例1.“2、3天就让我出院?那么快?!别人都说要住2~3周呢。”病人满是疑惑地说。主任:“病治好了就出院。您放心,您脑里的肿瘤已切掉了,视力也好了,检查都正常,您就放心回家吧。”这是8月17日(周一)谭源福主任早查房时同一垂体腺瘤术后患者的对话。该患者(韦某 女36岁,住院号1208296)因月经失调3年伴视力下降1月,以“垂体无功能性大腺瘤”收住院(8月12日周三入住),入院完善相关检查后于第3天(周五晚上9点)行经鼻蝶显微垂体瘤切除术,手术历时55分钟顺利完成,术后视力即获改善,第二天即可下床活动,饮食正常。术后核磁增强检查显示肿瘤已全切除,术区无血肿;术后尿稍多,垂体激素和电解质均正常。术后第三天出院,共住院5天(8月12—17日),总费用远低于预期,患者全家都喜出望外。 A某女36岁,术前鞍区核磁增强检查显示垂体大腺瘤(33mm x31mmx 24mm)B术后核磁增强检查显示肿瘤已切除例2,这一例也经历了同样的诊疗过程(周三入,周五手术,周一出):梁某男47岁,住院号1515532,因肢端肥大症十余年以垂体生长激素腺瘤于8月19日(周三)住院,8月21日(周五)晚上11点行经右鼻蝶垂体瘤显微切除术,历时45分钟顺利完成,肿瘤全切(图A,B),第二天即下床活动,饮食正常,尿量正常,术后复查垂体激素和电解质均正常,生长激素降至治愈标准(2ug/l以下)(术前18.447ug/l至术后1.686ug/l)。8月24日步行出院,共住院5天(19/8~24/8)。A术前MRI右鞍内增强低信号肿瘤灶 B术后CT:鞍内病灶已切除,鞍底骨完好例3,何某 女,32岁,住院号1517026,因头痛伴月经紊乱3月,以囊性垂体大腺瘤于2020年8月26日入院,视力视野正常;内分泌学检查:甲低T4 52.30(正常78.38-157.40) FT4 5.58(正常7.86-14.41),泌乳素低1.81ng/ml(正常7.95—45.85),皮质醇低21.1nmol/l(正常8AM185--624)。核磁增强显示垂体大腺瘤囊变伴陈旧性出血(图A)。28日上午行经右鼻蝶显微肿瘤切除,手术顺利,历时35分钟。术后当天即下床活动,饮食正常,有一过性尿多。内分泌学检查:甲低同术前T4 46.66nmol/l, FT4 5.91;泌乳素恢复10.63ng/ml,皮质醇恢复505.41nmol/l。 8月31日出院。共住院5天(26/8~31/8)。出院继续口服补充甲状腺素。A B图A垂体大腺瘤,囊变伴陈旧性出血(24mmx19mmx20mm) 图B术后MRI增强检查肿瘤切除,囊腔缩小垂体腺瘤是一较常见的神经肿瘤,约占15~20%。当前,手术切除仍是垂体腺瘤治疗的最重要手段,垂体瘤切除是一项技术性较强的4级手术。经鼻蝶微创手术已成垂体腺瘤切除的首选方法,欧美国家多是以专业团队进行诊疗,诊疗效率较高,术后住院时间短,病人多在术后2~5天内出院。 我们多年来潜心学习和精炼经鼻蝶垂体腺瘤切除微创技术,力图全术程微创化。1单鼻孔微创通道技术让鼻腔粘膜损伤极其微小,术毕鼻腔无需任何填塞,术后患者舒适度显著提升;2鞍底门开技术可让鞍底获得完全解剖修复;3瘤内顺序柔刮技术和4瘤周垂体腺(功能)保护技术能更有效地切除肿瘤,同时保护被严重压缩的残存垂体腺(功能),促进术后垂体功能恢复。全术程微创技术的实施,让垂体腺瘤手术疗效得到了显著提升,1有效切除肿瘤同时垂体腺(功能)获得较好保护;2手术创伤小,手术并发症少;3手术时间短,一般在1小时内可顺利完成;4术后恢复快(2~5天),住院时间短(5~10天),诊疗费用低(< 3万)。微创技术在经鼻蝶垂体腺瘤显微切除的全术程中实施,真正实现了治得好还好得快! 附1单鼻孔微创通道技术肾上腺素收缩右鼻腔粘膜,镜下吸除鼻腔内粘液和脏物,初显鼻腔通道,顺腔道缓慢轻柔置入薄嘴鼻扩器,于蝶窦开口前约5-10mm处推折鼻中隔,获有效操作通道。然后于折断骨缘切开右侧粘膜15mm,紧贴蝶嘴前骨质分离蝶窦开口前粘膜,右侧形成粘膜瓣。然后去除蝶嘴,鼻扩器推进至蝶窦内,显露鞍底。至此,单鼻孔微创通道完全形成,鼻粘膜创伤极其轻微,术毕,鼻腔也无需任何填塞(图A、B、C、D、E)。 A收缩鼻粘膜前 B收缩鼻粘膜厚 C无创置入薄嘴鼻扩推断鼻中隔 D蝶窦开口前粘膜切开形成粘膜瓣 E术毕鼻腔不放任何填塞物,双鼻腔通畅附2 鞍底门开(关)技术分单开门,双开门和三开门等多方式,视鞍底骨质具体情况而定,术前不做设定。单开门:宜用于骨质厚薄适中者。咬平鞍底蝶窦中隔骨嵴后,于拟开窗位置,凿断前和两侧鞍底骨质,在前侧边缘咬开一小口,伸入剥离子向后翘起,后缘折而不断,成门样打开。切除肿瘤后,像门样关闭,鞍底获解剖修复(图1、2、3)。但需注意当瘤腔较大,估计渗出较多时,鞍底不宜封的太紧,需在门边缘留一缺口供瘤腔内渗出物流出。当遇鞍底骨质极薄或中央破损时,则不能单开门,此时可以从中央破损处向周边直接撬起成双门或3门样打开。1 开门 关门2 开门 关门附3 瘤内顺序柔刮技术肿瘤质地分质地偏软和质地偏硬2种。刮瘤技术因肿瘤质地不同而相应改变对质软者可先用大号刮圈轻柔刮除底层肿瘤,然后顺序刮除下降的上层,依层次推进,以防剩余肿瘤下降不均或囊膈膜内突阻碍下降。初见鞍膈膜(鞍膈孔处为极薄的蛛网膜,易破,要特别注意保护!)时宜用棉片顶住下小心刮除周侧折角处,让鞍膈膜一致下降,减少残留。对质地偏硬者,难以用刮圈刮除,则宜采用锐器先于下端瘤中央挖出适当空间,然后牵引瘤边下耐心分块剥离,在剥离肿瘤鞍膈膜面时要特别耐心,遇剥离困难时,可先锐性切除部分肿瘤,留薄层残留也无妨,尽量避免鞍膈膜破损脑脊液漏。附4瘤周垂体腺(功能)保护技术在微腺瘤,正常垂体受压不重,颜色质地与正常垂体无异,呈微黄肉样;在大腺瘤和巨大瘤,被严重压迫的正常垂体腺组织在肿瘤切除减压后会明显起来,均不难识别,表现为肉红色软纤维样组织贴在瘤腔壁,1不要当“假包膜”随意去除;2不要任意烧灼损伤,渗血用明胶海绵轻压即可控制; 3刮瘤壁时一定要轻柔,4瘤腔填充不可过多,渗血较多时初始填塞可稍紧点,观察出血停止后 填塞中央区可适当取出,以减缓腔壁压迫;如渗血少或无明显渗血则微填明胶海绵即可;5减轻炎症反应:瘤腔内尽量不用不可吸收材料;严格无菌操作,鼻道有效消毒,打开鞍底前再消毒,和鞍底修复较好(与蝶窦鼻腔有效隔开)等均有利于减轻继发炎症反应性影响。 (垂体激素对维持人体各器官机能正常起非常重要作用,垂体瘤切除术中垂体腺(功能)保护值得术者高度重视)感谢广大病友和神外同道兄弟的多年信任,自2003年以来我们积累了遇伍佰例各类垂体腺瘤的手术经验,希望这点滴体会对感兴趣的同道有些许启示,越做越好!也希望同道兄弟多提宝贵意见,让微创技术惠及更多患者。
脑膜瘤(meningioma)起源于硬脑膜内层的蛛网膜帽细胞,是最常见的脑肿瘤,约占颅内肿瘤的15--20%,40-60岁女性最多发。肿瘤病理分良性(1级)、非典型(2级)和恶性(3级)三级,90%以上为良性。1级良性全切除后预后较好,而2-3级术后易复发预后欠佳,但也有少数良性(脑侵入型)全切后仍复发者。颅内脑膜覆盖的各部位均可发生脑膜瘤,但最常见为大脑镰窦旁、大脑突面、蝶骨嵴、嗅沟和鞍区;颅后窝以桥小脑角区较多见(<5%);脑室内也可发生脑膜瘤,约占2-5%,80%在侧脑室三角区。脑膜瘤一般生长较缓慢,早期症状体征多不明显,随肿瘤增大和局部脑压迫加重,可出现头胀痛,局部神经功能损害等症状体征(因部位不同而症状体征各异)诊断以核磁(MRI)检查最具价值,脑膜瘤MRI表现为瘤基底在硬膜、边界清晰、强化明显且较均一、可见硬膜尾征;此外可明确肿瘤与周围结构关系(瘤周水肿、包裹血管与否等)治疗选择:1.观察:无症状或极轻微、瘤体较小、局部压迫不明显;年龄较大(>70岁)而瘤体钙化生长极缓慢者,建议观察,年MRI检查一次。2.手术:有明显症状体征,肿瘤已较大、脑受压明显者3.伽玛刀治疗:肿瘤不大(<3cm)而手术风险较大者,或术后残留、复发者4.放疗:恶性肿瘤术后5.栓塞:肿瘤血供极丰富者,作为手术前辅助治疗颅底中线区脑膜瘤因与重要神经血管关系紧密,手术风险较大,一直是手术治疗难点,宜到大医院专科诊疗。专家特色:通过大量的各类脑膜瘤包括各种复杂巨大脑膜瘤的显微切除,积累了丰富的手术经验,在脑膜瘤手术策略和微创手术技巧上有很深刻的领悟,获得了令人满意的疗效。典型病例:脑膜瘤显微切除相关论文1. 谭源福,等:眶翼点入路切除鞍区颅底肿瘤 广西医科大学学报 2002;19(6):345-3462. 谭源福,等:颞下经岩经天幕入路切除岩尖巨大肿瘤 中华神经外科杂志2003;19(3):228-2293. 谭源福,等:瘤内切瘤技术在巨大颅内肿瘤切除中的应用.中华神经医学杂志2004;3(1):28-30.4. 谭源福,等:显微切除前床突脑膜瘤46例报告。中华外科杂志,2014;52(4):271-2755. 谭源福,等:经外侧额下入路显微切除鞍结节脑膜瘤。中华神经外科杂志,2014;30(5):475-4766. 谭源福,等:显微手术切除矢状窦旁脑膜瘤72例。中华显微外科杂志 2015;38(2)194-197。7. Zhi-Yi Chen……Yuan-Fu Tan.Intracranial meningioma surgery in the elderly (over 65 years) prognostic factors and outcome. Acta Neurochirurgica,2015:157:1549-1557. ( Yuan-Fu Tan---- Corresponding author)8. 谭源福,等单侧额下入路显微切除嗅沟脑膜瘤。外科(Hans Journal of Surgery)2016;5(1):1-119. 谭源福,等:显微切除天幕脑膜瘤 69例。中华显微外科杂志 2016;39(1)63-66。10. 谭源福:单侧枕下入路显微切除枕骨大孔腹侧肿瘤(专题发言)。中华医学会神经肿瘤大会2016年9月(西安) 11. 谭源福,等:岩斜脑膜瘤显微手术入路、策略和技巧。2017;待发表
垂体腺位于颅脑深处的蝶鞍内(鼻根正后方约60mm),最大径8-10mm,上方与视神经为邻。垂体腺是人体重要的内分泌腺体,分泌促肾上腺素、促甲状腺素、泌乳素(催乳素)、生长激素和促性腺激素,调节人体多种
人的松果体位于大脑中央,位置深在,离头颅外表深度超过7CM。松果体区肿瘤是指发生于松果体本身和松果体临近区组织的肿瘤总称。松果体瘤少见,约占颅内肿瘤的1%,多数为儿童青少年。其中生殖细胞瘤相对较常见,可分泌活性物;松果体实质细胞瘤包括:松果细胞瘤,松果中间分化实质瘤,松果母细胞瘤,和松果体乳突瘤;其它包括胶质瘤,脑膜瘤,以及先天发育异常如松果体囊肿,脂肪瘤,皮样和表皮样囊肿等肿瘤病理分三类: 1,生殖细胞瘤,约占27%,高发年龄在10--30岁。近半在松果体区,约1/3在鞍区。绝大多数为恶性,生长快,易颅内转移扩散。约2/3为纯生殖细胞瘤(pure geminomas,GE松果体区多),约1/3为非生殖生殖细胞瘤(nongeminomatous germ cell tumors, NGGCT鞍区多)包括胚胎癌、绒癌、内胚窦癌、畸胎瘤、混合瘤等纯生殖细胞瘤GE经单独放疗或联合放、化疗较容易治愈;非生殖生殖细胞瘤NGGCT需要最大程度的手术切除加强力的化疗和放疗;成熟畸胎瘤只需手术切除。就治疗角度而言,NGGCT最具有挑战性。 2,松果体实质细胞瘤约占27%,包括松果体细胞瘤(占13%),中间分化的实质肿瘤PPTID(占66%),松果体母细胞瘤(占21%)等;松果体母细胞瘤多发生于儿童、松果体细胞瘤则多发生于成年人。 3,临近结构的肿瘤 如胶质瘤占17%,乳头瘤占8%。松果体瘤中75%~80%是恶性的,其中包括生殖细胞瘤癌、成松果体细胞瘤和某些胶质瘤等其余为良性肿瘤,如松果体细胞瘤、畸胎瘤、皮样囊肿等。生殖细胞瘤部分具有分泌活性,其活性分泌物可从血浆和脑脊液检测到这些生物肿瘤标志物包括:AFP、beta-HCG、placental alkaline phosphatase。脑脊液或血清AFP升高见于内胚窦癌;HCG和AFP同时升高见于胚胎性癌;HCG显著升高见于绒癌;这些升高的值中,HCG、AFP可能升高10-100倍。中等程度的HCG升高可能见于GE血清或脑脊液HCG大于 50IU/L、AFP大于25 ng/ml 支持NGGCT的诊断。病史症状表现: 1发于儿童 1/3有性早熟,少数发育迟滞。 2颅内高压症状(90%有):头痛、呕吐视力下降。 3侵犯下丘脑 出现尿崩症、肥胖、嗜睡或其他下丘脑的神经精神症状神经系统。 4局部压迫症状:两眼上视不能、动眼神经麻痹,使眼球运动障碍,、共济失调,瞳孔反射改变、包括阿—罗瞳孔等。中脑压迫受损:意识下降、肢体无力或僵硬等诊断:上述症状表现结合头部CT和 MRI检查可明确诊断,对部分生殖细胞瘤血和脑脊液生物标志物检查对诊疗也有帮助。头部CT:可见松果体钙化灶扩大变散或偏离移位,伴脑室扩大,局部肿瘤占位等;头部MRI:可清楚显示松果体局部肿瘤大小、范围边界、血供和质地、肿瘤与周围重要结构关系,以及脑积水情况等,更有利于医生做治疗决策。松果体肿瘤的处理和预后依赖于组织学类型,肿瘤组织病理对治疗选择很重要治疗1对纯生殖细胞GE,试验性放疗(20GY)是标准措施。如果肿瘤经放疗后明显退缩,就接受55GY的大剂量放疗。 2低级别的胶质瘤、松果体细胞瘤或畸胎瘤,则手术治疗时首选, 3室管膜瘤或恶性胶质瘤,可以做局部放疗; 4松果体母细胞瘤和某些生殖细胞肿瘤需要行脑脊髓放疗 (放疗 对于NGGCT,虽然对于放疗也有反应,但是只在不多于10-25%的肿瘤中能控制肿瘤。伽玛刀治疗:可用于松果体细胞瘤和乳突瘤的首次治疗,也可用于松果体母细胞瘤、生殖细胞瘤和复发瘤的辅助助治疗) 5脑积水的控制:三脑室底造瘘或脑室-腹腔分流 或手术时加造瘘。 6显微切除手术:随技术进步,手术疗效越来越好!除了对放疗敏感的生殖细胞瘤,绝大多数首选手术切除。 7化疗:略预后,因组织学类型、病情的严重程度及治疗情况不同而异,本病的治疗也应以手术加放疗为宜,依据病理结果来设计靶区。松果体母细胞瘤、畸胎瘤和生殖细胞瘤对化疗敏感,畸胎瘤对放疗不敏感,而化疗却可获得较好的疗效。松果体细胞瘤pineocytoma分化好,1级(WHO) grade I,预后很好。松果体母细胞瘤分化差、侵袭性强,WHO grade IV4级,预后极差。中间分化实质瘤,(PPTID; WHO grades II and III),年轻成人多见,2-3级,有一定分化,预后较差。术后应放化疗。乳突瘤(PTPR; WHO grades II and III),年轻成人多见,2-3级,易复发和脊髓播散。术后应放化疗。诊疗技术特点我们在较长期的诊疗实践中积累了较丰富的松果体区肿瘤的诊疗经验,对该区显微手术切除技术具有很高的驾驭能力,形成了微创、同步造瘘解决脑积水 和并发症少、恢复快的技术特点。论文:谭源福等:枕下经天幕入路显微切除松果体区病灶(大会发言),中华医学会2019年全国神经肿瘤学术大会,四川成都2019年4月11—13日典型病例:例1 男,2岁,头痛呕吐1月入院,体查(--)。MRI:松果体囊实占位并脑积水。(病理:未成熟型畸胎瘤1级)经枕下经天幕显微全切肿瘤,同时行三脑室后部四叠体池造瘘治疗脑积水,术后患儿完全恢复正常。例2例3
脑肿瘤是颅腔内肿瘤的总称,分为脑内肿瘤(发生于自脑实质内)和脑外肿瘤(发生于于脑实质外组织)。常见脑内肿瘤包括脑胶质瘤(星形细胞瘤,少突胶质瘤,胶质母细胞瘤,室管膜瘤和儿童髓母细胞瘤等),中枢神经节细胞瘤,海绵状血管瘤,血管网织细胞瘤,中枢淋巴瘤和脑转移瘤等;常见脑外肿瘤有垂体腺瘤,脑膜瘤,听神经瘤,颅咽管瘤,神经鞘瘤和表皮样囊肿等。在当前,显微(微创)手术切除术仍是脑肿瘤的最主要、最重要的治疗方法。最大安全切除是手术原则。影响手术治疗效的关键有如下三个方面:1.主刀医师的技术和经验:脑肿瘤手术是高度专业化的技术,对手术医师有很高的专业要求。医师在完成5年临床医学通识教育毕业并取得医师资格后还需5年以上神经专科的系统培养,才能成为专科初级医生。随后至少需5-10年、年主刀完成初级手术50-100例以上,才能较熟练掌握基本手术技术、积累基本手术经验。然后经持续多年专注的临床工作,技术技巧的渐进熟练、经验随积累而丰富,并经不断学习、分析总结,渐进提高,渐由技术模仿到技术改进(更好),然后再上升到得心应手、游刃有余的专业境界(悟性和专注决定进程)。近年,越来越多的统计数据显示手术疗效与主刀医师年手术量呈正相关,即年手术量越大,或经验越丰富,手术并发症就越少、手术效果越好。2.肿瘤特征:包括位置、大小、病理性质和瘤周关系等肿瘤位置:大脑被坚硬颅骨包裹保护,颅骨腔为类球状结构,上大部为颅盖,手术打开相对较方便;前下部为颅底,与面部五官和颈部相接,颅底结构复杂,颅底近中线旁区有很多重要神经血管出入,颅底肿瘤与之密切相关,颅底肿瘤手术显露和切除均很不容易;此外,脑中央区和重要功能结构区的肿瘤手术均存在脑功能损害风险。因此,肿瘤位置是手术疗效的一个重要影响因素。肿瘤大小:颅腔容积刚性、固定,各脑组织、颅神经和脑血管在颅腔的位置均相对固定。肿瘤小时,对周围神经血管结构推压和影响小:肿瘤越大,其对周围神经血管结构推压和影响越大。一般当肿瘤达4cm(巨大瘤)以上时,影响就更显著了,巨大瘤的手术难度和风险均增加,疗效也易受影响。病理特性:肿瘤病理特性决定了肿瘤生长快慢、肿瘤血供、肿瘤质地(软硬)和侵袭属性(良恶性)。生长快、血供极丰富、质地硬和侵袭性强(恶性)的脑肿瘤,疗效相对欠佳。瘤周关系(与重要功能神经血管):瘤周关系(按密切程度)分为有一定距离、邻近、紧密、推压、粘连、侵袭(水肿)、包裹等多种;关系越密切,神经功能损害风险越高,疗效也常因此受影响。术前CT和MRI(核磁)检查和临床神经功能评查,有利于术者在术前了解肿瘤上述特征,帮助术者在术前制定适宜的手术策略和术中应用恰当的手术技巧。(注#:脑重要功能神经血管结构:脑干、脑室基底节、中央前后回-椎体束、鞍区-海绵窦区、松果体区、横窦矢状窦旁、岩斜区、桥小脑角区、枕骨大孔腹侧区、左额语言区等)3.患者健康状况(整体机能状况):包括生活质量评分(KPS:10分-100分)评分;年龄;心、肺、肝、肾等重要器官功能状况等。脑肿瘤手术是一有创治疗,尽管当前微创技术的广泛开展,相比以前的手术创伤有显著的降低,但程度不同的手术创伤仍难以避免,患者在手术中和手术后机体都要动用或消耗一定的机能储备来应对手术创伤(打击)。患者整体健康状况差时,可动用的机能储备就很有限,手术风险就增大。一般KPS≤70分,年龄≥60岁,心、肺、肝、肾等之一的功能出现较严重损害时,手术风险就会增加。
微创是指诊疗行为对患者心灵(精神)和身体(器官组织)损害轻微,创伤能修复或修复时间短,患者身心能很快恢复正常,无永久性损害(后遗症)发生。微创理念是指医生在诊疗过程中始终秉持微创思维,将微创技术、技巧全面贯彻于诊疗全程。微创技巧:心灵(精神)方面:推介疾病现行成熟有效的可靠诊疗技术和医师长期积累的成功诊疗经验,帮助患者树立战胜疾病的信心;切实从患者身心利益出发,合理安排诊疗措施;认真分析疾病状态和转归,帮助患者正确认识疾病,保持乐观积极心态,建立适宜的风险意识,客观对待副作用和并发症,引导合理预期;耐心与患者及家属交流沟通,了解患者担忧和难处,研究适宜的解决办法,让患者安心诊疗;客观对待临床症状体征,不掩饰也不夸大(不良后果),及时解答患者疑虑,避免患者过度焦虑和恐惧,帮助患者理性对待疾病的各种不适,并尽量及时予以缓解,让患者平静、愉悦度过诊疗过程;出院后保持有效的医患沟通渠道,并定期随访,了解术后病情恢复情况和生活状况,减轻患者后顾之忧。身体(器官组织)方面:应用各种微创技巧使手术区各器官组织结构包括血循环和神经支配 其结构和代谢均损伤轻微。脑外科手术创伤权重和分类颅脑创伤权重:1.脑组织及其血供和代谢 >> >> 2.脑脊液(CSF)异常 >> 3.头皮颅骨硬膜脑损伤类型:1.脑神经结构损伤,2脑神经动脉血供损伤,3脑静脉回流受阻,4脑局部代谢损伤,5.复合损伤,6.弥漫性损伤(缺氧、缺血、炎症、中毒和感染等)脑脊液异常分类:1脑脊液流失,2脑脊液性状改变,3脑脊液吸收率下降,4脑脊液循环受阻,5.脑脊液感染。头皮颅骨硬膜损伤类型:1头皮结构损伤,2血供受损,3头皮神经受损;4颅骨缺损,5颅骨失活,6颅骨破损;7硬膜缺损,8硬膜粘连等颅脑外科手术均可能导致上述各类型损伤发生,颅脑外科微创技巧就是应用全面的技术手段避免上述创伤或将上述各种创伤降至最低,避免和减少手术并发症,利于和促进术后快速全面的恢复。特色微创神经外科技术技巧:1.显微切除技术:利用光学显微镜将手术操作区脑结构放大5-10倍,更清晰显示病灶及及周围结构,精准分离、切除病灶,保护病灶周围结构。2.瘤内切瘤技术:严格在肿瘤内操作,切除肿瘤。(理论上,)只要操作不超出肿瘤边界,瘤周结构应无损伤。3.锁孔(微骨孔)技术:选择适宜颅骨入点,开一小孔(10mm--30mm直径),经小孔处理或切除脑病灶。4.神经内镜(或辅助)治疗技术:利用内镜清晰放大显示(二维)功能,显示深部结构间残余小病灶,减少损伤、避免残留5.影像(导航)精准定位技术:利用影像数字技术精准确定病灶位置及其适宜进入路径与颅表进入位置(投影),避免方向偏差和减少显露损伤。6.脑松弛技术:利用体位变化、脑脊液引流和脑体积缩小等方法,增加脑回缩、促进脑沟裂池等自然间隙的扩大,创造微创手术操作空间。7.微创切口显露技术:顺应头皮神经、血管分布走向,在适宜入点以最小神经、血管损伤方式设计切口。并用利刀(而非电刀!)实施切开,使切口头皮创伤包括血供和神经支配的损伤最小化。8.额乳突切口技术:将常用的耳前颞部切口后移至耳后即为额乳突切口,从而避免颞部神经血管和肌肉的损伤,并增加颞中后部显露。9.单路径处理双侧(或上下)病灶技术:将毗邻的双侧或上下两处病变 通过单一手术路径解决,减少双路径创伤10.经脑沟裂和结构间入路技术: 脑沟脑裂脑池是脑发育中自然存在的间隙,而脑组织内神经纤维束间也存在可分开的潜在间隙,充分利用这些间隙操作可减少和避免脑组织结构损伤。11.脑保护技巧:包括滑膜覆盖、温湿保护技术、微显露、单向轻牵位置维持技术等12.CSF修复技术:术中脑脊液常常发生流失、血“污染”和感染等,导致脑环境破坏,术中应采取措施尽量减少和避免,术毕即予补充恢复。13.入路原位重建技术:显露时保护和保存好切口各层组织,术毕将切开的各层组织原位缝合固定,实现切口组织原位重建。
脑干类圆柱状,约60mm长,10-20mm粗,自上而下分中脑、桥脑和延髓三部分(见下图)。脑干内布满重要神经核团和上下传导神经纤维,是人维系人神志、呼吸和心血管活动的中枢。脑干病变对人生命活动影响至关重要。脑干位置深在,脑干病变的手术显露困难,曾长期被视为手术禁区。近年,随医学快速发展和手术技术的进步,禁区被慢慢打开,脑干病变包括肿瘤、出血和海绵状血管瘤等显微手术治疗效果已渐渐凸显出来,脑干手术开展也渐进广泛起来……脑干肿瘤相对颅内肿瘤较少见,儿童稍多见,约占儿童颅内肿瘤的 10-15 %;成人则很少见,约占成人颅内肿瘤的2 %。肿瘤以胶质瘤多见,低级(2级)星形细胞瘤约占70%,高级别胶质瘤占10-20%,其它包括淋巴瘤、转移瘤等。活检显示部分非瘤性(良性)病变如:炎性灶,脓肿,脱髓鞘病变,脓肿,囊肿,寄生虫等,应特别注意鉴别,在30-50岁的成人,脑干非瘤性病变可达15±3%.脑干海绵状血管瘤又称海绵状血管畸形(CM),不是肿瘤!是脑干较常见的良性病变,占颅内CM的8-22%,突发少量出血和局部脑干神经功能受损是其最常见临床表现。直径≥18mm和再次出血是手术指征脑干功能损害临床表现:常见症状复视,口角歪斜,头面和肢体感觉异常,声嘶、呛咳,肌力减退、肢体活动受限,行走不稳,头晕嗜睡等。严重时可出现意识障碍、呼吸困难等。脑干病灶手术预后:受多因素影响:主要与术前脑干功能受损程度,病灶部位,病灶边界清晰与否,肿瘤恶性程度和手术创伤等有关。术前脑干损害较轻、病灶位置表浅、边界清晰、恶性度低、手术创伤小,则预后较好!当然,术者经验和术后重症管理对预后也相当重要!我们的经验:近十年来我们渐进地开展了各类脑干手术,最近2年年均均超过二十例,积累了较多显微手术的成功经验,尤其在适宜征和精准瘤灶内操作的把握上……典型病例:例1.女, 23岁,因右侧肢体无力、言语不流利3天入院。体查:神清言语欠流利,右侧上下肢肌力4级。CT: 脑干及左基底节出血。手术入路:左耳前颞下经天幕入路近全切,预后:随访3个月,完全恢复正常生活,KPS 100. 例2.男,20岁,因头晕、左侧肢体麻木无力半月入院。体查:神清语利,左侧肢体肌力4级,步态欠稳。外院2次MRI提示脑干出血性病灶。手术入路:右耳前颞下经天幕入路全切,预后:随访2个月,仍在康复治疗中,左侧肌力Ⅴ—,余正常,KPS 90. 例3.男,36岁,脑干出血术后5年,突发右肢无力、言语不清7天,加重1天入院。 体查:嗜睡,言语模糊右上下肢肌力4—,右侧浅感觉减退。CT:: 桥脑出血,较以前扩大手术入路:左外侧小脑上入路近全切,预后:术后2周,刚出院,回当地巩固康复治疗中,右侧肌力Ⅳ级,浅感觉减退,余正常,KPS 80.例4.男,34岁,发现脑干海绵状血管瘤(CM)2年,肢体麻木头痛吞咽困难2天入院,嗜睡状,声嘶。1天后呼吸急促,PaO2下降,插管呼吸机支持,随后改善,急查CT桥延部CM再出血。急诊手术,经后正中经小脑延髓裂入路,显微镜下于四脑室底中下部膨隆处穿刺后打开,全切CM, 术后继续呼吸机支持,并严重肺部感染,气管切开;术后10天后撤呼吸机, 15天后肺部感染控制,20天后封闭气管导管,25天后步行出院。 例5.女3岁,发现眼、面、肢体活动受限3周入院,左外展、面神经受损,右肢肌力3-4级。MRI检查显示左桥脑上延髓肿瘤 手术入路:经后正中四脑室后部入路,显微近全切除。 肿瘤病理:星形细胞瘤2级 随访4年,未见明显复发,受损神经功能仍有部分未恢复。 例6.男53岁,左上睑下垂右下肢乏力1月,查:左上睑下垂,左瞳5mm,右下肢肌力4级。 MRI检查显示左中脑(大脑脚)小病灶,一般强化。手术入路:左颞下经天幕入路,显微全切。肿瘤病理:星形细胞瘤2级随访1年,动眼神经功能部分恢复,下肢功能全恢复;生活正常。 例7.女15岁,头痛呕吐7天入院。查体——。手术入路:后正中经小脑延髓裂入路,显微镜下全切除。随访1年,正常上学,生活活动均正常。
随着影像检查(CT或MRI)的广泛使用,许多人被意外发现存在某种脑“病”----一种脑结构性异常或无害新生物(良性肿瘤),不少人因此而产生不安、甚至莫名的恐慌,寝食不安,四处求医,甚至确诊误治,导致本可避免的身心损害,特此,我简要说说这些常见的脑“病”,以解您的疑虑。1.脑蛛网膜囊肿:绝大多数蛛网膜囊肿为先天存在的,其内为正常脑脊液,不产生任何脑损害、不引起任何不适(症状),常为头部CT或MRI检查时无意发现,不需治疗干预。但蛛网膜囊肿容易被错误解读、或与身体某种不适无故联系,从而产生莫名恐慌,甚至冒险手术,导致脑损害,教训深刻。对此,建议影像(CT或MRI)动态复查,每年检查1次,连续2-3年检查证实囊肿无改变(不增大!),即可打消顾虑,安心生活、学习和工作。对极少数进行性增大、并出现脑神经压迫征象者则宜咨询脑外科专家,再审慎考虑治疗干预。2.无功能垂体微腺瘤:无功能垂体微腺瘤又叫偶发瘤,常为脑核磁(MRI)检查时有意或无意中发现。这种瘤真实发生率很高,据报道可达10-15%。因该微腺瘤无内分泌功能(不释放激素)、瘤体小不影响或压迫周围正常垂体腺,为无害良性肿瘤,且90%以上不会增长变大,可与人长期和平共处,不需治疗干预(手术)或伽玛刀治疗。建议:每年MRI检查(稳定不变)和垂体激素检查(正常),连续2-3年均稳定,便可安心、放心。3.婴幼儿硬膜下积液:1岁以内的婴幼儿在头部CT检查中不少发现有薄层硬膜下积液(“脑外脑积水”),常见双额部对称存在,无占位效应(对脑组织无推压作用),不需治疗干预。这多为脑发育相对(颅骨)迟缓所致,并非出血所致。可咨询脑外科专家,排除硬膜下出血所致积液等(后者常有致病原因:出凝血功能异常、产道挤压损伤或外伤史;后者影像表现不同:常为单侧,积液较多,占位效应明显等;后者临床症状明显:多哭吵闹,食少易吐,睡眠不佳,前囟张力高等)。对此,建议采取如下措施:在保证充足睡眠和正常合理营养基础上,多带孩子玩耍活动、多听音乐、看动漫、亲近大自然和适度晒太阳等,增进感官刺激和肢体活动,促进大脑发育。一般1岁半到2岁后,大脑发育起来了,积液就慢慢消失了。孩子表现无明显异常,也不建议频繁CT复查!(已证实头部CT检查对3岁以内孩子大脑有一定影响)4.脑局部缺陷或发育不全:在不同年龄的影像检查中都可见到脑局部缺陷或发育不全,以儿童较多见,发生部位多在颞极、额底、小脑和胼胝体等处,无相应脑功能缺损或缺失,也无任何不适,无需治疗干预。但不少父母或自己仍然会有担心,希望大脑完整、想补上,容易相信“善意”建议去做脑细胞移植或修复手术。因为当前和可预见的将来相当长时间内,中枢神经(脑)缺失人为修复都难实现,千万不要去做无谓的尝试。5.脑内脂肪瘤:脑内脂肪为胚胎发育时期脂肪细胞异位存留于脑内所致,常见于松果体区和胼胝体及附近,生长极慢,很少产生脑功能损伤,也极少显著增大,因此无需治疗干预。因脂肪常将局部细小血管包裹其中,且与周围脑组织粘连紧密,安全全切除很困难、手术效果欠佳,不建议尝试手术。可每2-3年复查一次,影像动态观察其变化,证实其稳定,让自己放心。6.无症状的海绵状血管瘤:海绵状血管瘤最常见症状为癫痫发作,出血和局部神经功能损害等。约20-50%无任何症状。海绵状血管瘤没有明确的供血动脉,也缺乏引流静脉,可伴有静脉畸形。MRI是最佳的诊断评价工具(CM呈“爆米花”样改变)。无无症状的海绵状血管瘤,多为头部影像(CT或MRI)检查时偶然发现,因对脑组织无损害,无需治疗干预。但有症状的,建议咨询脑外科医师后再审慎考虑治疗干预。7.小的无症状脑膜瘤:脑膜瘤起源于硬脑膜内层的蛛网膜帽细胞,是最常见的脑肿瘤,约占颅内肿瘤的15--20%,40-60岁女性最多发。肿瘤绝大多数为良性,生长较缓慢,对无症状的小脑膜瘤(<2cm),对脑长期无损害,不需治疗干预,尤其对于老年人。可每年行MRI检查,连续3年检查发现肿瘤确实生长缓慢,就大可放心;如观察中发现肿瘤增长显著,再考虑治疗干预也不迟。但对已引起明显症状(压迫脑神经、影响脑功能的)和瘤周存在明显水肿者,则宜找经验丰富的脑外科医师进一步诊疗(手术)。8.单纯脑静脉畸形:静脉为引流血管,其内压低,单纯脑静脉畸形为脑发育过程中出现的单一静脉结构异常,其内压力不高、不会出血,也不会损害周围脑组织而产生相应症状,而且它还行使局部血液引流功能!不应视作异常。如给予不当治疗干预,反而导致脑损害(影响局部脑静脉血回流)。但有时难以判断是否系单纯静脉畸形或为动静脉畸形或硬膜动静脉瘘,需行脑血管造影检查确诊。本文系谭源福医生授权好大夫在线(www.haodf.com)发布,未经授权请勿转载。
