulter, Fullerton, California, USA).

RESULTS

We found that patients with the TLR2/rs7656411 TT variant homozygote had a significantly reduced risk of asthma when compared with those with the GG wild-type homozygote (adjusted odds ratio [OR], 0.63; 95% confidence interval (CI], 0.41-0.98; P = .036). Furthermore, a positive association was observed between the T allele of rs2381289 in TLR6 and allergic rhinitis in asthma (OR, 1.79; 95% CI, 1.10-2.91; P = .025), while the A allele of rs11466651 in TLRIO was negatively associated with allergic rhinitis (OR, 0.49; 95% CI, 0.26-0.95; P = .046).

CONCLUSION

Our results indicate that a genetic variant in the TLR2 subfamily may play a role in susceptibility to asthma.

Primary intracranial leiomyomas: Report of two cases and review of the literature

A leiomyoma is a benign neoplasm composed of smooth muscle cells that commonly occurs in the genitourinary and gastrointestinal tracts. Primary intracranial leiomyoma, however, is extremely rare and only a few cases have been reported to date. In this study, we present two cases of primary intracranial leiomyomas in middle-aged men. Magnetic resonance images (MRI) showed lesions with homogeneous low signals on T1-, T2-, diffusion-weighted, and FLAIR sequences. Tumors were totally removed and there was no evidence of recurrence in the follow-up study. Pathological analysis with immunohistochemistry revealed that tumors had characteristics of benign smooth muscles. A review of relevant literature has been conducted.

[Grading system for diagnosis and treatment of intracranial nongerminomatous malignant germ cell tumors]

OBJECTIVE

To discuss the clinical feature, treatment and prognosis of intracranial nongerminomatous malignant germ cell tumors (NGMGCT).

METHODS

The records of 39 patients receiving treatment at our hospital between 1995 and 2007 were reviewed retrospectively. According to the classification of Matsutani, they were grouped into intermediate prognosis and poor prognosis groups based on tumor histology. Clinical manifestations, diagnosis, treatment and outcome were analyzed in each group.

RESULTS

In these 39 cases, there were 15 mix germ cell tumors, 15 immature teratomas, 7 embryonal carcinomas and 2 yolk sac tumors. All patients were treated surgically. The tumor was totally removed in 29 cases, sub-totally in 5 and partially in 3. Biopsy was performed in the other 2 cases. Thirty-four patients (87.2%) were followed up. The overall 5-year survival rate was 36.8%. The 5-year actuarial survival rate for patients in the intermediate prognosis and poor prognosis groups were 42.6% and 0 respectively. Chemoradiotherapy had a significant correlation with the prognosis of intermediate prognosis group (P = 0.039). The 5-year survival rate of immature teratoma patients receiving post-operative gamma knife surgery was 100%. It had significant difference (P = 0.0049) as compared to the 5-year survival rate of patients receiving no gamma knife surgery.

CONCLUSION

NGMGCT can be divided into the intermediate and poor groups based on the prognosis (P = 0.0003). Embryonal carcinoma can be classified to the intermediate prognosis group because of its similar prognosis with immature teratoma and mixed tumors composed mainly of germinoma or teratoma. Surgery remains the first choice for NGMGCT since treatment should be based on tumor histology. For patients in the intermediate prognosis group, a combined regimen of surgical resection, radiotherapy, chemotherapy and gamma knife surgery is mostly effective.

Computed tomography-guided aspiration versus key-hole craniotomy for spontaneous putaminal haemorrhage: a prospective comparison of minimally invasive procedures

OBJECTIVES

To compare the effectiveness of two minimally invasive procedures, namely computed tomography-guided aspiration and the key-hole approach, in the neurosurgical management for spontaneous putaminal haemorrhage, and to explore the indications for the two approaches.

DESIGN

A multicentre, single-blinded controlled trial.

SETTING

Hospitals taking part in this trial and the sources for patients were from China. Among others, the hospitals involved in the interventions included: the Beijing Tiantan Hospital (of the Capital University of Medical Sciences), the General Hospital of People's Liberation Army, the Peking Union Hospital, and the Shanghai Huashan Hospital (of the Fudan University medical school).

