Zhengcun Yan

Neuroendoscopic Surgery versus External Ventricular Drainage Alone or with Intraventricular Fibrinolysis for Intraventricular Hemorrhage Secondary to Spontaneous Supratentorial Hemorrhage: A Systematic Review and Meta-Analysis

Background and Purpose Although neuroendoscopy (NE) has been applied to many cerebral diseases, the effect of NE for intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial hemorrhage remains controversial. The purpose of this study was to analyze the effect of NE compared with external ventricular drainage (EVD) alone or with intraventricular fibrinolysis (IVF) on the management of IVH secondary to spontaneous supratentorial hemorrhage. Methodology/ Principal Findings A systematic search of electronic databases (PubMed, EMBASE, OVID, Web of Science, The Cochrane Library, CBM, VIP, CNKI, and Wan Fang database) was performed to identify related studies published from 1970 to 2013. Randomized controlled trials (RCTs) or observational studies (OS) comparing NE with EVD alone or with IVF for the treatment of IVH were included. The quality of the included trials was assessed by Jaded scale and the Newcastle-Ottawa Scale (NOS). RevMan 5.1 software was used to conduct the meta-analysis. Results Eleven trials (5 RCTs and 6 ORs) involving 680 patients were included. The odds ratio (OR) showed a statistically significant difference between the NE + EVD and EVD + IVF groups in terms of mortality (OR, 0.31; 95% CI, 0.16-0.59; P=0.0004), effective hematoma evacuation rate (OR, 25.50, 95%CI; 14.30, 45.45; P<0.00001), good functional outcome (GFO) (OR, 4.51; (95%CI, 2.81-7.72; P<0.00001), and the ventriculo-peritoneal (VP) shunt dependence rate (OR, 0.16; 95%CI; 0.06, 0.40; P<0.0001). Conclusion Applying neuroendoscopic approach with EVD may be a better management for IVH secondary to spontaneous supratentorial hemorrhage than NE + IVF. However, there is still no concluive evidence regarding the preference of NE vs. EVD alone in the case of IVH, because insufficient data has been published thus far. This study suggests that the NE approach with EVD could become an alternative to EVD + IVF for IVH in the future.

Endoscopic evacuation of basal ganglia hemorrhage via keyhole approach using an adjustable cannula in comparison with craniotomy.

Neuroendoscopic (NE) surgery as a minimal invasive treatment for basal ganglia hemorrhage is a promising approach. The present study aims to evaluate the efficacy and safety of NE approach using an adjustable cannula to treat basal ganglia hemorrhage. In this study, we analysed the clinical and radiographic outcomes between NE group (21 cases) and craniotomy group (30 cases). The results indicated that NE surgery might be an effective and safe approach for basal ganglia haemorrhage, and it is also suggested that NE approach may improve good functional recovery. However, NE approach only suits the selected patient, and the usefulness of NE approach needs further randomized controlled trials (RCTs) to evaluate.

Naloxone for severe traumatic brain injury: a meta-analysis.

Objective The efficiency of naloxone for the management of secondary brain injury after severe traumatic brain injury (sTBI) remains undefined. The aim of this study is to evaluate the current evidence regarding the clinical efficiency and safety of naloxone as a treatment for sTBI in mainland China. Methodology/Principal Findings A systematic search of the China Biology Medicine disc (CBM), China Science and Technology Journal Database (VIP), China National Knowledge Internet (CNKI), and Wan Fang Database was performed to identify randomized controlled trials (RCTs) of naloxone treatment for patients with sTBI in mainland China. The quality of the included trials was assessed, and the RevMan 5.1 software was employed to conduct this meta-analysis. Nineteen RCTs including 2332 patients were included in this study. The odds ratio (OR) showed statistically significant differences between the naloxone group and the control group (placebo) in terms of mortality at 18 months after treatment (OR, 0.51, 95%CI: 0.38–0.67; p<0.00001), prevalence of abnormal heart rates (OR, 0.30, 95%CI: 0.21–0.43; p<0.00001), abnormal breathing rate (OR, 0.25, 95%CI: 0.17–0.36; p<0.00001) at discharge, the level of intracranial pressure at discharge (OR, 2.00, 95%CI: 1.41–2.83; p = 0.0001), verbal or physical dysfunction rate (OR, 0.65, 95%CI: 0.43–0.98; p = 0.04), and severe disability rate (OR, 0.47, 95%CI: 0.30–0.73; p = 0.0001) at 18 months after the treatment. The mean difference (MD) showed statistically significant differences in awakening time at discharge (MD, −4.81, 95%CI: −5.49 to −4.12; p<0.00001), and GCS at 3 days (MD, 1.00, 95%CI: 0.70–1.30; p<0.00001) and 10 days (MD, 1.76, 95%CI: 1.55–1.97; p<0.00001) after treatment comparing naloxone with placebo group. Conclusions/Significance This study indicated that applying naloxone in the early stage for sTBI patients might effectively reduce mortality, control intracranial pressure (ICP), and significantly improve the prognosis.