180827.脑外伤去骨瓣减压后发生脑积水的危险因素190例TBI患者做了去骨瓣减压DC(男149,女41),术后30天存活130例,其中37例(28.4%)出现脑积水,34例(91.9%)需V-P分流手术,另3例早期颅骨修补术和暂时性腰引后积水缓解。多因素分析显示:纵裂积水(p<0.001)和术后3个月后延迟颅骨修补术(p<0.001)与需V-P分流或手术干预的脑积水发生相关,发生脑积水也与(半年时)不良预后有关。--延迟颅骨修补与伤后脑积水发生有关,纵裂积液(水瘤)是重伤减压术后发生脑积水的独立影像预言因素Risk factors for post-traumatichydrocephalusfollowing decompressive craniectomy.Acta Neurochir(Wien).2018 Jul 27AbstractNasi D1,Gladi M2,Di Rienzo A2,di Somma L2,Moriconi E2,Iacoangeli M2,Dobran M2.(Italy.)BACKGROUND:Post-traumatichydrocephalus(PTH)is one of the main complications of decompressive craniectomy(DC)after traumatic brain injury(TBI).Then,the recognition of risk factors and subsequent prompt diagnosis and treatment of PTH can improve the outcome of these patients.The purpose of this study was to identify factors associated with the development of PTH requiring surgical treatment in patients undergoing DC for TBI.METHODS:In this study,we collected the data of 190 patients(149 males and 41 females),who underwent DC for TBI in our Center.Then we analyzed the type of surgical treatment for all patients affected by PTH and the risk factors associated with the development of PTH.RESULTS:Post-traumatichydrocephalus(PTH)developed in 37 patients out of 130 alive 30days after DC(28.4%).The development of PTH required ventriculoperitoneal shunt(VPS)in 34 patients out of 37(91.9%),while,in the remaining 3 patients,cerebrospinal fluid hydrodynamic(CSF)disturbances resolved after urgent cranioplasty and temporary external lumbar drain.Multivariate analysis showed that the presence of interhemispheric hygroma(p<0.001)and delayed cranioplasty(3months after DC)(p<0.001)was significantly associated with the need for a VPS or other surgical procedure for PTH.Finally,among the 130 patients alive after 30days from DC,PTH was associated with unfavorable outcome as measured by the 6-month Glasgow Outcome Scale score(p<0.0001).CONCLUSIONS:Our results showed that delayed cranial reconstruction was associated with an increasing rate of PTH after DC.The presence of an interhemispheric hygroma was an independent predictive radiological sign of PTH in decompressed patients for severe TBI.KEYWORDS:Cranioplasty;Decompressive craniectomy;Post-traumatichydrocephalus;Traumatic brain injury;Ventriculoperitoneal shunt180818.脑外伤去骨瓣减压后发生需行V-P分流的脑积水的meta分析4个数据库(PubMed,Web of Science,Scopus,and Cochrane Library)的1983--2018年间,减压术后发生需行v-p分流的脑积水纳入分析,355份研究中共25份纳入meta分析,2402脑外伤后去骨瓣减压,354例出现伤后脑积水,事件发生率为17.7%(3.2--23.4%P<0.001,),成人为13%(9-18.5%,P<0.001)儿童37.6%(27.9--48.7%,P=0.029)---脑外伤后去骨瓣减压与伤后脑积水发生有关,尤其在儿童发生率高。Development of PosttraumaticHydrocephalusRequiring Ventriculoperitoneal Shunt After Decompressive Craniectomy for Traumatic Brain Injury:a Systematic Review and Meta-analysis of Retrospective Studies.Med Arch.2018 Jun;72(3):214-219.Fattahian R1,Bagheri SR1,Sadeghi M2,3.(Iran).BACKGROUND:Decompressive craniotomy(DC)is a known risk factor for the development of posttraumatichydrocephalus(PTH)in the patients with traumatic brain injury(TBI).Herein,the present study reported the development of PTH requiring ventriculoperitoneal(VP)shunt after DC for TBI.METHODS:Four databases(PubMed,Web of Science,Scopus,and Cochrane Library)were searched from 1983 to April 2018.The studies evaluating the prevalence of PTH requiring VP shunt after DC in the patients with TBIwere selected without language restriction.A random-effects meta-analysis using event rate(ER)and 95%confidence intervals(CIs),was runby RevMan5.3 software.RESULTS:Out of 355 studies obtained from the databases,25 studies were included and analyzed in the meta-analysis.The studies included 2402 patients undergoing DC for TBI,354 of whohad PTH.The pooled ER ofhydrocephalusin the patients undergoing DC for TBI was 17.7%[95%CI:13.2 to 23.4%;P<0.001].In addition,the pooled analysis showed that ER ofhydrocephaluswas 13%in adults[95%CI:9 to 18.5%;P<0.001]and 37.6%in children[95%CI:27.79 to 48.7%;P=0.029;I2=0%].CONCLUSION:The present study demonstrated that DC after TBI was associated with the development of PTH,especially in children compared to adults.KEYWORDS:Traumatic brain injury;decompressive craniotomy;hydrocephalus;ventriculoperitoneal shunt180714.预防无癫痫发作史的脑病术后癫痫左乙拉西坦/苯妥英钠哪个更好?--文献分析7个研报,803例。术后癫痫左乙拉西坦组1.26%(4/318),苯妥英钠组6.60%(32/485),左乙拉西坦预防效果显著优于苯妥英钠组(p<0.001);亚组分析:对所有脑病(p<0.001)和脑肿瘤(p<0.005),左乙拉西坦预防效果优于苯妥英钠组;药物副作用发生率无差异,但因药物副作用而停药的苯妥英钠组明显增多(p<0.001)结论:左乙拉西坦对非损伤脑手术后癫痫预防效果优于苯妥英钠,因药物副作用导致停药少。仍需与安慰剂的对照研究进一步论证。Phenytoin versus levetiracetam as prophylaxis for postcraniotomy seizure in patients with no history of seizures:systematic review and meta-analysis Journal of Neurosurgery Posted online on July 13,2018.Chang-Hyun Lee,MD,MSc1,Hae-Won Koo,MD2,Seong Rok Han,MD,PhD2,Chan-Young Choi,MD,PhD2,Moon-Jun Sohn,MD,PhD2,and Chae-Heuck Lee,MD,PhD2---Republic of KoreaBy Keywords:levetiracetam,phenytoin,seizure,de novo,craniotomy,brain tumor,epilepsyAbstractOBJECTIVEDe novo seizure following craniotomy(DSC)for nontraumatic pathology may adversely affect medical and neurological outcomes in patients with no history of seizures who have undergone craniotomies.Antiepileptic drugs(AEDs)are commonly used prophylactically in patients undergoing craniotomy;however,evidence supporting this practice is limited and mixed.The authors aimed to collate the available evidence on the efficacy and tolerability of levetiracetam monotherapy and compare it with that of the classic AED,phenytoin,for DSC.METHODSPubMed,Embase,Web of Science,and the Cochrane Library were searched for studies that compared levetiracetam with phenytoin for DSC prevention.Inclusion criteria were adult patients with no history of epilepsy who underwent craniotomy with prophylactic usage of phenytoin,a comparator group with levetiracetam treatment as the main treatment difference between the two groups,and availability of data on the numbers of patients and seizures for each group.Patients with brain injury and previous seizure history were excluded.DSC occurrence and adverse drug reaction(ADR)were evaluated.Seizure occurrence was calculated using the Peto odds ratio(POR),which is the relative effect estimation method of choice for binary data with rare events.RESULTSData from 7 studies involving 803 patients were included.The DSC occurrence rate was 1.26%(4/318)in the levetiracetam cohort and 6.60%(32/485)in the phenytoin cohort.Meta-analysis showed that levetiracetam is significantly superior to phenytoin for DSC prevention(POR 0.233,95%confidence interval[CI]0.117–0.462,p<0.001).Subgroup analysis demonstrated that levetiracetam is superior to phenytoin for DSC due to all brain diseases(POR 0.129,95%CI 0.039–0.423,p=0.001)and tumor(POR 0.282,95%CI 0.117–0.678,p=0.005).ADRs in the levetiracetam group were cognitive disturbance,thrombophlebitis,irritability,lethargy,tiredness,and asthenia,whereas rash,anaphylaxis,arrhythmia,and hyponatremia were more common in the phenytoin group.The overall occurrence of ADR in the phenytoin(34/466)and levetiracetam(26/432)groups(p=0.44)demonstrated no statistically significant difference in ADR occurrence.However,the discontinuation rate of AEDs due to ADR was 53/297 in the phenytoin group and 6/196 in the levetiracetam group(POR 0.266,95%CI 0.137–0.518,p<0.001).CONCLUSIONSLevetiracetam is superior to phenytoin for DSC prevention for nontraumatic pathology and has fewer serious ADRs that lead to discontinuation.Further high-quality studies that compare levetiracetam with placebo are necessary to provide evidence for establishing AED guidelines.ABBREVIATIONS ADR=adverse drug reaction;AED=antiepileptic drug;CI=confidence interval;DSC=de novo seizure following craniotomy;POR=Peto odds ratio;RCT=randomized controlled trial.180606.脊髓空洞为脑脊液流紊乱\脊髓拴系和髓内肿瘤所致的脊髓内液性空腔.本文总共1535例诊断为脊髓空洞,635例为中央管扩张,52例为胶质室管膜囊肿,52例为脊髓髓软化,2例为囊性髓内肿瘤.病理原因:604例病变在颅颈联合\CSF紊乱所致,最常见病理为Chiari I畸形543例;931例病变在椎管,最常见原因为椎管蛛网膜病变所致CSF阻塞533例,髓内肿瘤152例,拴系综合症69例.How Should Syringomyelia be Defined and Diagnosed?World Neurosurg.2018 Mar;111:e729-e745.doi:10.1016/j.wneu.2017.12.156.Epub 2018 Jan 6 Klekamp J(Quakenbrück,Germany.)OBJECTIVE:Syringomyelia is considered as a fluid-filled cavitation inside the spinal cord.However,there is no agreement whether a dilated central canal should be included under this heading or how glioependymal cysts,myelomalacias,or cystic tumors should be distinguished from syringomyelia.This article provides a definition of syringomyelia and guidelines for its diagnosis.METHODS:Between 1991 and 2015,of 3206 patients with spinal cord pathologies 2276 demonstrated cystic features.All patients underwent magnetic resonance imaging.Syringomyelia was differentiated from cystic intramedullary tumors,glioependymal cysts,myelomalacias,and dilatations of the central canal by clinical and radiologic criteria.RESULTS:A total of 1535 patients were diagnosed with syringomyelia,635 with dilatations of the central canal,52 with glioependymal cysts,52 with mylomalacias,and 2 with cystic intramedullary spinal cord tumors.Additional neuroradiologic studies revealed the causes of syringomyelia.As a result 604 patients showed pathologies at the craniocervical junction leading to disturbances of cerebrospinal fluid(CSF)flow.The commonest was a Chiari I malformation in 543 patients.Nine hundred thirty-one patients presented with pathologies in the spinal canal.The commonest causes were spinal arachnopathies,leading to CSF flow obstructions in 533 patients,intramedullary tumors in 152 patients,and tethered cord syndromes in 69 patients.CONCLUSIONS:The diagnosis of syringomyelia should be reserved for patients with a fluid-filled cavity in the spinal cord related to either a disturbance of CSF flow,spinal cord tethering,or an intramedullary tumor.For patients in whom such a relation cannot be established,the diagnosis of syringomyelia should be withheld.180601.207例自体颅骨修补,平均随访3.7年,总并发症39.6%,骨瓣去除19.3%,吸烟和45岁以下是骨瓣去除独立影响因素.30岁以下是骨瓣自吸收独立影响因素.Predictors of primary autograft cranioplasty survival and resorption after craniectomy.J Neurosurg.2018 May 11:1-8.doi:10.3171/2017.12.Korhonen TK1,2,Tetri S1,2,Huttunen J3,Lindgren A3,Piitulainen JM4,Serlo W5,Vallittu PK6,Posti JP6,7;Finnish National Cranial Implant Registry(FiNCIR)study group.Finland AbstractOBJECTIVE Craniectomy is a common neurosurgical procedure that reduces intracranial pressure,but survival necessitates cranioplasty at a later stage,after recovery from the primary insult.Complications such as infection and resorption of the autologous bone flap are common.The risk factors for complications and subsequent bone flap removal are unclear.The aim of this multicenter,retrospective study was to evaluate the factors affecting the outcome of primary autologous cranioplasty,with special emphasis on bone flap resorption.METHODS The authors identified all patients who underwent primary autologous cranioplasty at 3 tertiary-level university hospitals between 2002 and 2015.Patients underwent follow-up until bone flap removal,death,or December 31,2015.RESULTS The cohort comprised 207 patients with a mean follow-up period of 3.7 years(SD 2.7 years).The overall complication rate was 39.6%(82/207),the bone flap removal rate was 19.3%(40/207),and 11 patients(5.3%)died during the follow-up period.Smoking(OR 3.23,95%CI 1.50-6.95;p=0.003)and age younger than 45 years(OR 2.29,95%CI 1.07-4.89;p=0.032)were found to independently predict subsequent autograft removal,while age younger than 30 years was found to independently predict clinically relevant bone flap resorption(OR 4.59,95%CI 1.15-18.34;p=0.03).The interval between craniectomy and cranioplasty was not found to predict either bone flap removal or resorption.CONCLUSIONS In this large,multicenter cohort of patients with autologous cranioplasty,smoking and younger age predicted complications leading to bone flap removal.Very young age predicted bone flap resorption.The authors recommend that physicians extensively inform their patients of the pronounced risks of smoking before cranioplasty.KEYWORDS:BFR=bone flap resorption;CP=cranioplasty;DC=decompressive craniectomy;DM=diabetes mellitus;FiNCIR=Finnish National Cranial Implant Registry;ICP=intracranial pressure;SSI=surgical site infection;autograft;bone resorption;cranioplasty;graft survival;postoperative complicationsDOI:10.3171/2017.12.JNS172013180530.随机对照研究64例颅骨缺损修补术,32例用钛网,32例用自体颅骨,各死亡1例。随访1-2年以上,钛网例修补均成功,31例自体颅骨7例失败。自体颅骨修补12月后自行吸收持续发生,采用钛网修补可避免再手术和降低长期总住院费用A randomised controlled trial comparing autologous cranioplasty with custom-made titanium cranioplasty:long-term follow-up.Acta Neurochir(Wien).2018 May;160(5):885-891.Honeybul S1,2,Morrison DA3,Ho KM4,5,Lind CRP6,7,Geelhoed E8.(Australia).AbstractOBJECTIVE:To compare the long-term outcomes of patients who had been randomly allocated to receive primary titanium cranioplasty or autologous bone graft following decompressive craniectomy.METHODS:Sixty-four patients had been previously enrolled and randomised to receive either their own bone graft or a primary titanium cranioplasty.Functional and cosmetic outcomes had previously been assessed at 1-year following the cranioplasty procedure.Hospital records and the Picture Archiving communication system were reviewed to determine how many patients had cranioplasty failure or associated complications such as seizures beyond 1 year-with a minimum of 24-month follow-up.RESULTS:Amongst the 31 patients in the titanium group(one patient had died),no patients had a partial or complete cranioplasty failure at 12 months follow-up and there had been no failures beyond 12 months.Amongst the 31 patients who had an autologous cranioplasty(one patient had died),7 patients had complete resorption of the autologous bone such that it was adjudged a complete failure at 12-month follow-up.Five of these patients had had titanium augmentation and two patients declined further surgery.Both of these patients requested cranial augmentation for functional and cosmetic reasons subsequent to the 12-month follow-up.Another patient who had previously been noted to have moderate resorption at 12 months presented 1 year later with progressive bone flap resorption and also required subsequent augmentation for functional and cosmetic reasons.When follow-up was extended to a minimum of 24 months,use of titanium instead of autologous bone for primary cranioplasty resulted in a significant reduction in the number of patients who required rescue cranioplasty(0 vs 25%,95%confidence interval[CI]9.1-42.1%;p=0.001).In addition,there were significantly less total hospital healthcare costs in those patients randomised to the titanium arm of the trial(difference=A$9999,95%CI 2231-17,768;p=0.015).CONCLUSIONS:Bone resorption continued to occur beyond 12 months after autologous cranioplasty;use of primary titanium cranioplasty after decompressive craniectomy reduced the number of reoperations needed and the associated long-term total hospital costs.KEYWORDS:Autologous cranioplasty;Decompressive craniectomy;Randomised controlled trial;Titanium cranioplasty180429.