PATIENTS

From September 2001 to November 2003, data were available for analysis from a total of 841 patients with spontaneous putaminal haemorrhage from 135 hospitals all over China (except Tibet, Hong Kong, Taiwan, and Macao). All follow-up data were for at least 3 months.

MAIN OUTCOME MEASURES

Mortality, Glasgow Coma Scale score, postoperative complications, Kanofsky Performance Scale score, and Barthel Index.

RESULTS

There were 563 patients who underwent computed tomography-guided aspiration, and 165 were treated by the key-hole approach. Respective mortality rates 1 month after the operation were 17.9% and 18.3%; at 3 months they were 19.4% and 19.4%. In those undergoing computed tomography-guided aspiration, mortality rates at 3 months after the operation were 28.2% in patients with Glasgow Coma Scale scores of 8 or below, as opposed to 8.2% in those with higher scores. This amounted to a 3.4-fold difference. In those treated by the key-hole approach, the corresponding rates were 30.2% and 7.6%, which amounted to a 4-fold difference. The corresponding mortality at 3 months in patients with complications was 3.9 times as great as in those without complications. In those with haematoma volumes of 70 mL or greater, it was 2.7 times as much as in those in whom the volumes below 30 mL. The postoperative complication rate of computed tomography-guided aspiration (23.7%) did not differ significantly from that in those having the key-hole approach (25.7%) [P=0.420].

CONCLUSIONS

Computed tomography-guided aspiration is not superior to the key-hole approach for treating spontaneous putaminal haemorrhage in terms of favourable outcomes, mortality, and morbidity. However, it could be the first-choice approach for those with bleeds of 50 mL or less, while the key-hole approach may be more suitable for those with larger haematomas.

TRANSSPHENOIDAL PITUITARY MACROADENOMAS RESECTION GUIDED BY POLESTAR N20 LOW-FIELD INTRAOPERATIVE MAGNETIC RESONANCE IMAGING

OBJECTIVE

To evaluate the applicability of low-field intraoperative magnetic resonance imaging (iMRI) during transsphenoidal surgery of pituitary macroadenomas.

METHODS

Fifty-five transsphenoidal surgeries were performed for macroadenomas (modified Hardy's Grade II–IV) resections. All of the surgical processes were guided by real-time updated contrast T1-weighted coronal and sagittal images, which were acquired with 0.15 Tesla PoleStar N20 iMRI (Medtronic Navigation, Louisville, CO). The definitive benefits as well as major drawbacks of low-field iMRI in transsphenoidal surgery were assessed with respect to intraoperative imaging, tumor resection control, comparison with early postoperative high-field magnetic resonance imaging, and follow-up outcomes.

RESULTS

Intraoperative imaging revealed residual tumor and guided extended tumor resection in 17 of 55 cases. As a result, the percentage of gross total removal of macroadenomas increased from 58.2% to 83.6%. The accuracy of imaging evaluation of low-field iMRI was 81.8%, compared with early postoperative high-field MRI (Correlation coefficient, 0.677; P <0.001). A significantly lower accuracy was identified with low-field iMRI in 6 cases with cavernous sinus invasion (33.3%) in contrast to the 87.8% found with other sites (Fisher's exact test, P <0.001).

CONCLUSION

The PoleStar N20 low-field iMRI navigation system is a promising tool for safe, minimally invasive, endonasal, transsphenoidal pituitary macroadenomas resection. It enables neurosurgeons to control the extent of tumor resection, particularly for suprasellar tumors, ensuring surgical accuracy and safety, and leading to a decreased likelihood of repeat surgeries. However, this technology is still not satisfying in estimating the amount of the parasellar residual tumor invading into cavernous sinus, given the false or uncertain images generated by low-field iMRI in this region, which are difficult to discriminate between tumor remnant and blood within the venous sinus.

