Binghui Qiu

Anatomical Study of the Arachnoid Envelope Over the Pineal Region

BACKGROUND The distribution of the arachnoid membrane and its relationship with the neurovascular structures in the pineal region are still not fully understood. OBJECTIVE Because the arachnoid membrane has an intimate relationship with the neurovascular structures in the pineal region and it will always be encountered surgically, we attempted to clarify the formation and distribution of the arachnoid envelope over the pineal region (AEPG). METHODS The formation and distribution of the AEPG and its relationship with the neurovascular structures in the pineal region were examined by anatomic dissection in 20 adult cadaveric formalin-fixed heads. RESULTS The supratentorial and infratentorial outer arachnoid membranes converged at the tentorial apex and then embraced and ran forward along the vein of Galen to form the AEPG. The AEPG could be divided into 2 parts. Typically, the posterior part of the AEPG enveloped the vein of Galen and the terminal segments of its tributaries, and the anterior part of the AEPG enveloped the suprapineal recess, the pineal gland, and the distal segment of the internal cerebral veins. The compartment demarcated by the AEPG did not communicate with the adjacent subarachnoid cisterns or space. CONCLUSION Previous knowledge about the AEPG, as well as the superior boundary and the contents of the quadrigeminal cistern, needs to be revised. The arrangement and individual variation of AEPG are important for a better understanding of the various growth patterns of the pineal tumors and the relationship between the tumor and the neurovascular structures in the pineal region.

Is Intracranial Pressure Monitoring of Patients With Diffuse Traumatic Brain Injury Valuable? An Observational Multicenter Study.

BACKGROUND Although intracranial pressure (ICP) monitoring of patients with severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, any benefits remain controversial. OBJECTIVE To evaluate the effects of ICP monitoring on the mortality of and functional outcomes in patients with severe diffuse TBI. METHODS Data were collected on patients with severe diffuse TBI (Glasgow Coma Scale [GCS] score on admission <9 and Marshall Class II-IV) treated from January 2012 to December 2013 in 24 hospitals (17 level I trauma centers and 7 level II trauma centers) in 9 Chinese provinces. We evaluated the impact of ICP monitoring on 6-month mortality and favorable outcome using propensity score-matched analysis after controlling for independent predictors of these outcomes. RESULTS ICP monitors were inserted into 287 patients (59.5%). After propensity score matching, ICP monitoring significantly decreased 6-month mortality. ICP monitoring also had a greater impact on the most severely injured patients on the basis of head computed tomography data (Marshall computed tomography classification IV) and on patients with the lowest level of consciousness (GCS scores 3-5). After propensity score matching, monitoring remained nonassociated with a 6-month favorable outcome for the overall sample. However, monitoring had a significant impact on the 6-month favorable outcomes of patients with the lowest level of consciousness (GCS scores 3-5). CONCLUSION ICP monitor placement was associated with a significant decrease in 6-month mortality after adjustment for the baseline risk profile and the monitoring propensity of patients with diffuse severe TBI, especially those with GCS scores of 3 to 5 or of Marshall computed tomography classification IV.

Individualized surgical strategies for Rathke cleft cyst based on cyst location.

OBJECT An assessment regarding both surgical approaches and the extent of resection for Rathke cleft cysts (RCCs) based on their locations has not been reported. The aim of this study was to report the results of a large series of surgically treated patients with RCCs and to evaluate the feasibility of individualized surgical strategies for different RCCs. METHODS We retrospectively reviewed 87 cases involving patients with RCCs (16 intrasellar, 50 intra- and suprasellar, and 21 purely suprasellar lesions). Forty-nine patients were treated via a transsphenoidal (TS) approach, and 38 were treated via a transcranial (TC) approach (traditional craniotomy in 21 cases and supraorbital keyhole craniotomy in 17). The extent of resection was classified as gross-total resection (GTR) or subtotal resection (STR) of the cyst wall. Patients were thus divided into 3 groups according to the approach selected and the extent of resection: TS/STR (n = 49), TC/STR (n = 23), and TC/GTR (n = 15). RESULTS Preoperative headaches, visual dysfunction, hypopituitarism, and diabetes insipidus (DI) resolved in 85%, 95%, 55%, and 65% of patients, respectively. These rates did not differ significantly among the 3 groups. Overall, complications occurred in 8% of patients in TS/STR group, 9% in TC/STR group, and 47% in TC/GTR group, respectively (p = 0.002). Cerebrospinal fluid (CSF) leakage (3%), new hypopituitarism (9%), and DI (6%) were observed after surgery. All CSF leaks occurred in the endonasal group, while the TC/GTR group showed a higher rate of postoperative hypopituitarism (p = 0.7 and p < 0.001, respectively). It should be particularly noted that preoperative hypopituitarism and DI returned to normal, respectively, in 100% and 83% of patients who underwent supraorbital surgery, and with the exception of 1 patient who had transient postoperative DI, there were no complications in patients treated with supraorbital surgery. Kaplan-Meier 3-year recurrence-free rates were 84%, 87%, and 86% in the TS/STR, TC/STR, and TC/GTR groups, respectively (p = 0.9). CONCLUSIONS It is reasonable to adopt individualized surgical strategies for RCCs based on cyst location. Gross-total resection does not appear to reduce the recurrence rate but increase the risk of postoperative complications. The endonasal approach seems more appropriate for primarily intrasellar RCCs, while the craniotomy is recommended for purely or mainly suprasellar cysts. The supraorbital route appears to be preferred over traditional craniotomy for its minimal invasiveness and favorable outcomes. The endoscopic technique is helpful for either endonasal or supraorbital surgery.