脑膜瘤术前栓塞预后:2002-2014年633例(2.34%)术前栓塞26,375例(97.66%)未栓塞.术前栓塞者脑水肿发生率高(25.2%vs 17.7%,p=0.009),术后贫血和输血高(21.8%vs 13.8%,p=0.003),住院时间长(42.8%vs 35.7%,p=0.039).,死亡率无差异-------提示术前要求栓塞的脑膜瘤患者需要更多的监护和治疗Impact of preoperative endovascular embolization on immediate meningioma resection outcomesMichael G.Brandel,BA,Robert C.Rennert,MD,Arvin R.Wali,MAS,David R.Santiago-Dieppa,MD,Neurosurgical FocusApril 2018/Vol.44/No.4/Page E6 Department of Neurosurgery,University of California,San Diego,La Jolla,CaliforniaBy Keywords:meningioma,embolization,resection,cerebral edema,timing,discharge disposition AbstractOBJECTIVEPreoperative embolization of meningiomas can facilitate their resection when they are difficult to remove.The optimal use and timing of such a procedure remains controversial given the risk of embolization-linked morbidity in select clinical settings.In this work,the authors used a large national database to study the impact of immediate preoperative embolization on the immediate outcomes of meningioma resection.METHODSMeningioma patients who had undergone elective resection were identified in the National(Nationwide)Inpatient Sample(NIS)for the period 2002–2014.Patients who had undergone preoperative embolization were propensity score matched to those who had not,adjusting for patient and hospital characteristics.Associations between preoperative embolization and morbidity,mortality,and nonroutine discharge were investigated.RESULTSOverall,27,008 admissions met the inclusion criteria,and 633 patients(2.34%)had undergone preoperative embolization and 26,375(97.66%)had not.The embolization group was younger(55.17 vs 57.69 years,p<0.001)with a lower proportion of females(63.5%vs 69.1%,p=0.003),higher Charlson Comorbidity Index(p=0.002),and higher disease severity(p<0.001).Propensity score matching retained 413 embolization and 413 nonembolization patients.In the matched cohort,preoperative embolization was associated with increased rates of cerebral edema(25.2%vs 17.7%,p=0.009),posthemorrhagic anemia or transfusion(21.8%vs 13.8%,p=0.003),and nonroutine discharge(42.8%vs 35.7%,p=0.039).There was no difference in mortality(≤2.4%vs≤2.4%,p=0.82).Among the embolization patients,the mean interval from embolization to resection was 1.49 days.On multivariate analysis,a longer interval was significantly associated with nonroutine discharge(OR 1.33,p=0.004)but not with complications or mortality.CONCLUSIONSRelative to meningioma patients who do not undergo preoperative embolization in the same admission,those who do have higher rates of cerebral edema and nonroutine discharge but not higher rates of stroke or death.Thus,meningiomas requiring preoperative embolization represent a distinct clinical entity that requires prolonged,more complex care.Further,among embolization patients,the timing of resection did not affect the risk of in-hospital complications,suggesting that the timing of surgery can be determined according to surgeon discretion.180426脑血管畸形AVM出血推迟干预可好?回顾分析102例出血AVM,月再出血风险0.98%(<1%),结合文献AVM再出血风险主要发生在首次出血后6个月内,以及早期AVM周水肿和部分畸形血管术中显示欠清,早期手术干预神经损伤增加风险,作者建议出血后1个月时手术干预较适宜(还有待大宗前瞻对照研究).但对结节内和近结节处有动脉瘤的AVM病人,日再出血风险高(是无动脉瘤者的14倍),则宜尽早干预(不要推迟)消除风险.Delayed treatment of ruptured brain AVMs:is it ok to wait?Journal of Neurosurgery April 2018/Vol.128/No.4/Pages 999-1005 Jeffrey S.Beecher,DO,Kristopher Lyon,MD,Vin Shen Ban,MBBChir,MRCS,MSc,Department of Neurological Surgery,UT Southwestern Medical Center,Dallas,TexasBy Keywords:arteriovenous malformation,delayed surgery,rehemorrhage risk,vascular disorders AbstractOBJECTIVEDespite a hemorrhagic presentation,many patients with arteriovenous malformations(AVMs)do not require emergency resection.The timing of definitive management is not standardized in the cerebrovascular community.This study was designed to evaluate the safety of delaying AVM treatment in clinically stable patients with a new hemorrhagic presentation.The authors examined the rate of rehemorrhage or neurological decline in a cohort of patients with ruptured brain AVMs during a period of time posthemorrhage.METHODSPatients presenting to the authors’institution from January 2000 to December 2015 with ruptured brain AVMs treated at least 4 weeks posthemorrhage were included in this analysis.Exclusion criteria were ruptured AVMs that required emergency surgery involving resection of the AVM,prior treatment of AVM at another institution,or treatment of lesions within 4 weeks for other reasons(subacute surgery).The primary outcome measure was time from initial hemorrhage to treatment failure(defined as rehemorrhage or neurological decline as a direct result of the AVM).Patient-days were calculated from the day of initial rupture until the day AVM treatment was initiated or treatment failed.RESULTSOf 102 ruptured AVMs in 102 patients meeting inclusion criteria,7(6.9%)failed the treatment paradigm.Six patients(5.8%)had a new hemorrhage within a median of 248 days(interquartile range 33–1364 days).The total“at risk”period was 18,740 patient-days,yielding a rehemorrhage rate of 11.5%per patient-year,or 0.96%per patient-month.Twelve(11.8%)of 102 patients were found to have an associated aneurysm.In this group there was a single(8.3%)new hemorrhage during a total at-risk period of 263 patient-days until the aneurysm was secured,yielding a rehemorrhage risk of 11.4%per patient-month.CONCLUSIONSIt is the authors’practice to rehabilitate patients after brain AVM rupture with a plan for elective treatment of the AVM.The present data are useful in that the findings quantify the risk of the authors’treatment strategy.These findings indicate that delaying intervention for at least 4 weeks after the initial hemorrhage subjects the patient to a low(<1%)risk of rehemorrhage.The authors modified the treatment paradigm when a high-risk feature,such as an associated intracranial aneurysm,was identified180323.去骨瓣减压后脑梗塞研究:173例中重型脑外伤(重型140例81%),54例(31.2%)发生脑梗,70%在3天内发生。术后脑梗塞大脑后A区最常见(83.3%),(椎基底区20%,死亡100%和豆纹区18%,死亡70%)。术后脑梗预后差(死亡率48%、植物生存29.6%);术前GCS评分低(≤5,68.6%)、瞳孔散大(75.6%)、硬膜下血肿(98.1%)和骨瓣太大(132cm2>120 cm2)是独立不良预后因素.结论:外伤后脑梗是重型脑外伤后一个严重并发症,GCS计分低并伴瞳孔散大的急性硬膜下血肿伤后3天内应CT复查;对GCS≤5分的患者去大骨瓣减压的作用和益处仍需进一步研究论证。Posttraumatic cerebral infarction after decompressive craniectomy for traumatic brain injury:incidence,risk factors and outcome.Turk Neurosurg.2017 Jul 23.doi:10.5137/1019-5149.JTN.20761-17.1Su TM1,Lan CM,Lee TH,Shih FY,Hsu SW,Lu CH.(Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine.)AbstractAIM:To investigate the incidence,timing,risk factors of posttraumatic cerebral infarction(PTCI)and its influence on mortality in patients with moderate to severe traumatic brain injury(TBI).MATERIAL AND METHODS:After reviewing the medical records and radiographs over a 6-year period,173 patients with moderate to severe TBI were enrolled to determine the risk factors for the development of PTCI following unilateral decompressive craniectomy(DC).RESULTS:The incidence of PTCI following DC was 31.2%.Infarction in the posterior cerebral artery territory was the most common site of PTCI.The PTCI group had a significantly increased mortality(p 0.001)and unfavorable outcome(p 0.001).After stepwise logistic regression analysis,preoperative Glasgow Coma Scale(GCS)score(p 0.001,odds ratio[OR]=0.536,95%confidence interval[CI]=0.407-0.706),pupillary dilation(p=0.016,OR=3.2,95%CI=1.24-8.28),subdural hematoma(SDH)(p=0.01,OR=16.87,95%CI=1.97-144.30)and craniectomy size(p=0.017,OR=1.02,95%CI=1.0-1.04)remained independently associated with PTCI development following DC.CONCLUSION:Our study demonstrated PTCI is a severe complication in patients with acute TBI.We recommend repeating computed tomography within 3 days of trauma to detect the occurrence of PTCI in patients with subdural hematoma who have low preoperative GCS score and pupillary dilation,irrespective of neurologic status.More studies are necessary to clarify the role and benefit of DC in patients with a GCS score of 5 or less.180222.早行颅骨缺损修补(90天内),患者神经功能改进更大Early Cranioplasty is Associated with Greater Neurological Improvement:A Systematic Review and Meta-AnalysisJames G Malcolm,PhD;Rima S Rindler,MD;Jason K Chu,MD,MS;Falgun Chokshi,MD;Jonathan A Grossberg,MD...Neurosurgery,Volume 82,Issue 3,1 March 2018,Pages 278–288,BACKGROUNDCranioplasty after decompressive craniectomy is a common neurosurgical procedure,yet the optimal timing of cranioplasty has not been well established.OBJECTIVETo investigate whether the timing of cranioplasty is associated with differences in neurological outcome.METHODSA systematic literature review and meta-analysis was performed using MEDLINE,Scopus,and the Cochrane databases for studies reporting timing and neurological assessment for cranioplasty after decompressive craniectomy.Pre-and postcranioplasty neurological assessments for cranioplasty performed within(early)and beyond(late)90 d were extracted.The standard mean difference(SMD)was used to normalize all neurological measures.Available data were pooled to compare pre-cranioplasty,postcranioplasty,and change in neurological status between early and late cranioplasty cohorts,and in the overall population.RESULTSEight retrospective observational studies were included for a total of 528 patients.Studies reported various outcome measures(eg,Barthel Index,Karnofsky Performance Scale,Functional Independence Measure,Glasgow Coma Scale,and Glasgow Outcome Score).Cranioplasty,regardless of timing,was associated with significant neurological improvement(SMD.56,P=.01).Comparing early and late cohorts,there was no difference in precranioplasty neurological baseline;however,postcranioplasty neurological outcome was significantly improved in the early cohort(SMD.58,P=.04)and showed greater magnitude of change(SMD 2.90,P=.02).CONCLUSIONCranioplasty may improve neurological function,and earlier cranioplasty may enhance this effect.Future prospective studies evaluating long-term,comprehensive neurological outcomes will be required to establish the true effect of cranioplasty on neurological outcome.180221.儿童药物难治性癫痫手术/药物随机对照研究:1年时手术组77%无发作,而药物组仅7%无发作---手术疗效显著优于服药!Seizing the Moment:A Randomized Trial of Surgery for Drug-Resistant Pediatric EpilepsyNikita G Alexiades,MDGuy M.McKhann,II,MD Neurosurgery,Volume 82,Issue 3,1 March 2018,Pages N31–N32,15 February 2018To date,2 randomized trials have examined temporal lobectomy in adults with drug-resistant epilepsy with highly favorable results.2 Although no high-quality studies have explored the benefit of surgery in children with drug-resistant epilepsy,a meta-analysis of the literature found 1 yr seizure freedom rates of 74%and 45%for lesional and non-lesional pediatric epilepsy,respectively.3 Dwivedi et al4 now report in The New England Journal of Medicine the first randomized controlled trial of surgery versus medical therapy for children with drug-resistant epilepsy.The research team at the All India Institute of Medical Sciences designed a single-center randomized trial primarily comparing 1-yr seizure freedom rates in children treated either with surgery or continued best medical therapy.The study encompassed all pediatric epilepsy patients presenting to this tertiary care facility,only excluding patients where consensus could not be reached regarding the location of epileptic focus,or those with a history of status epilepticus,severe metabolic abnormalities,or systemic disease.As a result,the study population included a diversity of structural lesions and semiologies with surgical approach tailored to each.A total of 116 patients were enrolled and randomized with 57 in the surgery group who underwent surgery within 1 mo of randomization and 59 in the medical therapy group who were placed on their current standard of care surgery waiting list which typically lasts 1 yr or more.All seizure localization was accomplished using long-term video EEG and 3-Tesla magnetic resonance imaging scans,with the addition of ictal and interictal SPECT,PET,or magnetoencephalography when appropriate.No patients underwent invasive monitoring with stereoelectroencephalography implantation or subdural grid placement.The primary outcome investigated was seizure freedom at 1 yr based on blinded assessment of seizure diaries with various standardized scores related to seizure severity,behavior,and overall quality of life assessed at baseline and at 1-year follow-up as secondary outcomes.A single patient in the medical therapy group was lost to follow-up and included in intention-to-treat analyses.All other patients were followed for at least 1 yr.In total,the surgical patients underwent 14 temporal lobe resections,12 non-temporal lobe lesion resections,15 hemispherotomies,10 callosotomies,and 6 disconnection or resections of hypothalamic hamartomas,with no crossover from the medical-therapy group.At 1 yr,77%of patients in the surgery group were completely free of seizures compared to 7%of patients in the medical therapy group.Of the patients who underwent surgery,37%were completely seizure free for the entire 1-yr follow-up,while 40%experienced seizures in the postoperative period but subsequently progressed to seizure freedom.Patients in the surgery group demonstrated significant reductions on the Hague seizure severity scale along with significant improvements in behavior and overall quality of life indices,with no significant between-group differences related to intelligence quotient or social quotient on standardized testing.The authors present the first randomized controlled trial of surgery versus medical therapy for pediatric drug-resistant epilepsy,with encouraging results.Despite broad inclusion criteria,including patients with nonlesional epilepsy,the present study resulted in seizure freedom in 77%of patients treated surgically at 1 yr,with only 1 patient with lesional epilepsy not achieving seizure freedom.Additionally,the surgical group included 10 patients who underwent corpus callosotomy which generally results in~10%chance of seizure freedom.5 Had these patients been excluded from the present study,rates of seizure freedom may have been even more significant.Invasive seizure monitoring was not employed as part of the author's institutional protocol,though its use may have further improved outcomes,particularly in nonlesional cases.This important study provides class I evidence that epilepsy surgery improves seizure control and quality of life in patients with childhood-onset drug-resistant epilepsy.REFERENCES1.Baca CB,VickreyBG,Caplan R,Vassar SD,Berg AT.Psychiatric and medical comorbidity and quality of life outcomes in childhood-onset epilepsy.Pediatrics.2011;128(6):e1532-e1543.2.WiebeS,Blume WT,Girvin JP,Eliasziw M.A randomized,controlled trial of surgery for temporal-lobe epilepsy.N Engl J Med.2001;345(5):311-318.3.Tellez-Zenteno JF,Hernandez Ronquillo L,Moien-Afshari F,Wiebe S.Surgical outcomes in lesional and non-lesional epilepsy:a systematic review and meta-analysis.Epilepsy Res.2010;89(2-3):310-318.4.Dwivedi R,Ramanujam B,Chandra PS et al.Surgery for drug-resistant epilepsy in children N Engl J Med.2017;377(17):1639-1647.5.IwasakiM,UematsuM,NakayamaTet al.Parental satisfaction and seizure outcome after corpus callosotomy in patients with infantile or early childhood onset epilepsy.Seizure.2013;22(4):303-305.180207.