The optimal time-window for surgical treatment of spontaneous intracerebral hemorrhage: result of prospective randomized controlled trial of 500 cases

The aim of this clinical study was to determine the optimal time-window for surgical treatment of spontaneous intracerebral hemorrhage (ICH). From January 1998 to September 2000, 17 hospitals in Shanghai participated in a prospective randomized controlled trial. Among a consecutive series of 500 patients with spontaneous ICH, 234 underwent medical treatment and 266 patients received surgical treatment. According to the interval from initial onset to treatment, they were divided into 3 stages: ultra-early (< or =7 h), early (7-24 h), and delayed (> 24 h). Perioperative evaluation (Glasgow Outcome Score), long-term outcome (the activities of daily living [ADL] score), mortality, as well as incidence of associated complications were compared respectively. We found that: a) in the ultra-early and early stages, both the perioperative and long-term outcome of surgical treatment was definitely better than medical treatment; b) for the outcome of surgical treatment, there was no significant difference between ultra-early and early stages; c) in ultra-early stage, risk of postoperative rebleeding was significantly higher, and decreased henceforth; d) in delayed stage, incidence of associated respiratory, urinary, and gastrointestinal system complications was higher in surgery group than in medication group. In summary, our study yielded conclusive evidence that the early stage (within 7-24 h) was the optimal time-window for surgical intervention of spontaneous ICH.

Diagnosis and treatment of intracranial immature teratoma

OBJECTIVE

The purpose of this paper is toexplore the clinical features, treatment and prognosis of intracranial immature teratomas.

METHODS

The clinical data, serum levels of tumor markers, treatment regimens and prognosis of 15 patients with intracranial immature teratomas were reviewed retrospectively.

RESULTS

In patients whose plasma alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-HCG) were determined, AFP and beta-HCG were elevated in 57.1 and 16.7% of the cases, respectively. All patients received surgical treatment. The tumor was totally removed in 12 cases, subtotally in 2, and partially in 1 case. After surgery, of the 15 patients, 9 received radiotherapy, 4 gamma knife surgery and 7 chemotherapy. Thirteen patients were followed up. Compared to the common 5-year survival rate of 40%, in patients who received gamma knife surgery, the 5-year survival rate after surgery was 100%, which is better than the 5-year survival rate of patients who did not receive gamma knife surgery (p = 0.0049). Postoperative radiotherapy and chemical therapy had no significant impact on the 5-year survival rate (p > 0.05).

CONCLUSIONS

The prognosis of intracranial immature teratomas is poor. The detection of their clinical manifestation, the analysis of imaging features and the serum levels of tumor markers are helpful in diagnosing intracranial teratomas. The total removal of the tumor is important to cure the disease. We did not see a difference in outcome between patients who received postoperative chemotherapy or radiotherapy and those who did not. Regular follow-up MRI examinations are necessary so that the conditions of the patients can be closely monitored. If a patient has residual or recurrent tumor after surgery, gamma knife surgery can be effective.

The Department of Neurosurgery at Shanghai Huashan Hospital

The Department of Neurosurgery at Shanghai HuaShan Hospital is one of the oldest neurosurgical departments in China and is also one of the country's leading academic neurosurgery programs. The department was established in 1953 under the direction of Yuquan Shi, one of the pioneers and founders of neurosurgery in China, and is currently directed by Liang-Fu Zhou. The HuaShan Neurosurgical Group Hospital and the Shanghai HuaShan Institution of Neurosurgery were established in 2000. The department currently has 67 faculty and 450 beds distributed among one main hospital (HuaShan Hospital) and seven affiliates. More than 8000 neurosurgical procedures are performed annually. The Shanghai Emergency Center of Neurosurgery is also maintained by the department. The Department of Neurosurgery at HuaShan Hospital will continue to grow in strength and position as one of the leaders in the field of neurosurgery.

Diagnosis and management of intracranial malignant peripheral nerve sheath tumors

OBJECTIVE

Intracranial malignant peripheral nerve sheath tumors (MPNSTs) are rare and generally carry a poor prognosis. We have analyzed our experience with MPNSTs and conducted a review of the literature in an attempt to identify a rational approach to the management of these tumors.

METHODS

Eight patients underwent surgical treatment for intracranial MPNSTs during a 10-year period from 1996 to 2005. The general strategy was to perform complete resection whenever possible and to provide adjuvant radiotherapy for residual tumor. Chemotherapy was not used in this group. The clinical, radiological, operative, and pathological findings of the patients were reviewed retrospectively.