Determining an Optimal Cutoff of Serum β-Human Chorionic Gonadotropin for Assisting the Diagnosis of Intracranial Germinomas

Background Beta (β)-human chorionic gonadotropin (β-HCG) is used to confirm the diagnosis and plan treatment of intracranial germinomas. However, the cutoff values of serum β-HCG in diagnosis of intracranial germinomas reported in the literature are inconsistent. To establish an appropriate cutoff value of serum β-HCG for diagnosis of intracranial germinomas, we retrospectively reviewed the records of intracranial tumor patients who received serum β-HCG and α-fetoprotein (AFP) tests for diagnostic purposes at our hospital from 2005 to 2014. Methods A total of 93 intracranial germinomas and 289 intracranial non-germ cell tumors were included in this study. Receiver operating characteristic (ROC) analysis was used to evaluate the sensitivity and specificity of 3 cutoffs (0.1, 0.4, and 0.5 mIU/mL) for diagnosing intracranial germinomas. The serum β-HCG level of intracranial germinoma patients was further analyzed to investigate the effect of metastasis status and tumor location on serum β-HCG level. Results The area under the ROC curve was 0.81 (P < .001), suggesting β-HCG is an effective marker. Of the 3 cutoff values, 0.1 mIU/mL possessed a highest sensitivity (66.67%) and good specificity (91%). Although there was no β-HCG level difference between metastatic and non-metastatic intracranial germinoma patients, the diagnostic rate of metastatic neurohypophyseal germinomas was significantly higher than that of its non-metastatic counterpart (P < .05), implying that the location of the germinoma might need to be considered when β-HCG is used as a marker to predict metastasis. Conclusions Determining an optimal cutoff of serum β-HCG is helpful for assisting the diagnosis of intracranial germinoma.

Mild induced hypothermia for patients with severe traumatic brain injury after decompressive craniectomy

Purpose: To evaluate the efficacy and safety of mild induced hypothermia for intracranial hypertension in patients with traumatic brain injury after decompressive craniectomy. Methods: A total of 60 adults with intracranial pressure (ICP) of more than 20 mm Hg after decompressive craniectomy were randomly assigned to standard care (control group) or hypothermia (32°C‐35°C) plus standard care. Then, ICP, cerebral perfusion pressure, Glasgow Outcome Scale score, and complications were assessed. Results: There was a significant difference in ICP and cerebral perfusion pressure between the 2 groups. Favorable outcomes occurred in 12 (40.0%) and 7 (36.5%) patients in the hypothermia and control groups, respectively (P = .267). Kaplan‐Meier curves revealed a marked difference in survival between the hypothermia and control groups (P = .032). There were significant differences in pulmonary infection and electrolyte disorders between the hypothermia and control groups (P = .038 and .033, respectively). Conclusion: Mild induced hypothermia can reduce intracranial hypertension after decompressive craniectomy, decreasing patient mortality. Hypothermia should be considered one of the main treatments for intracranial hypertension after decompressive craniectomy in patients with traumatic brain injury. HighlightsThis is a randomized controlled trial research.Mild induced hypothermia therapeutics can reduce the intracranial hypertension after the decompressive craniectomy and can reduce the mortality of the patients.

An isolated primary Rathke's cleft cyst in the cerebellopontine angle

Rathkes cleft cysts (RCCs) are benign cysts typically located in the sellar or suprasellar region; ectopic isolated lesions are extremely rare. The authors describe the case of a 25-year-old man with a giant symptomatic RCC arising primarily at the cerebellopontine angle (CPA), only the second case reported thus far. The patient presented with a 2-year history of right hearing impairment and tinnitus accompanied by vertigo and headache and a 2-week history of right facial numbness. Subsequently, he underwent total cyst removal via retrosigmoid craniotomy with a good recovery. He experienced no recurrence during a 64-month follow-up period. The possible pathogenesis, differential diagnosis, and surgical treatment of such cysts are discussed in this article. Isolated ectopic RCCs can arise from the ectopic migration of Rathkes pouch cells during the embryonic period. It is still difficult to distinguish ectopic RCCs from other cystic lesions of the CPA given the lack of specific imaging features. Aggressive resection of the cyst wall is not recommended, except when lesions do not closely adhere to adjacent structures.