非功能性垂体腺瘤发现时普遍较大,经鼻蝶手术切除为首选。但术后常有残留,多巴胺受体拮抗剂DA(如溴隐亭)治疗可防止85%患者的残瘤增大,减少再手术和放疗,可考虑残留患者常规服用Management of NFAs:medical treatment.Even-Zohar N1,Greenman Y2,3.(Tel Aviv,Israel.)Pituitary.2018 Jan 17.AbstractINTRODUCTION:Non-functioning pituitary adenomas(NFPAs)are in general large tumors that present with symptoms secondary to local pressure on adjacent structures.Transsphenoidal surgery is the first line of treatment but residual tumor mass is often detected post-operatively.Medical therapy,in any stage of tumor management,is not well established.METHODS:A literature search was performed to review the available data on medical treatment of NFPAs.RESULTS:Medications investigated for the treatment of NFPAs include dopamine receptor agonists(DA)and somatostatin receptor ligands.Randomized controlled trials are lacking,but available data suggest that DA have a positive effect on tumor remnant stabilization after surgery and could be considered in this setting.Temozolomide is reserved for aggressive tumors,although future studies are required.CONCLUSIONS:NFPA are often not amenable to complete surgical resection.Conservative follow-up after surgery is associated with a high prevalence of tumor remnant progression.DA therapy may prevent residual tumor enlargement in over 85%of these patients,with a substantial consequent reduction in the need for repeat surgery or radiation therapy.It is our view that DA treatment should be routinely considered for the management of NFPA patients with incompletely resected tumors.KEYWORDS:Dopamine agonists;Medical treatment;Non-functioning pituitary adenoma;Peptide receptor radionuclide therapy(PRRT);Somatostatin receptor agonists;Temozolamide180116.脑外伤后起始CT检查显示中线(纵裂)蛛网膜下腔出血可作为严重弥漫轴索损伤标志Traumatic midline subarachnoid hemorrhage on initial computed tomography as a marker of severe diffuse axonal injuryDaddy Mata-Mbemba,MD,PhD1,2,Shunji Mugikura,MD,PhD1,Atsuhiro Nakagawa,MD,PhD2,et al:Journal of NeurosurgeryPosted online on January 5,2018 By Keywords:diffuse axonal injury,traumatic subarachnoid hemorrhage,traumatic brain injury,computed tomography,early outcome,long-term outcome,trauma AbstractOBJECTIVEThe objective of this study was to test the hypothesis that midline(interhemispheric or perimesencephalic)traumatic subarachnoid hemorrhage(tSAH)on initial CT may implicate the same shearing mechanism that underlies severe diffuse axonal injury(DAI).METHODSThe authors enrolled 270 consecutive patients(mean age[±SD]43±23.3 years)with a history of head trauma who had undergone initial CT within 24 hours and brain MRI within 30 days.Six initial CT findings,including intraventricular hemorrhage(IVH)and tSAH,were used as candidate predictors of DAI.The presence of tSAH was determined at the cerebral convexities,sylvian fissures,sylvian vallecula,cerebellar folia,interhemispheric fissure,and perimesencephalic cisterns.Following MRI,patients were divided into negative and positive DAI groups,and were assigned to a DAI stage:1)stage 0,negative DAI;2)stage 1,DAI in lobar white matter or cerebellum;3)stage 2,DAI involving the corpus callosum;and 4)stage 3,DAI involving the brainstem.Glasgow Outcome Scale–Extended(GOSE)scores were obtained in 232 patients.RESULTSOf 270 patients,77(28.5%)had DAI;tSAH and IVH were independently associated with DAI(p<0.05).Of tSAH locations,midline tSAH was independently associated with both overall DAI and DAI stage 2 or 3(severe DAI;p<0.05).The midline tSAH on initial CT had sensitivity of 60.8%,specificity of 81.7%,and positive and negative predictive values of 43.7%and 89.9%,respectively,for severe DAI.When adjusted for admission Glasgow Coma Score,the midline tSAH independently predicted poor GOSE score at both hospital discharge and after 6 months.CONCLUSIONSMidline tSAH could implicate the same shearing mechanism that underlies severe DAI,for which midline tSAH on initial CT is a probable surrogate.180113.荟萃分析(64篇,嗅沟脑膜瘤891例和鞍结节脑膜瘤1444例):内镜经鼻切除嗅沟脑膜瘤和鞍结节脑膜瘤疗效不及显微经颅切除方法:内镜经鼻显微经颅p值全切率%---嗅沟脑膜瘤70.9 88.5 p<0.01---鞍节脑膜瘤83.0 85.8 p=0.34视力改善---嗅沟脑膜瘤----p=0.33---鞍节脑膜瘤----p<0.01CSF漏%---嗅沟脑膜瘤25.1 10.5 p<0.01---鞍节脑膜瘤19.3 5.81p<0.01动脉损伤%---嗅沟脑膜瘤----p=0.10---鞍节脑膜瘤4.89 1.86p=0.03死亡率%---嗅沟脑膜瘤----p=0.88---鞍节脑膜瘤----p=0.14The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas—a meta-analysisIvo S.MuskensEmail author Vanessa BricenoTom L.OuwehandJoseph P.Castlen William B.Gormley et al:Acta Neurochirurgica January 2018,Volume 160,Issue 1,pp 59–75|AbstractObjectIn the past decade,the endonasal transsphenoidal approach(eTSA)has become an alternative to the microsurgical transcranial approach(mTCA)for tuberculum sellae meningiomas(TSMs)and olfactory groove meningiomas(OGMs).The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.MethodsA systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines.Pooled incidence was calculated for gross total resection(GTR),visual improvement,cerebrospinal fluid(CSF)leak,intraoperative arterial injury,and mortality,comparing eTSA and mTCA,with p-interaction values.ResultOf 1684 studies,64 case series were included in the meta-analysis.Using the fixed-effects model,the GTR rate was significantly higher among mTCA patients for OGM(eTSA:70.9%vs.mTCA:88.5%,p-interaction<0.01),but not significantly higher for TSM(eTSA:83.0%vs.mTCA:85.8%,p-interaction=0.34).Despite considerable heterogeneity,visual improvement was higher for eTSA than mTCA for TSM(p-interaction<0.01),but not for OGM(p-interaction=0.33).CSF leak was significantly higher among eTSA patients for both OGM(eTSA:25.1%vs.mTCA:10.5%,p-interaction<0.01)and TSM(eTSA:19.3%,vs.mTCA:5.81%,p-interaction<0.01).Intraoperative arterial injury was higher among eTSA(4.89%)than mTCA patients(1.86%)for TSM(p-interaction=0.03),but not for OGM resection(p-interaction=0.10).Mortality was not significantly different between eTSA and mTCA patients for both TSM(p-interaction=0.14)and OGM resection(p-interaction=0.88).Random-effect models yielded similar results.ConclusionIn this meta-analysis,eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.171222.儿童重型脑外伤行ICP监测住院时间长、受到更多降颅内压干预,对儿童脑外伤神经功能预后无改善。-------30家医院3084例(2007-2012年)18岁以下GCS≤8的脑外伤儿童,1002(32.5%)例伤后24内ICP监测,2082(67.5%)例未监测ICP;两组神经功能预后无统计学差异。(此结果与成人重型脑外伤ICP监测结果相似)Severe Traumatic Brain InjuryNeurosurgery,Volume 82,Issue 1,1 January 2018,Pages N9–N10,13 December 2017 David L.Penn,MD,MSJohn H.Chi,MD,MPHMark R.Proctor,MDEvidence for the use of intracranial pressure(ICP)monitoring,in both adults and pediatric populations,to improve mortality and neuropsychologic outcomes has been limited.One randomized controlled trial demonstrated nonsuperiority of ICP monitoring compared to radiographic and clinical monitoring on a composite outcome of survival,consciousness,and functional status.1 In contrast,an observational study conducted in large pooled pediatric populations,using random-intercept multilevel modeling,demonstrated improvement in hospital mortality;however,this study did not examine long-term outcomes.2 In attempts to balance the respective limitations of each study,recent work published by Bennett et al3 in JAMA Pediatrics examines the role of ICP monitoring in both mortality and functional outcome.Using the Pediatric Health Information System database and the National Trauma Data Bank,the authors included 3084 patients admitted between 2007 and 2012,less than 18 yr of age,who had experienced severe traumatic brain injury(TBI;Glasgow Coma Scale≤8 in the emergency department),at 30 hospitals.Patients were excluded if they were transferred from another acute care hospital,left against medical advice,had been admitted for previous TBI,or had a diagnosis code for late effects of TBI.Among these patients,1002(32.5%)underwent placement of an ICP monitor within 24 h and 2082(67.5%)had no ICP monitor(or had one placed after 24 h).Propensity score matching was used for the analysis of data.This statistical technique for observational data aims to balance covariates predicting treatment that can create biases between groups from confounding variables,ie mechanism of trauma or specific radiological findings.Covariates accounted for include:demographics,clinical events,types of injury,neurological examinations,and hospital capability variables.The primary outcome model estimated associations between ICP monitoring and mortality(including discharge to hospice)or poor functional survival,in a binary model.Secondary outcome and subgroup analysis was conducted associating ICP monitoring with mortality alone,mortality or tracheostomy,and mortality or gastrotomy.Using these methods,there was no statistically significant difference in functional survival between the group that underwent ICP monitoring and the group that did not.Secondary analysis demonstrated increased likelihood of mortality,discharge to hospice,or tracheosotmy or gastrostomy placement with ICP monitor placement.Lastly,it was determined that children who underwent ICP monitoring had longer hospitalization and received more therapeutic interventions targeted towards reducing intracranial hypertension.These results support the findings of the randomized controlled trial conducted by Chesnut et al.1With lack of strong evidence,it is not surprising that the use of ICP monitoring in both adults and children is variable.Although it seems intuitively obvious that having this data point would be beneficial,large observational studies in adults and now in children do not clearly support the benefit.Current guidelines for pediatric patients state that although elevated ICP is associated with poorer outcomes,it is only a level III recommendation to use ICP monitoring in children with severe TBI.4 Recommendations from adult guidelines are slightly more firm,using level IIb evidence,stating that ICP should be monitored in patients with Glasgow Coma Scale less than 8 and an abnormal computed tomography(CT)scan or a normal CT scan in patients who meet 2 of the 3 following criteria:age>40,unilateral or bilateral motor posturing,or systolic blood pressure less than 90 mm Hg.5 While ethical constraints make it difficult to perform randomized controlled trials in such a heterogeneous and critically ill population,continuing to perform larger observational studies,such as this one,using advanced statistical analysis may make it easier to guide clinical decision making.REFERENCES1.Chesnut RM et al.A trial of intracranial-pressure monitoring in traumatic brain injury N Engl J Med 2012;367(26):2471-24813.Bennett TD,DeWitt PE,Greene TH et al.Functional outcome after intracranial pressure monitoring for children with severe traumatic brain injury.JAMA Pediatr.2017;171(10):965-971.171129.去大骨瓣减压术硬膜扩大成形严密缝合与否对照研究---硬膜松散缝合快速关颅过程安全、不增加并发症:分2组,松散缝合组(27例),严密缝合组(28例);两组年龄、术时GCS,GOS,随访时间和并发症(包括CSF漏,伤口感染,脑脓肿,皮瓣下积液等分别4例对5例)无统计差异;手术时间严密缝合组132分钟,松散缝合组101分钟;松散组平均费用减少420美元(减23,4%)Randomized controlled study comparing 2 surgical techniques for decompressive craniectomy:with watertight duraplasty and without watertight duraplastyEduardoVieira,MD,Thiago C.Guimares,MD,Igor V.Faquini,MD,Jose L.SilvaJr.,MD,(Department of Neurological Surgery,Hospital da Restaurao,Recife,Brazil)Journal of NeurosurgeryPosted online on November 17,2017By Keywords:decompressive craniectomy,traumatic brain injury,brain edema,duraplastyAbstractOBJECTIVEDecompressive craniectomy(DC)is a widely used procedure in neurosurgery;however,few studies focus on the best surgical technique for the procedure.The authors’objective was to conduct a prospective randomized controlled trial comparing 2 techniques for performing DC:with watertight duraplasty and without watertight duraplasty(rapid-closure DC).METHODSThe study population comprised patients ranging in age from 18 to 60 years who were admitted to the Neurotrauma Service of the Hospital da Restaurao with a clinical indication for unilateral decompressive craniectomy.Patients were randomized by numbered envelopes into 2 groups:with watertight duraplasty(control group)and without watertight duraplasty(test group).After unilateral DC was completed,watertight duraplasty was performed in the control group,while in the test group,no watertight duraplasty was performed and the exposed parenchyma was covered with Surgicel and the remaining dura mater.Patients were then monitored daily from the date of surgery until hospital discharge or death.The primary end point was the incidence of surgical complications(CSF leak,wound infection,brain abscess,or subgaleal fluid collections).The following were analyzed as secondary end points:clinical outcome(analyzed using the Glasgow Outcome Scale[GOS]),surgical time,and hospital costs.RESULTSFifty-eight patients were enrolled,29 in each group.Three patients were excluded,leaving 27 in the test group and 28 in the control group.There were no significant differences between groups regarding age,Glasgow Coma Scale score at the time of surgery,GOS score,and number of postoperative follow-up days.There were 9 surgical complications(5 in the control group and 4 in the test group),with no significant differences between the groups.The mean surgical time in the control group was 132 minutes,while in the test group the average surgical time was 101 minutes,a difference of 31 minutes(p=0.001).The mean reduction in total cost was$420.00 USD(a 23.4%reduction)per procedure in the test group.CONCLUSIONSRapid-closure DC without watertight duraplasty is a safe procedure.It is not associated with a higher incidence of surgical complications(CSF leak,wound infection,brain abscess,or subgaleal fluid collections),and it decreased surgical time by 31 minutes on average.There was also a hospital cost reduction of$420.00 USD(23.4%reduction)per procedure.171116.