RESULTS

Six of the eight patients underwent primary operations; two of the eight patients had previously undergone other transcranial surgery operations. Total tumor resection was achieved in five patients. At this time, two have been recurrence-free for 3.5 and 5 years, respectively, and the other three patients had a mean postoperative survival of 7 months. There was one case of near total (>90%) and two cases of partial (<90%) tumor removal; the postoperative survival rate was 4, 4, and 2 months, respectively. Only two patients in our group accepted radiotherapy after surgery; one survived only 4 months and the other has been recurrence-free for 5 years.

CONCLUSION

MPNSTs are fast-growing, invasive tumors with rather unsatisfactory outcomes. Total surgical resection seems to be the most effective therapeutic method, and radiotherapy may play a role in local control.

Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage

BACKGROUND

Posttraumatic hydrocephalus is a common complication of head injury. However, hydrocephalus after tSAH has seldom been addressed. We present this clinical study to determine the incidence of hydrocephalus and analyze the risk factors for developing hydrocephalus in patients with tSAH.

METHODS

A consecutive series of 301 patients with tSAH were retrospectively reviewed to determine the effects of the admission GCS score, age, sex, decompressive craniectomy, intraventricular hemorrhage, and features of tSAH (according to the initial computerized tomography scans) on the development of hydrocephalus. Risk factors for hydrocephalus were evaluated by using logistic regression analysis.

RESULTS

Of the 301 patients, hydrocephalus was observed in 36 (11.96%). Increasing age (P< .05), intraventricular hemorrhage (P< .05), and thickness (P< .01) or distribution (P< .05) of tSAH were significantly associated with the development of hydrocephalus. No relationship was found between hydrocephalus and sex, admission GCS score, location of tSAH, or decompressive craniectomy.

CONCLUSION

Hydrocephalus frequently occurs in patients with tSAH. Increasing age, low GCS score on admission, intraventricular hemorrhage, and severe SAH could be risk factors for facilitating the development of hydrocephalus.

Development of a novel endothelial cell-seeded endovascular stent for intracranial aneurysm therapy

The metallic stent has been widely used in endovascular treatment of intracranial aneurysms and arterial stenosis. Endothelialization at the neck of the aneurysm or stenotic lesion after stent deployment plays a pivotal role in preventing aneurysm recurrence, as well as local thrombus formation and restenosis. To deliver autologous endothelial cells and to promote the endothelialization on the luminal wall of the parent artery, we established an endothelial cell-seeded intracranial stent device. Endothelial cells were isolated from canine jugular vein and identified by FACS assay and immunohistochemistry. We demonstrated that the seeded endothelial cells formed a confluent endothelial layer on the stent's surface. After being brushed with 100 dyne/cm(2) of shear stress, we found that this endothelial layer remained intact for at least 48 h on the heparinized polymer coated stent, rather than the poly-lactic-acid coated stent (p < 0.05). The results suggest that an autologous endothelial cell-seeded stent may be a feasible and optimal tool for endothelial delivery during stenting and may overcome some limitations of the traditional bare stent in the treatment of intracranial aneurysms and arterial stenosis.

CLINICAL EVALUATION AND FOLLOW-UP OUTCOME OF DIFFUSION TENSOR IMAGING-BASED FUNCTIONAL NEURONAVIGATION

OBJECTIVE

To evaluate diffusion tensor imaging (DTI)-based functional neuronavigation in surgery of cerebral gliomas with pyramidal tract (PT) involvement with respect to both perioperative assessment and follow-up outcome.

METHODS

A prospective, randomized controlled study was conducted between 2001 and 2005. A consecutive series of 238 eligible patients with initial imaging diagnosis of cerebral gliomas involving PTs were randomized into study (n = 118) and control (n = 120) groups. The study cases underwent DTI and three-dimensional magnetic resonance imaging scans. The maps of fractional anisotropy were calculated for PT mapping. Both three-dimensional magnetic resonance imaging data sets and fractional anisotropy maps were integrated by rigid registration, after which the tumor and adjacent PT were segmented and reconstructed for presurgical planning and intraoperative guidance. The control cases were operated on using routine neuronavigation.