Decompressive craniectomy for severe middle cerebral artery infarction: a meta-analysis of randomised controlled trials

BACKGROUND Severe middle cerebral artery infarction is defined as an acute infarction in the entire middle cerebral artery territory. Several case series have indicated that decompressive hemicraniectomy for severe middle cerebral artery infarction is lifesaving. However, data concerning the long-term functional outcome are insufficient. We did a systematic review and meta-analysis to assess the efficacy of decompressive hemicraniectomy for patients with severe middle cerebral artery infarction. METHODS According to PRISMA guidelines, we searched databases containing articles published in English (MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials CENTRAL) and Chinese (Chinese Biomedical Literature Database, China Science and Technology Journal Database, and China National Knowledge Infrastructure) for randomised controlled trials (RCTs) of decompressive hemicraniectomy published before January, 2016. We extracted data on patient characteristics, methodological quality, and outcome measures. The outcomes assessed included mortality and good functional outcome (GFO). We did a subgroup analysis to determine the effect of age and surgical timing on mortality and functional outcomes. FINDINGS 14 studies were included in this meta-analysis, including 830 patients with severe middle cerebral artery infarction. In the total population, mortality was lower in the decompressive hemicraniectomy group than in the conventional treatment group at 6 months after onset (odds ratio [OR] 0·19, 95% CI 0·11-0·33; p<0·0001), and at 12 months (OR 0·18, 0·11-0·28; p<0·0001). The pooled OR of GFO was 3·15 (95% CI 1·49-6·69; p=0·003) at 6 months, and 1·95 (1·19-3·19; p=0·008) at 12 months. Survival with moderately severe disability was higher in the decompressive hemicraniectomy group at 6 months (OR 3·90, 95% CI 2·23-6·83; p<0·0001) and 12 months (OR 4·36, 2·55-7·36; p<0·0001). However, with regard to survival with severe disability, no significant differences were observed (p=0·55 at 6 months, p=0·81 at 12 months). In the subgroup analysis, compared with conventional treatment, decompressive hemicraniectomy significantly decreased mortality in patients older than 60 years (p<0·0001) and 60 years or younger (p<0·0001). With regard to survival with moderately severe or severe disability, significant differences were observed between treatment groups both in patients older than 60 years (p=0·0002) and 60 years or younger (p=0·0002). No significant differences between treatment groups were found in the subgroup analysis of surgical timing. INTERPRETATION Compared with conventional treatment, decompressive hemicraniectomy could significantly reduce mortality and improve prognosis both in patients older than 60 years and those aged 60 years or younger with severe middle cerebral artery infarction. However, compared with conventional treatment, more patients who receive decompressive hemicraniectomy might survive with moderately severe or severe disability. FUNDING None.

Endoscopic Intradural Subtemporal Keyhole Kawase Approach to the Petroclival and Ventrolateral Brainstem Regions.