重型脑外伤后高血钠与伤后早期死亡独立相关----重型脑外伤588例,血钠正常63.1%,轻度13.1%,中度8.5%,重度15.3%,入院1周内发生占79.3%,出现急性肾损(creatinine of≥0.3 mg/dl)占27.3%,与高血钠程度显著相关(p<0.001),出院时25.2%死亡,高血钠是死亡显著独立预示因子(hazard ratios for mild:3.4,moderate:4.4,and severe:8.4;p<0.001)Morbidity and mortality associated with hypernatremia in patients with severe traumatic brain injuryAditClaudia S.Robertson,MD,and Shankar P.Gopinath,MD Neurosurgical FocusNovember 2017/Vol.43/No.5/Page E2AbstractOBJECTIVEHypernatremia is independently associated with increased mortality in critically ill patients.Few studies have evaluated the impact of hypernatremia on early mortality in patients with severe traumatic brain injury(TBI)treated in a neurocritical care unit.METHODSA retrospective review of patients with severe TBI(admission Glasgow Coma Scale score≤8)treated in a single neurocritical care unit between 1986 and 2012 was performed.Patients with at least 3 serum sodium values were selected for the study.Patients with diabetes insipidus and those with hypernatremia on admission were excluded.The highest serum sodium level during the hospital stay was recorded,and hypernatremia was classified asnone(≤150 mEq/L),mild(151–155 mEq/L),moderate(156–160 mEq/L),and severe(>160 mEq/L).Multivariate Cox regression analysis was performed to determine independent predictors of early mortality.RESULTS.A total of 588 patients with severe TBI were studied.The median number of serum sodium measurements for patients in this study was 17(range 3–190).No hypernatremia was seen in 371 patients(63.1%),mild hypernatremia in 77 patients(13.1%),moderate hypernatremia in 50 patients(8.5%),and severe hypernatremia in 90 patients(15.3%).Hypernatremia was detected within the 1st week of admission in 79.3%of patients(n=172),with the majority of patients(46%)being diagnosed within 72 hours after admission.Acute kidney injury,defined as a rise in creatinine of≥0.3 mg/dl,was observed in 162 patients(27.6%)and was significantly associated with the degree of hypernatremia(p<0.001).At discharge,148 patients(25.2%)had died.Hypernatremia was a significant independent predictor of mortality(hazard ratios for mild:3.4,moderate:4.4,and severe:8.4;p<0.001).Survival analysis showed significantly lower survival rates for patients with greater degrees of hypernatremia(log-rank test,p<0.001).CONCLUSIONSHypernatremia after admission in patients with severe TBI was independently associated with greater risk of early mortality.In addition to severe hypernatremia,mild and moderate hypernatremia were significantly associated with increased early mortality in patients with severe TBI.ABBREVIATIONSGCS=Glasgow Coma Scale;HR=hazard ratio;TBI=traumatic brain171024.伤后早期MRI检查对预后评估有重要价值:伤后6个月及以上死亡和不良预后患者均有脑干损伤;弥漫性触索损伤患者不良预后风险增加;损伤灶越深和后下部者不良神经功能预后增加。The Prognostic Value of MRI in Moderate and Severe Traumatic Brain Injury:A Systematic Review and Meta-Analysis.AbstractHaghbayan H1,Boutin A,Laflamme M,Lauzier F,Shemilt M,Moore L,Zarychanski R,Douville V,Fergusson D,Turgeon AF.Crit Care Med.2017 Oct 12.doi:10.1097/CCM.0000000000002731OBJECTIVES:Traumatic brain injury is a major cause of death and disability,yet many predictors of outcome are not precise enough to guide initial clinical decision-making.Although increasingly used in the early phase following traumatic brain injury,the prognostic utility of MRI remains uncertain.We thus undertook a systematic review and meta-analysis of studies evaluating the predictive value of acute MRI lesion patterns for discriminating clinical outcome in traumatic brain injury.DATA SOURCES:MEDLINE,EMBASE,BIOSIS,and CENTRAL from inception to November 2015.STUDY SELECTION:Studies of adults who had MRI in the acute phase following moderate or severe traumatic brain injury.Our primary outcomes were all-cause mortality and the Glasgow Outcome Scale.DATA EXTRACTION:Two authors independently performed study selection and data extraction.We calculated pooled effect estimates with a random effects model,evaluated the risk of bias using a modified version of Quality in Prognostic Studies and determined the strength of evidence with the Grading of Recommendations,Assessment,Development,and Evaluation.DATA SYNTHESIS:We included 58 eligible studies,of which 27(n=1,652)contributed data to meta-analysis.Brainstem lesions were associated with all-cause mortality(risk ratio,1.78;95%CI,1.01-3.15;I=43%)and unfavorable Glasgow Outcome Scale(risk ratio,2.49;95%CI,1.72-3.58;I=81%)at greater than or equal to 6 months.Diffuse axonal injury patterns were associated with an increased risk of unfavorable Glasgow Outcome Scale(risk ratio,2.46;95%CI,1.06-5.69;I=74%).MRI scores based on lesion depth demonstrated increasing risk of unfavorable neurologic outcome as more caudal structures were affected.Most studies were at high risk of methodological bias.CONCLUSIONS:MRI following traumatic brain injury yields important prognostic information,with several lesion patterns significantly associated with long-term survival and neurologic outcome.Given the high risk of bias in the current body of literature,large well-controlled studies are necessary to better quantify the prognostic role of early MRI in moderate and severe traumatic brain injury.171022.脑外伤后颅内压监测研究:研究支持重型颅脑损伤应用颅内压监测;去骨瓣减压和巴比妥疗法是重型颅脑损伤后颅高压有效治疗方法;但幸存者重残比率显著升高。ICP management in patients suffering from traumatic brain injury:a systematic review of randomized controlled trials.AbstractAbraham P1,Rennert RC1,Gabel BC1,Sack JA1,Karanjia N1,Warnke P2,Chen CC3.Acta Neurochir(Wien).2017 Oct 20.doi:10.1007/s00701-017-3363-1BACKGROUND:Severe traumatic brain injury(sTBI)is a major cause of morbidity and mortality.Intracranial pressure(ICP)monitoring and management form the cornerstone of treatment paradigms for sTBI in developed countries.We examine the available randomized controlled trial(RCT)data on the impact of ICP management on clinical outcomes after sTBI.METHODS:A systematic review of the literature on ICP management following sTBI was performed to identify pertinent RCT articles.RESULTS:We identified six RCT articles that examined whether ICP monitoring,decompressive craniectomy,or barbiturate coma improved clinical outcomes after sTBI.These studies support(1)the utility of ICP monitoring in the management of sTBI patients and(2)craniectomy and barbiturate coma as effective methods for the management of intracranial hypertension secondary to sTBI.However,despite adequate ICP control in sTBI patients,a significant proportion of surviving patients remain severely disabled.CONCLUSIONS:If one sets the bar at the level of functional independence,then the RCT data raises questions pertaining to the utility of decompressive craniectomy and barbiturate coma in the setting of sTBI.KEYWORDS:Decompressive craniectomy;Intracranial pressure;Traumatic brain injury170919.重复内镜三脑室底造瘘治疗迟发(>6月)再阻塞性脑积水10例,长期随访显示80%有效Long-Term Follow-Up of Repeat Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus.Oertel J1,Vulcu S2,Eickele L2,Wagner W3,Cinalli G4,Rediker J2.World Neurosurg.2017 Mar;99:556-565.AbstractOBJECTIVE:Endoscopic third ventriculostomy(ETV)is a safe and less-invasive treatment strategy for patients with obstructive hydrocephalus and provides excellent outcome.Nevertheless,repeat ETV in cases of ETV failure is a controversial issue.METHODS:Between 1993 and 1999,113 patients underwent a total of 126 ETVs at the Department of Neurosurgery,Mainz University Hospital.Obstructive hydrocephalus was the causative pathology in all cases.A very long-term follow-up of up to 16 years could be achieved.All medical reports of patients who received ETV were reviewed and analyzed with focus on ETV failure with following repeat ETV and its initial as well as very long-term success.RESULTS:Thirty-one events of ETV failure occurred during the follow-up period.Thirteen patients underwent repeat ETV:3 patients during the first 3 months(early repeat ETV),the other 10 patients after 7-78 months(late repeat ETV,mean 33 months).All repeat ETV were performed without complications.Follow-up evaluation after successful repeat ETV ranged from<1 month up to 14 years(mean 7 years).Of the 3 early revisions,2 failed and 1 other patient died during follow-up whereas only 2 of the late repeat ETV failed.Very long-term success rate of late repeat ETV up to 14 years yielded 80%.CONCLUSIONS:Repeat ETV in cases of late ETV failures represents an excellent option for cerebrospinal fluid circulation restoration up to 14 years of follow-up.Repeat ETV in early ETV failure in contrast is not favored by the performing surgeons;and factors of ETV failure should be analyzed very carefully before a decision for repeat ETV is made.Copyright2017 Elsevier Inc.All rights reserved.KEYWORDS:ETV failure;Neuroendoscopy;Repeat ETV;Very long-term outcome170915.伤后脑脂肪栓塞(CFE)—表现、诊断和预后:伤后或骨科术后出现原因不明的意识障碍应高度警惕(CFE),MRI弥散加权成像显示特征性的白质散在高信号病灶提示(CFE),大部分患者预后良好Cerebral Fat Embolism:Clinical Presentation,Diagnostic Steps and Long-Term Follow-Up.Dunkel J1,Roth C1,Erbguth F2,Dietrich W2,Hügens-Penzel M3,Ferbert A1.Eur Neurol.2017 Sep 12;78(3-4):181-187.doi:10.1159/000479002AbstractOBJECTIVE:Symptomatic cerebral fat embolism(CFE)is a rare complication that occurs after a traumatic injury or orthopaedic surgery and is diagnostically challenging.No data is currently available concerning long-term follow-up.METHODS:We identified from medical records 9 patients with CFE and revised the clinical signs and the diagnostic process.We then analysed long-term follow-up data,targeting clinical course after discharge,neurological impairment,and current quality of life,using the Barthel index and the modified Rankin Scale.RESULTS:All 9 patients initially showed severe neurological deficits,including disturbance of consciousness ranging from somnolence to coma.During the follow-up period for 3-58 months after the insult 2 patients had died.The 7 patients who remained alive had either recovered completely or showed only minor neurological deficits after rehabilitation.They were nearly independent in daily life and needed only minimal assistance.We performed the first brain biopsy in a patient with CFE.CONCLUSION:Most patients had a good outcome after long-term follow-up.In patients with an unexplained altered state of consciousness after a traumatic injury or an orthopaedic surgery,an MRIwith diffusion-weighted imaging must be performed to uncover thecharacteristic pattern of disseminated hyperintense lesions in the white matter that are associated with CFE.170908.2231例AVM伽玛刀治疗(平均随访63.7月)中1398例证实有效(闭塞),早期闭塞(18月内)198例,后期闭塞(>18月)1200例,较小、位于额叶基底节或小脑、深静脉引流和接受剂量>24 Gy的AVM患者更易早期生效Early versus late arteriovenous malformation responders after stereotactic radiosurgery:an international multicenter study Or Cohen-Inbar,MD,PhD1,Robert M.Starke,MD,MSc1,9,Gabriella Paisan,BA1,Hideyuki Kano,MD,PhD2,Paul P.Huang,MD3,et al:Journal of NeurosurgerySeptember 2017/Vol.127/No.3/Pages 503-511AbstractBy Keywords:radiosurgery,Gamma Knife,arteriovenous malformation,early obliteration,embolization,vascular disorders,stereotactic radiosurgeryOBJECTIVEThe goal of stereotactic radiosurgery(SRS)for arteriovenous malformation(AVM)is complete nidus obliteration,thereby eliminating the risk of future hemorrhage.This outcome can be observed within the first 18 months,although documentation of AVM obliteration can extend to as much as 5 years after SRS is performed.A shorter time to obliteration may impact the frequency and effect of post-SRS complications and latency hemorrhage.The authors'goal in the present study was to determine predictors of early obliteration(18 months or less)following SRS for cerebral AVM.METHODSEight centers participating in the International Gamma Knife Research Foundation(IGKRF)obtained institutional review board approval to supply de-identified patient data.From a cohort of 2231 patients,a total of 1398 patients had confirmed AVM obliteration.Patients were sorted into early responders(198 patients),defined as those with confirmed nidus obliteration at or prior to 18 months after SRS,and late responders(1200 patients),defined as those with confirmed nidus obliteration more than 18 months after SRS.The median clinical follow-up time was 63.7 months(range 7–324.7 months).RESULTSOutcome parameters including latency interval hemorrhage,mortality,and favorable outcome were not significantly different between the 2 groups.Radiologically demonstrated radiation-induced changes were noted more often in the late responder group(376 patients[31.3%]vs 39 patients[19.7%]for early responders,p=0.005).Multivariate independent predictors of early obliteration included a margin dose>24 Gy(p=0.031),prior surgery(p=0.002),no prior radiotherapy(p=0.025),smaller AVM nidus(p=0.002),deep venous drainage(p=0.039),and nidus location(p<0.0001).Basal ganglia,cerebellum,and frontal lobe nidus locations favored early obliteration(p=0.009).The Virginia Radiosurgery AVM Scale(VRAS)score was significantly different between the 2 responder groups(p=0.039).The VRAS score was also shown to be predictive of early obliteration on univariate analysis(p=0.009).For early obliteration,such prognostic ability was not shown for other SRS-and AVM-related grading systems.CONCLUSIONSEarly obliteration(≤18 months post-SRS)was more common in patients whose AVMs were smaller,located in the frontal lobe,basal ganglia,or cerebellum,had deep venous drainage,and had received a margin dose>24 Gy.ABBREVIATIONS AVM=arteriovenous malformation;GKRS=Gamma Knife170905.