RESULTS

There was a trend for high-grade gliomas (HGGs) in the study group to be more likely to achieve gross total resection (74.4 versus 33.3%, P &lt; 0.001). There was no significant difference of low-grade gliomas resection between the two groups. Postoperative motor deterioration occurred in 32.8% of control cases, whereas it occurred in only 15.3% of the study cases (P &lt; 0.001). The 6-month Karnofsky Performance Scale score of study cases was significantly higher than that of control cases (86 ± 20 versus 74 ± 28 overall, P &lt; 0.001; 93 ± 10 versus 86 ± 17 for low-grade gliomas, P = 0.013; and 77 ± 27 versus 53 ± 32 for HGGs, P = 0.001). For 81 HGGs, the median survival of study cases was 21.2 months (95% confidence interval, 14.1–28.3 mo) compared with 14.0 months (95% confidence interval, 10.2–17.8 mo) of control cases (P = 0.048). The estimated hazard ratio for the effect of DTI-based functional neuronavigation was 0.570, representing a 43.0% reduction in the risk of death.

CONCLUSION

DTI-based functional neuronavigation contributes to maximal safe resection of cerebral gliomas with PT involvement, thereby decreasing postoperative motor deficits for both HGGs and low-grade gliomas while increasing high-quality survival for HGGs.

Multiple intracranial cavernous malformations: clinical features and treatment

BACKGROUND

Although patients with MCMs have increasingly been found in clinics, little has been focused on them. Thus, we intended to investigate these patients' clinical presentations, family history, radiological characters, and treatment strategy.

METHODS

A retrospective review of the files and family investigations were conducted for 30 patients with MCMs. All patients underwent MRI examination. Symptomatic patients underwent the surgical treatment with image-guided technique.

RESULTS

There were 19 male and 11 female patients with a total 79 lesions. The common presentations were seizures, hemorrhages, or focal neurological deficits. Nine patients had positive or doubtful family history. The FLAIR sequence of MRI showed the highest sensitivity in the detection of CM lesions. In 27 symptomatic patients with 69 lesions, total removal was achieved in 19 patients with 48 lesions. In the other 8 patients with 21 lesions, 13 lesions were removed. Preoperative symptoms were improved in 21 patients and unchanged in 5. Preoperative neurological deficits temporarily worsened in one, and a new onset of seizure occurred in other one; but both gradually improved during the follow-up period. Among 3 patients with asymptomatic MCMs, one patient had hemorrhage during the follow-up period and underwent surgical operation.

CONCLUSIONS

Because a high frequency of family CM occurs in MCMs, a detailed family investigation is mandatory for each patient with MCM. Selection of higher sensitive MRI sequence would contribute to detection of more CM lesions. Microsurgery assisted with the neuroimaging techniques is the treatment of choice for symptomatic MCMs.

Increased protein and mRNA expression of endostatin in the ischemic brain tissue of rabbits after middle cerebral artery occlusion

OBJECTIVE

To explore the changes of endostatin (a strong anti-angiogenesis factor) and vascular endothelial growth factor (VEGF) in the brain tissues of rabbits following cerebral ischemia induced by middle cerebral artery occlusion (MCAO).

METHODS

Twenty-four New Zealand white rabbits were randomly divided into 5 groups: control (n = 5), sham-operation (n = 4), 2-hour ischemia (n = 5), 24-hour ischemia (n = 5), and 48-hour ischemia (n = 5). The expression of VEGF and endostatin were measured by enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry, respectively. In situ hybridization was used to characterize the expression of mRNA for the endostatin.

RESULTS

Both the protein (at least 50%, P < 0.01) and mRNA (at least 70%, P < 0.05) of endostatin increased significantly in the ischemic brain tissues after MCAO compared with the control group. VEGF increased at least 270% in the brain after cerebral ischemia (P < 0.05).

CONCLUSION

Cerebral ischemia leads to an up-regulation of endostatin in the brain, which is not associated with the increase of VEGF in the brain. The increase of endostatin may serve as a deleterious mechanism for ischemic injury through blocking angiogenesis.

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors' knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.