Surgical strategies for neurological function preservation in severe brain contusion.

AIM Traditional surgical strategies for severe brain contusion are constantly associated with variable degree of postoperative neurological dysfunction, which is in part attributed to the location and severity of contusion. The purpose of this study was to compare and evaluate these current surgical strategies, with an emphasis on neurological function preservation. MATERIAL AND METHODS A retrospective review of surgical strategies employed for 142 cases of severe brain contusion was performed. The surgical strategies were stratified into four types, Type I, Simple DC, without resection of contusion; II, Resection of contusion, combined with DC; III, Safe cerebral lobe resection and DC, without resection of contusion; IV, Simple resection of contusion, without decompression. The patients were accordingly separated into four groups. RESULTS The favorable prognosis rate in Group I, II and III was higher than Group IV on 6-month follow-up Glasgow Outcome Score (GOS). No significant difference of mortality rate was observed among Group I, II and III (p > 0.05), but the favorable prognosis rate of Group II was lower than Group I and III (p < 0.05). CONCLUSION Simple DC and safe cerebral lobe resection combined with DC might achieve better therapeutic effect, and could be recommended as the preferred surgical strategies for severe brain contusion.

A rat model for pituitary stalk electric lesion-induced central diabetes insipidus: application of 3D printing and further outcome assessments

A stable and reproducible rat injury model is not currently available to study central diabetes insipidus (CDI) and the neurohypophyseal system. In addition, a system is needed to assess the severity of CDI and measure the accompanying neurobiological alterations. In the present study, a 3D-printed lesion knife with a curved head was designed to fit into the stereotaxic instrument. The neuro-anatomical features of the brain injury were determined by in vivo magnetic resonance imaging (MRI) and arginine vasopressin (AVP) immunostaining on brain sections. Rats that underwent pituitary stalk electrical lesion (PEL) exhibited a tri-phasic pattern of CDI. MRI revealed that the hyperintenseT1-weighted signal of the pituitary stalk was interrupted, and the brain sections showed an enlarged end proximal to the injury site after PEL. In addition, the number of AVP-positive cells in supraoptic nucleus (SON) and paraventricular nucleus (PVN) decreased after PEL, which confirmed the success of the CDI model. Unlike hand-made tools, the 3D-printed lesion knives were stable and reproducible. Next, we used an ordinal clustering method for staging and the k-means’ clustering method to construct a CDI index to evaluate the severity and recovery of CDI that could be used in other multiple animals, even in clinical research. In conclusion, we established a standard PEL model with a 3D-printed knife tool and proposed a CDI index that will greatly facilitate further research on CDI.

Bifocal germinomas in the pineal region and hypothalamo-neurohypophyseal axis: Primary or metastasis?

Whether bifocal germinomas (BFGs) synchronously presenting within the pineal region and the hypothalamo-neurohypophyseal axis (HNA) are primary germinomas of dual-origin remains to be elucidated. We analyzed MRI images and clinical features of 95 neurohypophyseal germinomas and 21 BFG patients and developed a tentative definition of the BFGs. We found dual-primary BFGs (true BFGs) do exist. The fundamental difference between primary and metastatic HNA germinomas was the direction of tumor growth. For a true BFG, the primary HNA tumor grew from the neurohypophysis toward the hypothalamus and almost invaded the whole pituitary stalk. For a false BFG (primary pineal germinoma with HNA metastasis), the metastatic HNA tumor first appeared at the third ventricular floor (TVF), grew toward the neurohypophysis, but commonly did not invade the inferior pituitary stalk. Compared to false BFGs, true BFGs commonly had diabetes insipidus as the first symptom, dysfunction of the anterior pituitary, no high-intensity MRI signal at the posterior pituitary, a larger extension of the HNA tumor, and fewer numbers of remote lesions from cerebrospinal fluid seeding. Accordingly, 12.8% (12/96) of our germinoma patients had true BFGs, and of these, 58.3% (7/12) were free of remote metastases and warranted treatment with limited radiotherapy. True BFGs with remote metastases and all false BFGs should be treated with craniospinal irradiation. We provided evidence for the diagnosis of true BFGs that is useful for radiotherapy strategy, suggesting that the existence of metastasis to other locations is not a diagnostic criterion for a true BFG.