与显微垂体手术比较,内镜垂体手术并发症多发、费用更高。(2010至2014年5886例,最常见病变为垂体瘤,显微54.49%内镜45.51%。总并发症率40.04%,内镜应用趋向增多)Comparison of Complications,Trends,and Costs in Endoscopic vs Microscopic Pituitary Surgery:Analysis From a US Health Claims DatabaseAnthony O.Asemota,MD,MPH;Masaru Ishii,MD,PhD;Henry Brem,MD;Gary L.Gallia,MD,PhDNeurosurgery,Volume 81,Issue 3,1 September 2017,Pages 458–472,BACKGROUND:Microsurgical and endoscopic techniques are commonly utilized surgical approaches to pituitary pathologies.There are limited data comparing these 2 procedures.OBJECTIVE:To evaluate postoperative complications,associated costs,and national and regional trends of microscopic and endoscopic techniques in theUnited Statesemploying a nationwide database.METHODS:The Truven MarketScan database 2010 to 2014 was queried and Current Procedural Terminology codes identified patients that underwent microscopic and/or endoscopic transsphenoidal pituitary surgery.International Classification of Diseases codes identified postoperative complications.Adjusted logistic regression and matched propensity analysis evaluated independent odds for complications.RESULTS:Among 5886 cases studied,54.49%were microscopic and 45.51%endoscopic.The commonest surgical indications were benign pituitary tumors.Annual trends showed increasing utilization of endoscopic techniques vs microscopic procedures.Postoperative complications occurred in 40.04%of cases,including diabetes insipidus(DI;16.90%),syndrome of inappropriate antidiuretic hormone(SIADH;2.02%),iatrogenic hypopituitarism(1.36%),fluid/electrolyte abnormalities(hypoosmolality/hyponatraemia[5.03%]and hyperosmolality/hypernatraemia[2.48%]),and cerebrospinal fluid(CSF)leaks(CSF rhinorrhoea[4.42%]and other CSF leak[6.52%]).In our propensity-based model,patients that underwent endoscopic surgery were more likely to develop DI(odds ratio[OR]=1.48;95%confidence interval[CI]=1.28-1.72),SIADH(OR=1.53;95%CI=1.04-2.24),hypoosmolality/hyponatraemia(OR=1.17;95%CI=1.01-1.34),CSF rhinorrhoea(OR=2.48;95%CI=1.88-3.28),other CSF leak(OR=1.59;95%CI=1.28-1.98),altered mental status(OR=1.46;95%CI=1.01-2.60),and postoperative fever(OR=4.31;95%CI=1.14-16.23).There were no differences in hemorrhagic complications,ophthalmological complications,or bacterial meningitis.Postoperative complications resulted in longer hospitalization and increased healthcarecosts.CONCLUSION:Endoscopic approaches are increasingly being utilized to manage sellar pathologies relative to microsurgery.Postoperative complications occur in both techniques with higher incidences observed following endoscopic procedures.170903弥漫性中线胶质瘤(DMGs)初现治疗曙光:DMGs常见于儿童桥脑,诊断后平均生存期9个月,死亡率100%。DMGs近来被发现80%存在组蛋白H3-K27M赖-蛋氨酸突变。最近研究显示其与“溴”结构域蛋白有关联,“溴”结构域蛋白抑制剂JQ1体外实验证实可减少这些肿瘤细胞基因转录,体内实验(鼠)显示其可显著延长患鼠生存。这为可怕的DMGs治疗产生了一线希望之光。Diffuse Midline Gliomas:Closer to a Cure?Reid Hoshide,MD,MPHRahul Jandial,MD,PhDNeurosurgery,Volume 81,Issue 3,1 September 2017,Pages N19–N20Diffuse midline gliomas(DMGs)are known to be one of the most unforgiving cancers.Many times these cancers attack children at the prime of their youth.The median survival duration from the time of diagnosis is only 9 mo,and boasts a 100%mortality rate.Their aggressive behavior within the highly eloquent brainstem makes it easy to comprehend the brutal nature of these tumors.Treatment modalities such as radiotherapy and chemotherapy have shown modest results.Disappointingly,surgical resections have not been shown to reliably improve outcomes.Surgical management options for DMGs were deemed to be so futile that a 1993 statement from the Children's Cancer Group recommended against any procedure for DMGs,even for biopsies to establish a tissue diagnosis.They recommended that DMGs become a diagnosis by radiographic recognition only.It was not until a decade later when a consortium had walked back on this recommendation,perhaps in light of recent advances in stereotaxy and the need for molecular profiling for targeted treatment and research.And thankfully they did.Genetic studies with specific interest in the molecular profiling of DMGs led to the finding of a histone mutation with a lysine to methionine replacement at position 27,or H3-K27M for short.This genetic aberration is seen in 80%of DMGs.Because of this intimate correlation,the World Health Organization convened in 2016 to reclassify the previous entity of“Diffuse Intrinsic Pontine Gliomas(DIPGs)”as“Diffuse Midline Gliomas—H3-K27M mutant.”Discovering this genetic aberration led to a surge of studies,looking to examine every detail of this H3-K27M mutation and its properties in gliomagenesis.A recent study performed by Piunti et al1 examined a known relationship between the H3-K27M mutation and 2 bromodomain proteins at the sites of actively transcribed genes.Bromodomain proteins,broadly,are proteins that bind to acetylated histones to promote gene transcription.This curiosity led to their further investigation into inhibiting the activity of these transcription promoters.A bromodomain inhibitor,JQ1,was introduced to DMG tumor cells in Vitro,which resulted in a statistically significant reduction in gene transcription in these tumor cells compared to controls.Interestingly,the JQ1 molecule was seen to increase the presence of genes that are found in the differentiation of mature neurons,suggesting that they have an added,antiproliferative effect by promoting cell-cycle arrest.Next,they performed in Vivo studies,using xenografts of human-derived,untreated DMG cells into the brainstems of mice.Intraperitoneal injections of JQ1 were administered to these mice for 10 d.The results were astounding.On average,the treated mice lived significantly longer,had reduced bioluminescent signal,and had postmortem histologic and immunochemical evidence of reduced proliferation and increased cell-cycle arrest which mirrored their previous in Vitro studiesPiuntiA,HashizumeR,MorganMAet alTherapeutic targeting of polycomb and BET bromodomain proteins in diffuse intrinsic pontine gliomas.Nat Med.2017;23(4):493-500.170901血管内介入治疗(去栓)急性缺血性中风(脑大血管阻塞)短中期改善患者预后Sustained Benefit of Endovascular Therapy in Acute Ischemic Stroke Mithun G.Sattur,MDKent R.Richter,BSErich M.UmbargerBernard R.Bendok,MD,MSCI Neurosurgery,Volume 81,Issue 3,1 September 2017,Pages N26–N27,Published:21 August 2017Endovascular thrombectomy for large vessel intracranial occlusion has been established beyond doubt as standard of care in select patients with acute ischemic stroke.1 Several sentinel randomized trials were published in 2015 and were responsible for demonstrating the benefit of endovascular mechanical thrombectomy in improving outcomes as measured by modified Rankin scores(mRS)and reducing mortality.2 These studies examined mRS scores at 90 d postintervention and found positive results with mechanical thrombectomy.While this conveyed short-term advantage for the properly selected endovascular stroke patient,sustained benefit has not been well documented in controlled trials.The investigators for the MR CLEAN study3 adopted an extended study design beyond the original study in which they sought to follow enrolled patients for 2 yr.The primary outcome was mRS at 2 yr and secondary outcomes were mortality and quality of life(QOL).Of the 500 patients in the original study,391 patients had 2-yr outcome data.One hundred ninety-four were in the intervention group and 197 in the“conventional”group(who did not undergo endovascular therapy).The results of the study indicated that endovascularly treated patients had statistically better odds(ratio of 1.68 andP=.007)of favorable mRS outcome at 2 yr.They also had higher QOL scores(P=.006).1It should be noted that the study highlights some nuances that challenge a simplistic interpretation of commonly applied assessment scales.Lower rates of mRS 0 or 1 were seen at 2 yr in comparison to 90-d scores in the original study.The interpretation was that challenges with daily activities tend to be magnified outside of rehab settings,that are typical of patients studied early in their poststroke course.This implies that the administration and documentation of mRS scores is subject to vagaries and is not infallible.Better stroke outcome measures are necessary in the broader sense of stroke trials.Interestingly,subgroup analyses according to NIHSS(National Institutes of Health Stroke Scale)score,age,occlusion of the internal carotid artery terminus,additional extracranial internal carotid artery obstruction,time from stroke onset to randomization and the Alberta Stroke Program Early CT score did not show any relation to intervention.This may not be consistent with routine clinical experience.A plausible explanation would be the inconsistency of measurement and quantification of ischemic penumbra tissue and the need for robust,user-friendly techniques to achieve the same.The rate of major vascular events in either treatment arm was surprisingly low and likely does not reflect average community practice.This potentially hints at continual risk factor modification and this cannot be emphasized enough.Also of interest is that the study showed some difference in mortality rates in favor of endovascular therapy that did not reach significance,while death rates were similar between the 2 groups in the original study.In summary,the evidence that endovascular thrombectomy leads to improved outcomes,both short and medium term,is convincing.Extending the beneficiary pool to patients outside the conventional time window is being investigated4 and is the next exciting step in endovascular neurosurgical stroke management.Sophisticated yet accessible and rapid penumbral imaging will increasingly become the decision-making step.Accelerated device development to improve recanalization rates in patients with challenging anatomy is also a step in the right direction.All of this needs to be coupled with improvements in emergency medical and triage systems,critical care management,risk factor management,and application of deep learning methods to stroke databases.Neurosurgery is uniquely positioned to spearhead these and other innovations in stroke care and thus help tackle an important public health problem.1.Powers WJ,Derdeyn CP,Biller J et al 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment.Stroke.2015;46(10):3020-3035.2.Berkhemer OA,Fransen PS,Beumer D et al A randomized trial of intraarterial treatment for acute ischemic stroke.N Engl J Med.2015;372(1):11-20.3.Goyal M,Menon BK,van Zwam WH et al Endovascular thrombectomy after large-vessel ischaemic stroke:a meta-analysis of individual patient data from five randomized trials.Lancet.2016;387(10029):1723-172314.van den Berg LA,Roos YB.Two-Year Outcome after Endovascular Treatment for Stroke.N Engl J Med.2017;376(26):2597.170831.1010例脊髓硬膜外血肿分析:平均年龄47.97 years(range 0–91 years),男性60%(p<0.001).较多见于10多岁和50多岁.42%未报告原因.C-6(31%)and T-12(22%)最常见,最长6椎体(75%).入院时806(84%)有重度神经功能损伤(NG 2 or 3),腰部血肿神经功能损伤较轻(NG 0 or 1)..40岁以上死亡高(9%;p<0.01).病因包括:医源性(18%)如药物性凝血病理,腰穿损伤等;非医源性(29%)的如损伤,遗传性或代谢性凝血功能异常,怀孕;和多因素(11.1%)所致;极少数为特发性(原因不清)。处理因病因而不同,大多数需手术(80%)。预后受患者入院时临床状况、神经损伤状态、年龄和血肿位置等影响Spinal epidural hematomas:personal experience and literature review of more than 1000 casesJournal of Neurosurgery:SpineAug 2017/Vol.27/No.2/Pages 198-208MaurizioDomenicucci,MD1,CristinaMancarella,MD1,GiorgioSantoro,MD1,By Keywords:spinal epidural hematoma,outcome,review,coagulopathy,trauma,lumbar puncture,pregnancyAbstractOBJECTIVEThe goal of this study was to identify factors that contribute to the formation of acute spinal epidural hematoma(SEH)by correlating etiology,age,site,clinical status,and treatment with immediate results and long-term outcomes.METHODSThe authors reviewed their series of 15 patients who had been treated for SEH between 1996 and 2012.In addition,the authors reviewed the relevant international literature from 1869(when SEH was first described)to 2012,collecting a total of 1010 cases.Statistical analysis was performed in 959(95%)cases that were considered valid for assessing the incidence of age,sex,site,and clinical status at admission,correlating each of these parameters with the treatment results.Statistical analysis was also performed in 720(71.3%)cases to study the incidence of etiological factors that favor SEH formation:coagulopathy,trauma,spinal puncture,pregnancy,and multifactorial disorders.The clinical status at admission and long-term outcome were studied for each group.Clinical status was assessed using the Neuro-Grade(NG)scale.RESULTSThe mean patient age was 47.97 years(range 0–91 years),and a significant proportion of patients were male(60%,p<0.001).A bimodal distribution has been reported for age at onset with peaks in the 2nd and 6th decades of life.The cause of the SEH was not reported in 42%of cases.The etiology concerned mainly iatrogenic factors(18%),such as coagulopathy or spinal puncture,rather than noniatrogenic factors(29%),such as genetic or metabolic coagulopathy,trauma,and pregnancy.The etiology was multifactorial in 11.1%of cases.The most common sites for SEH were C-6(n=293,31%)and T-12(n=208,22%),with maximum extension of 6 vertebral bodies in 720 cases(75%).At admission,806(84%)cases had moderate neurological impairment(NG 2 or 3),and only lumbar hematoma was associated with a good initial clinical neurological status(NG 0 or 1).Surgery was performed in 767(80%)cases.Mortality was greater in patients older than 40 years of age(9%;p<0.01).sex did=""not=""influence=""any=""of=""these=""p="">0.05).CONCLUSIONSFactors that contribute to the formation of acute SEH are iatrogenic,not iatrogenic,or multifactorial.The treatment of choice is surgery,and the results of treatment are influenced by the patient’s clinical and neurological status at admission,age,and the craniocaudal site.170822.