Morphological Observation and In Vitro Angiogenesis Assay of Endothelial Cells Isolated From Human Cerebral Cavernous Malformations

BACKGROUND AND PURPOSE

Little is known about the role of endothelial cells (ECs) in the pathogenesis of cerebral cavernous malformation because of the difficulties to obtain highly pure ECs. Thus, this study attempted to establish a reliable procedure to isolate and culture ECs from human cerebral cavernous malformation lesions. The biological features and the angiogenic potential of the cultured ECs were also investigated.

METHODS

A modified protocol was developed to isolate and culture cerebral cavernous malformation endothelial cells (CECs)from surgically resected human specimens. The biological features of CECs were investigated by electron microscope, immunostaining, real-time polymerase chain reaction, fluorescence-activated cell sorter, and Western blotting. The tube formation by CECs was examined in an in vitro angiogenesis model with or without the addition of vascular endothelial growth factor.

RESULTS

CECs from the specimens unaffected by the intraoperative bipolar coagulation were cultivated successfully with higher than 95% purity. Comparing to the ECs from control brain tissue, CECs presented primitive nucleus in ultrathin section, expressed higher levels of vascular endothelial growth factor receptor-1 and vascular endothelial growth factor receptor-2, and spontaneously formed tube structures in a 3-dimensional collagen matrix. The tube formation by CECs was significantly promoted by vascular endothelial growth factor treatment.

CONCLUSIONS

A modified protocol for the attainment of purified CECs and the first in vitro angiogenesis model of CECs were successfully established. We provided initial evidence that CECs had enhanced angiogenic potential and showed increased responsiveness to vascular endothelial growth factor.

[Clinical experience of 70 cases of cerebral arteriovenous malformations embolization with Onyx, a novel liquid embolic agent]

OBJECTIVE

To report our clinical experience of using Onyx, a new liquid embolic agent, to treat cerebral arteriovenous malformations (AVMs) as well as its efficacy.

METHODS

Seventy cases were placed with 6F sheath in the femoral artery after Seldinger puncture and 6F guiding catheter was introduced into the internal carotid artery or vertebral artery, then a microcatheter was navigated into the nidus of AVMs. Slow injection of Onyx under fluoroscopic control was performed to embolize cerebral AVMs using the "plug and push" technique.

RESULTS

Thirteen AVM cases (18.6%) were totally occluded by Onyx and 5 cases of which didn't recurrence at 6-month after operation. Thirty-eight cases (54.3%) were subtotally occluded, while another 19 cases (27.1%) were partially embolized. Severe cerebral hemorrhage occurred in 4 cases, 2 of which had mild to severe hemiplegia after operation, and one died. Mild hemiplegia was also found in 1 case due to functional area embolization, and visual field deficit in 2 cases.

CONCLUSIONS

Onyx has unique and distinctive superiority in treating cerebral AVMs. Nonetheless, the correct embolization technique should be learned to achieve good clinical results and avoid complications.

Histopathological study of five cases with sporadic meningioangiomatosis

We report five cases of sporadic meningioangiomatosis, three males and two females, ranging in age from 12 to 36 years at diagnosis. The lesion was found incidentally by MRI after a head trauma in one case; the other four subjects had a seizure disorders, which improved following surgical resection of the cortical lesions. Grossly, the lesionectomy specimens were of a whitish color and firm consistency. Histological examination revealed that the lesions were confined to the cortex with focal involvement of the overlying leptomeninges, and revealed unifying features of meningioangiomatosis, such as proliferating microvessels with perivascular cuffs of spindle-cell proliferation within the cortex. Two cases had numerous calcifications; one was associated with a prominent fibrocalcifying component. Immunostaining results were variable among the cases. Only vimentin was consistently positive. Some of the spindle cells were weak positive for EMA in two cases. Immunoreactions with anti-CD34 detected within the cytoplasm of the spindle cells were observed in three of the five cases. The Ki-67 proliferation index of all the cases was very low, less than 0.1%. Neurofibrillary tangles were identified in only one of the five cases using the Bodian and immunostaining methods. These findings indicate that meningioangiomatosis lesions show a wide range of clinicopathological features, making diagnosis difficult. A histopathological spectrum and differential diagnoses were discussed with a review of the literature. Since this lesion is a distinct clinicopathological entity and hamartomatous in nature, it is important to make a correct diagnosis in order to avoid further aggressive treatment.