多中心回顾性群体研究伤后能说话而(最后)死亡(“talk and die”)的脑外伤患者危险因素:年长,男性,高损伤计分,低GCS计分,合并病(充血性心衰,慢性肾病,肝硬化,血液病等),入院时低血压,硬膜下出血,脑挫伤和颅盖骨折等Multicenter Retrospective Cohort Study of“Talk and Die”After Traumatic Brain InjuryKeita Shibahashi,Kazuhiro Sugiyama,Yoshihiro Okura,Hidenori Hoda,Yuichi HamabeWorld Neurosurgery Volume 107,Pages 82-86(November 2017)BackgroundPatients who“talk and die”after traumatic brain injury(TBI)are potentially salvageable.The reported incidences and risk factors for the“talk and die”phenomenon are conflicting and do not take into account recent improvements in trauma care.The aim of this study was to determine the incidences of“talk and die”after TBI in a modern trauma care system,as well as associated risk factors.MethodsWe identified patients who experienced TBI(abbreviated injury scale 3–5)between 2004 and 2015 who talked on admission(i.e.,their verbal component on the Glasgow Coma Scale was≥3 on admission)using a nationwide trauma registry(the Japan Trauma Data Bank).The end point was in-hospital mortality.We compared patients who talked and died with those who talked and survived.ResultsDuring the study period,236,698 patients were registered in the database.Of the 24,833 patients who were eligible for analysis,956(4.0%)patients subsequently died in the hospital.The in-hospital mortality rate significantly decreased over the past 12 years.Older age;male sex;a higher injury severity score;a lower Glasgow Coma Scale score;comorbidities(congestive heart failure,chronic kidney disease,liver cirrhosis,and hematologic disorders);hypotension on arrival;subdural hemorrhage;contusion;and vault fracture were independently associated with higher in-hospital mortality.ConclusionEven in modern trauma care systems,some patients still talk and die after TBI.We identified certain risk factors in patients with TBI that elicit the requirement for close observation,even if these patients talk after TBI.170817.比较经内镜和显微手术切除鞍区病灶共9670例,总并发症率内镜较高(内镜47%,显微39%),内镜组神经受损、多尿和脑脊液漏的风险较显微组更大,费用稍高($32,959 compared to$29,977),内镜组术后伽玛刀可能性降低。---内镜切除鞍区病灶的优势仍待更多证据证明Endoscopic vs.Microscopic Resection of Sellar Lesions-A Matched Analysis of Clinical and Socioeconomic Outcomes.Front Surg.2017 Jun 22;4:33.Azad TD1,Lee YJ2,Vail D1,Veeravagu A1,Hwang PH2,Ratliff JK1,Li G1.Department of Neurosurgery,Stanford University School of Medicine,Stanford,CA,United States.AbstractBACKGROUND:Direct comparisons of microscopic and endoscopic resection of sellar lesions are scarce,with conflicting reports of cost and clinical outcome advantages.OBJECTIVE:To determine if the proposed benefits of endoscopic resection are realized on a population level.METHODS:We performed a matched cohort study of 9,670 adult patients in the MarketScan database who underwent either endoscopic or microscopic surgery for sellar lesions.Coarsened matching was applied to estimate the effects of surgical approach on complication rates,length of stay(LOS),costs,and likelihood of postoperative radiation.RESULTS:We found that LOS,readmission,and revision rates did not differ significantly between approaches.The overall complication rate was higher for endoscopy(47%compared to 39%,OR 1.37,95%CI 1.22-1.53).Endoscopic approach was associated with greater risk of neurological complications(OR 1.32,95%CI 1.11-1.55),diabetes insipidus(OR 1.65,95%CI 1.37-2.00),and cerebrospinal fluid rhinorrhea(OR 1.83,95%CI 1.07-3.13)compared to the microscopic approach.Although the total index payment was higher for patients receiving endoscopic resection($32,959 compared to$29,977 for microscopic resection),there was no difference in long-term payments.Endoscopic surgery was associated with decreased likelihood of receiving post-resection stereotactic radiosurgery(OR 0.67,95%CI 0.49-0.90)and intensity-modulated radiation therapy(OR 0.78,95%CI 0.65-0.93).CONCLUSION:Our results suggest that the transition from a microscopic to endoscopic approach to sellar lesions must be subject to careful evaluation.Although there are evident advantages to transsphenoidal endoscopy,our analysis suggests that the benefits of the endoscopic approach are yet to be materialized.KEYWORDS:complication rate;endoscopy;microscopy;pituitary;sellar lesions170816.急性自发脑出血、高血压患者,早期严控高血压处理总体安全、并减少血肿扩大How Should We Lower Blood Pressure after Cerebral Hemorrhage?A Systematic Review and Meta-Analysis.Lattanzi S1,Cagnetti C,Provinciali L,Silvestrini M.Cerebrovasc Dis.Italy。2017;43(5-6):207-213AbstractBACKGROUND:The optimal treatment of high blood pressure(BP)after acute intra-cerebral hemorrhage(ICH)is controversial.SUMMARY:The aim of the study was to evaluate the safety and efficacy of early intensive vs.conservative BP lowering treatment in patients with ICH.Randomized controlled trials with active and control groups receiving intensive and conservative BP lowering treatments were identified.The following outcomes were assessed:3-month mortality and combined death or major disability,24-h hematoma growth,early neurological deterioration,occurrence of hypotension,severe hypotension,and serious treatment-emergent adverse events.Five trials were included involving 4,350 participants,2,162 and 2,188 for intensive and conservative treatment groups,respectively.The pooled risk ratio of 3-month death or major disability was 0.96(0.91-1.01)and the weighted mean difference in absolute hematoma growth was-1.53(95%CI-2.94 to-0.12)mL in the intensive compared to conservative BP-lowering.There were no differences across the treatments in the incidence rates of 3-month mortality,early neurological deterioration,hypotension,and treatment-related adverse effects other than renal events.Key Messages:The early intensive anti-hypertensive treatment was overall safe and reduced the hematoma expansion in patients presenting with acute-onset spontaneous ICH and high BP levels.KEYWORDS:Acute stroke;Blood pressure;Cerebrovascular disease;Intracerebralhemorrhage170815.腰穿持续外引流可安全有效减低交通性脑外积水所致颅内高压Using external lumbar CSF drainage to treat communicating external hydrocephalus in adult patients after acute traumatic or non-traumatic brain injury.Acta Neurochir(Wien).2017 Aug 8.doi:10.1007/s00701-017-3290-1Manet R1,2,Payen JF3,4,5,Guerin R4,Martinez O6,Hautefeuille S7,Francony G4,GergeléL8.1 France.AbstractBACKGROUND:Despite various treatments to control intracranial pressure(ICP)after brain injury,patients may present a late onset of high ICP or a poor response to medications.External lumbar drainage(ELD)can be considered a therapeutic option if high ICP is due to communicating external hydrocephalus.We aimed at describing the efficacy and safety of ELD used in a cohort of traumatic or non-traumatic brain-injured patients.METHODS:In this multicentre retrospective analysis,patients had a delayed onset of high ICP after the initial injury and/or a poor response to ICP treatments.ELD was considered in the presence of radiological signs of communicating external hydrocephalus.Changes in ICP values and side effects following the ELD procedure were reported.RESULTS:Thirty-three patients with a median age of 51 years(25-75th percentile:34-61 years)were admitted after traumatic(n=22)or non-traumatic(n=11)brain injuries.Their initial Glasgow Coma Scale score was 8(4-11).Eight patients underwent external ventricular drainage prior to ELD.Median time to ELD insertion was 5 days(4-8)after brain insult.In all patients,ELD was dramatically effective in lowering ICP:25 mmHg(20-31)before versus 7 mmHg(3-10)after(p<0.001).None of the patients showed adverse effects such as pupil changes or intracranial bleeding after the procedure.One patient developed an ELD-related infection.CONCLUSIONS:These findings indicate that ELD may be considered potentially effective in controlling ICP,remaining safe if a firm diagnosis of communicating external hydrocephalus has been made.170814.去骨瓣减压后15-30天行颅骨修补可降低感染、癫痫和骨瓣自吸收,等待到3个月后进行可减少脑积水但可增加癫痫风险Timing of cranioplasty:a 10.75-year single-center analysis of 754 patients.J Neurosurg.2017 Aug 11:1-5.doi:10.3171/2016.11.JNS161917Morton RP1,Abecassis IJ1,Hanson JF1,Barber JK1,Chen M1,Kelly CM1,Nerva JD1,Emerson SN1,Ene CI1,Levitt MR1,2,Chowdhary MM1,Ko AL1,Chesnut RM1.1.Departments of 1 Neurological Surgery.2 Mechanical Engineering,University of Washington School of Medicine,Seattle,Washington.AbstractOBJECTIVEDespite their technical simplicity,cranioplasty procedures carry high reported morbidity rates.The authors here present the largest study to date on complications after cranioplasty,focusing specifically on the relationship between complications and timing of the operation.METHODS The authors retrospectively reviewed all cranioplasty cases performed at Harborview Medical Center over the past 10.75 years.In addition to relevant clinical and demographic characteristics,patient morbidity and mortality data were abstracted from the electronic medical record.Cox proportional-hazards models were used to analyze variables potentially associated with the risk of infection,hydrocephalus,seizure,hematoma,and bone flap resorption.RESULTS Over the course of 10.75 years,754cranioplasties were performed at a single institution.Sixty percent of the patients who underwent these cranioplasties were male,and the median follow-up overall was 233 days.The 30-day mortality rate was 0.26%(2 cases,both due to postoperative epidural hematoma).Overall,24.6%percent of the patients experienced at least 1 complication including infection necessitating explantation of the flap(6.6%),postoperative hydrocephalus requiring a shunt(9.0%),resorption of the flap requiring synthetic cranioplasty(6.3%),seizure(4.1%),postoperative hematoma requiring evacuation(2.3%),and other(1.6%).The rate of infection was significantly higher if the cranioplasty had been performed<14 days after the initial craniectomy(p=0.007,Holm-Bonferroni-adjusted p=0.028).Hydrocephalus was significantly correlated with time to cranioplasty(OR 0.92 per 10-day increase,p<0.001)and was most common in patients whose cranioplasty had been performed<90 days=""after=""initial=""craniectomy.new-onset=""only=""occurred=""in=""patients=""who=""had=""undergone=""their=""cranioplasty="">90 days after initial craniectomy.Bone flap resorption was the least likely complication for patients whose cranioplasty had been performed between 15 and 30 days after initial craniectomy.Resorption was also correlated with patient age,with a hazard ratio of 0.67 per increase of 10 years of age(p=0.001).CONCLUSIONSCranioplasty performed between 15 and 30 days after initial craniectomy may minimize infection,seizure,and bone flap resorption,whereas waiting>90 days may minimize hydrocephalus but may increase the risk of seizure.KEYWORDS:IPH=intraparenchymal hemorrhage;MCA=middle cerebral artery;SAH=subarachnoid hemorrhage;TBI=traumatic brain injury;complication;cranioplasty;infection;resorption;timing;traumatic brain injury170804无反应瞳孔的急性硬膜下血肿患者术前加强脱水(90-100g甘露醇),其死亡和重残率降低Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils.A cohort studyAuthors and affiliations Arturo ChieregatoEmail author Alessandra Venditto Emanuele Russo Costanza Martino Giovanni BiniActa Neurochirurgica August 2017,Volume 159,Issue 8,pp 1553–1559AbstractBackgroundThe outcome of patients with severe traumatic brain injury(TBI)and acute traumatic subdural hematoma(aSDH)admitted to the emergency room with bilaterally dilated,unreactive pupils(bilateral mydriasis)is notoriously poor.MethodsOf 2074 TBI patients consecutively admitted to our facility between 1997 and 2012,115 had a first CT scan with aSDH,unreactive bilateral mydriasis,and a Glasgow Coma Score of 3 or 4.Sixty-two patients were unoperated and died within hours or a few days.The remaining 53 patients(2.5%of the 2074 consecutive patients)were scheduled for emergent evacuation of the aSDH.We compared three different dosages of mannitol to landmark different comprehensive levels of treatment:(1)a“basic”level of treatment characterized by a single conventional dose(18 to 36 g),(2)“reinforced”treatment landmarked by a single high dose(54 to 72 g),and(3)“aggressive”treatment landmarked by a single high dose(90 to 106 g).Doses above 36 g were administered intravenously over a period of 5 min.ResultsOf the 53 selected patients,7 were aggressively managed(13.2%)and 24(45.3%)received reinforced treatment.Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol.After adjustment for age,aggressive management was significantly associated with a lower risk of death and persistent vegetative state[adjusted OR 0.016(95%0.001–0.405)].Patients surviving after aggressive management suffered more severe disability at 1 year.ConclusionThe study shows an association between reduced mortality and persistent vegetative state,albeit at the cost of increased long-term severe disability in survivors,and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.Keywords Brain injuries Mannitol Mydriasis Outcome Subdural hematoma Transtentorial herniation170802.超全切除(超过肿瘤增强区)的胶质母细胞瘤患者具有生存优势,其总生存率超过全切除,对生存的影响作用大于年龄,KPS评分和肿瘤体积等的影响力The Survival Advantage of“Supratotal”Resection of Glioblastoma Using Selective Cortical Mapping and the Subpial TechniqueYoshua Esquenazi,MD;Elliott Friedman,MD;Zheyu Liu,MS;Jay-Jiguang Zhu,MD,PhD;Sigmund Hsu,MD...Neurosurgery(2017)81(2):275-288.AbstractBACKGROUND:A substantial body of evidence suggests that cytoreductive surgery is a prerequisite to prolonging survival in patients with glioblastoma(GBM).OBJECTIVE:To evaluate the safety and impact of“supratotal”resections beyondthe zone of enhancement seen on magnetic resonance imaging scans,using a subpial technique.METHODS:We retrospectively evaluated 86 consecutive patients with primary GBM,managed by the senior author,using a subpial resection technique with or without carmustine(BCNU)wafer implantation.Multivariate Cox proportional hazards regression was used to analyze clinical,radiological,and outcome variables.Overall impacts of extent of resection(EOR)and BCNU wafer placement were compared using Kaplan-Meier survival analysis.RESULTS:Mean patient age was 56 years.The median OS for the group was 18.1 months.Median OS for patients undergoing gross total,near-total,and subtotal resection were54,16.5,and 13.2 months,respectively.Patients undergoing near-total resection(P=.05)or gross total resection(P<.01)experienced statistically significant longer survival time than patients undergoing subtotal resection as well as patients undergoing≥95%EOR(P<.01)when compared to<95%EOR.The addition of BCNU wafers had no survival advantage.CONCLUSIONS:The subpial technique extends the resection beyond the contrast enhancement and is associated with an overall survival beyond that seen in similar series where resection of the enhancement portion is performed.The effect of supratotal resection on survival exceeded the effects of age,Karnofsky performance score,and tumor volume.A prospective study would help to quantify the impact of the subpial technique on quality of life and survival as compared to a traditional resection limited to the enhancing tumor.170801.CT中线移位>5 mm,脑室内出血,复合伤,急救后GCS<15分,和CT环池消失等可做为轻型儿童脑外伤患者是否要进入重症(ICU)管理的决策因素.Medical necessity of routine admission of children with mild traumatic brain injury to the intensive care unitJared D.Ament,MD,MPH1,Krista N.Greenan,MD,MPH1,Patrick Tertulien,MPH,MS1,Joseph M.Galante,MD2,Daniel K.Nishijima,MD,MAS3,and Marike Zwienenberg,MD1Journal of Neurosurgery:PediatricsJun 2017/Vol.19/No.6/Pages 668-674By Keywords:traumatic brain injury,clinical decision rule,ICU monitoring,triage,resource allocation,traumaAbstractOBJECTIVE Approximately 475,000 children are treated for traumatic brain injury(TBI)in theUSeach year;most are classified as mild TBI(Glasgow Coma Scale[GCS]Score 13–15).Patients with positive findings on head CT,defined as either intracranial hemorrhage or skull fracture,regardless of severity,are often transferred to tertiary care centers for intensive care unit(ICU)monitoring.This practice creates a significant burden on the health care system.The purpose of this investigation was to derive a clinical decision rule(CDR)to determine which children can safely avoid ICU care.METHODS The authors retrospectively reviewed patients with mild TBI who were≤16 years old and who presented to a Level 1 trauma center between 2008 and 2013.Data were abstracted from institutional TBI and trauma registries.Independent covariates included age,GCS score,pupillary response,CT characteristics,and Injury Severity Score.A composite outcome measure,ICU-level care,was defined as cardiopulmonary instability,transfusion,intubation,placement of intracranial pressure monitor or other invasive monitoring,and/or need for surgical intervention.Stepwise logistic regression defined significant predictors for model inclusion with p<0.10.The authors derived the CDR with binary recursive partitioning(using a misclassification cost of 20:1).RESULTS A total of 284 patients with mild TBI were included in the analysis;40(14.1%)had ICU-level care.The CDR consisted of 5 final predictor variables:midline shift>5 mm,intraventricular hemorrhage,nonisolated head injury,postresuscitation GCS score of<15,and cisterns absent.The CDR correctly identified 37 of 40 patients requiring ICU-level care(sensitivity 92.5%;95%CI 78.5–98.0)and 154 of 244 patients who did not require an ICU-level intervention(specificity 63.1%;95%CI 56.7–69.1).This results in a negative predictive value of 98.1%(95%CI 94.1–99.5).CONCLUSIONS The authors derived a clinical tool that defines a subset of pediatric patients with mild TBI at low risk for ICU-level care.Although prospective evaluation is needed,the potential for improved resource allocation is significant.1.慢性硬膜下血肿术后复发可用地塞米松有效治疗Effects of Dexamethasone in the Treatment of Recurrent Chronic Subdural HematomaYu Zhang,Shiping Chen,Yangchun Xiao,Wenhua Tang World Neurosurgery Volume 105,Pages 115-121(September 2017)Objective Recurrent chronic subdural hematoma(CSDH)is not rare.Some studies have demonstrated the role of dexamethasone in the medical management of chronic subdural hematoma.However,no systematic study in the treatment of recurrent CSDH has been published.The aim of our study is to evaluate the efficacy and safety of dexamethasone in patients with recurrent CSDH.MethodsWe retrospectively reviewed medical records of consecutive patients from July 2010 to September 2014.A total of 27 patients with symptomatic recurrent CSDH were included in the analysis.Follow-up for each patient consisted of computed tomography or magnetic resonance imaging every 28 days from admission to the resolution of hematoma.Data were collected on hematoma volume,complications,and outcome.ResultsAmong the 27 patients,3 patients with recurrent CSDH were only treated by burr hole surgery.Of the other 24 patients who primarily underwent dexamethasone treatment,17(70.8%)patients were treated successfully with medical treatment,whereas 7 patients required reoperation.Complications were noted in 3(12.5%)patients(1 hyperglycemia,1 urinary tract infection,and 1 pneumonia).There was 1 mortality(4.2%)for massive brain infarction.Twenty-one of the 24 patients(87.5%)recovered to their previous functional levels.There was no statistical significance in Fisher text between surgery and dexamethasone regarding success,complication,and functional recovery rate.ConclusionsPatients with recurrent CSDH can be treated successfully and safely with the nonsurgical medical treatment of dexamethasone.By use of this method,reoperation may be avoided.2.嗅沟脑膜瘤经眶上额下开颅显微切除费用显著低于经鼻内镜切除(发达国家)Supraorbital Versus Endoscopic Endonasal Approaches for Olfactory Groove Meningiomas:A Cost-Minimization StudyGurpreet S.Gandhoke,Matthew Pease,Kenneth J.Smith,Raymond F.Sekula Jr World Neurosurgery Volume 105,Pages 126-136(September 2017)ObjectiveTo perform a cost-minimization study comparing the supraorbital and endoscopic endonasal(EEA)approach with or without craniotomy for the resection of olfactory groove meningiomas(OGMs).MethodsWe built a decision tree using probabilities of gross total resection(GTR)and cerebrospinal fluid(CSF)leak rates with the supraorbital approach versus EEA with and without additional craniotomy.The cost(not charge or reimbursement)at each“stem”of this decision tree for both surgical options was obtained from our hospital's finance department.After a base case calculation,we applied plausible ranges to all parameters and carried out multiple 1-way sensitivity analyses.Probabilistic sensitivity analyses confirmed our results.ResultsThe probabilities of GTR(0.8)and CSF leak(0.2)for the supraorbital craniotomy were obtained from our series of 5 patients who underwent a supraorbital approach for the resection of an OGM.The mean tumor volume was 54.6 cm3(range,17–94.2 cm3).Literature-reported rates of GTR(0.6)and CSF leak(0.3)with EEA were applied to our economic analysis.Supraorbital craniotomy was the preferred strategy,with an expected value of$29,423,compared with an EEA cost of$83,838.On multiple 1-way sensitivity analyses,supraorbital craniotomy remained the preferred strategy,with a minimum cost savings of$46,000 and a maximum savings of$64,000.Probabilistic sensitivity analysis found the lowest cost difference between the 2 surgical options to be$37,431.ConclusionCompared with EEA,supraorbital craniotomy provides substantial cost savings in the treatment of OGMs.Given the potential differences in effectiveness between approaches,a cost-effectiveness analysis should be undertaken3.重型脑外伤患者早期气管切开(6天内)可缩短ICU时间和住院时间,改善预后Experience with Traumatic Brain Injury:Is Early Tracheostomy Associated with Better Prognosis?Hosseinali Khalili,Shahram Paydar,Rasool Safari,Peyman Arasteh,Amin Niakan,Amin Abolhasani Foroughi World Neurosurgery Volume 103,Pages 88-93(2017)ObjectiveIn this study we compared the effects of early tracheostomy(ET)versus late tracheostomy on traumatic brain injury(TBI)-related outcomes and prognosis.Patients and MethodsData on 152 TBI patients with a Glasgow Coma Scale(GCS)score of≤8,admitted to Rajaee Hospital between March 1,2014 and August 23,2015,were collected.Rajaee Hospital is the main referral trauma center in southernIranand is affiliated with Shiraz University of Medical Sciences.Patients who had tracheostomy before or at the sixth day of their admission were considered as ET,and those who had tracheostomy after the sixth day of admission were considered as late tracheostomy.ResultsPatients with ET had a significantly lower hospital stay(46.4 vs.38.6 days;P=0.048)and intensive care unit stay(34.9 vs.26.7 days;P=0.003).Mortality rates were not significantly different between the 2 groups(P>0.99).Although not statistically significant,favorable outcomes(Glasgow Outcome Scale>4)were higher and ventilator-associated pneumonia rates were lower among the ET group(P=0.346 and P=492,respectively).Multivariate analysis showed that ET significantly improves 6-month prognosis(Glasgow Outcome Scale>4)(odds ratio=2.535;95%confidence interval:1.030–6.237).Higher age was inversely associated with favorable prognosis(odds ratio=0.958;confidence interval:0.936–0.981).Glasgow Coma Scale and Rotterdam score did not show any effect on 6-month prognosis.ConclusionDespite previous concern regarding increased mortality rates among patients who undergo ET,performing a tracheostomy for patients with severe TBI<6 days after their hospital admission,in addition to decreasing hospital and intensive care unit stays,will improve patient prognosis.4.经分流阀注0.1ml 5%糖液,20分钟后再抽测可简单评判分流管通畅与否A Simple and Reliable Method for the Diagnosis of Ventriculoperitoneal Shunt MalfunctionHongri Zhang,Jinghua Peng,Xiaowei Hao,Xiaofan Guo,Gang Li World Neurosurgery Volume 103,Pages 355-359(2017)ObjectiveTo provide a simple and reliable method for the diagnosis of ventriculoperitoneal shunt malfunction.MethodsA total of 14 participants were enrolled in this study,consisting of 7 patients with suspected shunt malfunction and 7 control cases with apparent normal drainage.In all cases,0.1 mL of 5%glucose solution was injected into the reservoir and 0.1 mL of cerebrospinal fluid was withdrawn from the reservoir 20 minutes later to measure glucose concentration.ResultsThe glucose concentration in cerebrospinal fluid of the shunt malfunction group was greater than that of the control group(P<0.05).ConclusionsThe proposed method is reliable,safe,and relatively simple for the diagnosis of ventriculoperitoneal shunt malfunction and provides a reference for treatment5.大骨瓣减压后颅骨缺损修补和V-P分流术同时进行比分期进行手术并发症率更高、更严重Evaluation of simultaneous cranioplasty and ventriculoperitoneal shunt proceduresJournal of NeurosurgeryAug 2014/Vol.121/No.2/Pages 313-318By Keywords:cranioplasty,ventriculoperitoneal shunt,complication,traumatic brain injuryAbstractObjectSome patients with severe brain swelling treated with decompressive craniectomy may develop hydrocephalus.Consequently,these patients require cranioplasty and a ventriculoperitoneal(VP)shunt to relieve the hydrocephalus.However,there is no consensus as to the timing of the cranioplasty and VP shunt placement in patients requiring both.The authors assessed the results of performing cranioplasty and VP shunt placement at the same time in patients with cranial defects and hydrocephalus.MethodsA retrospective review was performed of 51 patients who had undergone cranioplasty and VP shunt operations after decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at the authors'institution.Patient characteristics,data on whether the operations were performed simultaneously,brain bulging,hydrocephalus,cranial defect size,and complications were analyzed.ResultsThe overall complication rate was 43%(22 of 51 patients).In 32 cases,cranioplasty and VP shunt placement were performed at the same time.Complications included subdural hematoma,subdural fluid collection,and infection.The group undergoing cranioplasty and VP shunt placement at the same time had higher complication rates than the group undergoing the procedures at different times(56%vs 21%,respectively).The severity of complications was also greater in the former group.Patients with severe brain bulging had higher complication rates than did those without brain bulging(51%vs 0%,respectively).Cranial defect size,severity of hydrocephalus,indication for decompressive craniectomy,age,sex,and interval between decompressive craniectomy and subsequent operation did not affect complication rates.ConclusionsPatients undergoing cranioplasty and VP shunt placement at the same time had higher complication rates,especially those with severe brain bulging.
(---谭源福摘录)1.促肾上腺皮质激素(ACTH)缺乏(继发性肾上腺皮质功能减退)晨8:00前后血皮质醇水平达到高峰,而午夜0点降到最低。国际上公认的诊断标准为:晨8:00血皮质醇<3ug/dL可直接判定为肾上腺皮质功能减退,血皮质醇>19ug/clL判定为肾上腺皮质功能正常,3ug/dL名血皮质醇名19ug/dL或临床怀疑皮质功能减退者需进一步行兴奋试验辅助诊断。晨8:00血皮质醇<5ug/dL时,存在肾上腺皮质功能减退的可能性>92%;而>13ug/dL时,皮质功能减退的可能性<9%,建议可以将5ug/dL和13ug/dL分别作为诊断或排除皮质功能减退的2个切点,介于两者之间时行兴奋试验进一步诊断。这一标准在临床工作中更为实用。治疗ACTH缺乏的方法为补充生理剂量的糖皮质激素。药物选择以短效激素如氢化可的松或醋酸可的松为佳,如果不能获得也可选用泼尼松等中效激素,不推荐使用地塞米松。一日总剂量为氢化可的松10~30mg,醋酸可的松12.5~37.5mg,分为2-3次口服,一般晨起2/3量,下午1/3量。另外需要注意的是,ACTH缺乏的患者出现发热、胃肠炎等疾病或应激情况时,糖皮质激素的替代剂量需要增加1~2倍,重大疾病或手术时往往需要静脉滴注氢化可的松100~150mg/d。2.促甲状腺激素(TSH)缺乏(垂体性甲状腺功能减退)术后TSH缺乏的诊断主要依据血清FT4水平低于正常参考范围。TSH缺乏的替代治疗首选左旋甲状腺素钠片(L-T4),也可以选择甲状腺片,小剂量开始,逐步加量,维持FT4在正常范围。调整剂量时的随访间隔为1个月或更长(L-T4半衰期7d),多数患者需要的剂量范围为25~100(xg/d,平均约1.6ug/kg(80-100ug)。治疗过程中应定期随访FT3、FT4水平3.成人促性腺激素缺乏男性患者可根据晨9:00前后睾酮水平低于正常(<10~12nmol/L)、同时FSH和LH正常或降低诊断促性腺激素缺乏,在不育症患者还可行精液检测以明确精子的活力。绝经期女性患者FSH、LH低于正常参考范围即可诊断促性腺激素缺乏;而非绝经期女性的诊断标准为:月经稀发、闭经或雌二醇水平降低(<100pmol/L),并且FSH、LH正常或降低。治疗方案因不同性别、不同年龄、不同的生育要求而不同。青春期女性可给予小剂量雌激素促进第二性征发育;雌孕激素人工周期疗法是育龄期女性最适当的选择,但不能恢复排卵;而对有生育要求者,可使用以下方案促排卵:HMG75IU/d逐渐加量至150IU/d促进卵泡发育,检测卵泡直径达到16~18mm后给予HCG5000IU促进排卵;绝经期女性一般不需替代治疗。男性患者中,尚未发育的青少年可予小剂量雄激素(庚酸睾酮50mg/月,缓慢加量至成人剂量)促进性征发育,必要时给予HCG促进性腺发育;成年男子可通过雄激素制剂维持性功能,如口服十一酸睾酮160-240mg/d,每2~3周肌注庚酸睾酮250mg;有生育要求者可给予HCG1000~2000IU,每周2次肌注治疗,生精一般需要6~9个月以上的连续用药。4.成人生长激素缺乏(AGHD)生长激素缺乏是垂体功能减退中最为常见的,但是在成人患者该症缺乏特异和明显的临床症状ACHD的替代剂量小于儿童,应采用个性化的剂量策略,小剂量起始(女性0.9IU/d,男性0.6IU/d,老年、肥胖、糖尿病及有糖尿病风险者0.3IU/d),监测IGF-1,缓慢加量,维持IGF-1位于正常值范围。维持剂量范围通常为女性1.2~3.0IU/d,男性0.6~1.5IU/d。如果出现外周水肿、关节痛、头痛等不良反应,需要考虑减少剂量,严重时需停药。