Objective: To study the endoscope anatomy of the petroclival and ventrolateral brainstem regions via the intradural subtemporal keyhole Kawase approach and discuss the feasibility and indications of this approach to the regions. Materials and Methods: Craniotomy procedures performed via the intradural subtemporal keyhole Kawase approach were simulated on 16 sides of 8 adult cadaveric heads fixed by formalin, and the related anatomical structures were observed through the 0-degree endoscope or alternatively 30-degree one. Measurements of the shortest distances from the highest point of arcuate eminence to the 4 anatomic marks and the lengths of the Kawase rhombus were recorded, and the 2 kinds of milled ranges of petrous apex were compared. Result: Most of the related anatomical structures could be clearly observed under the endoscope. The shortest distances from the highest point of arcuate eminence to the foramen spinosum, the greater superficial petrosal nerve hiatus, the intersection of the greater superficial petrosal nerve and mandibular nerve, and the outside edge of the trigeminal impression are 22.90 ± 2.34, 14.05 ± 2.09, 24.94 ± 1.98, 23.49 ± 2.38 mm. The area of routine milled Kawase rhombus is 3.04 ± 0.47 cm2, which would increase 0.66 cm2 on average after the maximum drilling of the petrous apex. Conclusions: The intradural subtemporal keyhole Kawase approach can provide an ideal exposure to the petroclival and ventrolateral brainstem regions via the endoscope with less damaging of the normal structures. It can be used to treat the lesions located in those areas through the natural gap combined with the drilling of petrous apex bone.

Combined monitoring of intracranial pressure and bispectral index in patients with severe craniocerebral trauma post-operatively.

OBJECTIVE To investigate the value of simultaneous bispectral index (BIS) and intracranial pressure (ICP) monitoring to evaluate postoperative consciousness and short-term prognosis in patients with severe traumatic brain injury. METHODS We evaluated 30 brain trauma coma patients in the Peoples Hospital of Northern Jiangsu Province from January 2014 to December 2014 and evaluated Glasgow Coma Scale (GCS) scores at 8-h intervals for 3days after surgery. BIS and ICP values were recorded at the same time. Based on the GCS score, patients were divided into two groups: group A (GCS score 3-≤5) and group B (>5-≤8). Natural survival rates were analyzed statistically and compared between groups. RESULTS Chi-square testing revealed a significant difference in survival rates between the groups (P<0.05). Spearmans rank correlation analysis revealed that BIS value was positively correlated with coma degree post-operatively in patients with severe traumatic brain injury, and negatively correlated with ICP values (r=0.532, P<0.05; r=0.521, P<0.05, respectively). CONCLUSION In patients with severe craniocerebral injury, higher severity, higher ICP, and lower BIS were associated with a worse prognosis. Combined monitoring of BIS and ICP is very useful when evaluating the coma degree and prognosis of patients with severe craniocerebral injury post-operatively.

Rare giant bilateral calvarial hyperostosis across the superior sagittal sinus secondary to brain meningioma: A case report

The current study presents a case of a 43-year-old female with giant bilateral calvarial hyperostosis across the superior sagittal sinus, secondary to brain meningioma. The patient presented with a huge mass in the bilateral calvarial region, and diagnoses of huge skull hyperplasia and meningioma were strongly suggested by computed tomography and magnetic resonance imaging examination. In addition, digital subtraction angiography demonstrated that the left middle meningeal artery and branches of the left superficial temporal artery were the major sources of blood supply to the tumor, with the little involvement of the right middle meningeal artery and branches of the right superficial temporal artery. The patient successfully underwent simultaneous embolization of the tumor-supplying vessels, total resection of the giant calvarial hyperostosis and intracranial tumor and skull cranioplasty. Additionally, histological study of the mass revealed a meningioma. The management of such a case presents a surgical challenge, however, the current study provides a good reference for the future treatment of similar diseases.

Midline Suboccipital Endoscopic Transcerebellomedullary Fissure Keyhole Approach

Objective: To study the endoscopic anatomy of the 4th ventricle and lateral brainstem regions via the midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach assisted by a neuronavigation system and discuss the feasibility and indications of this approach. Materials and Methods: Craniotomy procedures performed via the midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach were simulated on 8 adult cadaveric heads fixed by formalin, and the related anatomic structures in the 4th ventricles or around the brainstem were observed through the 0° endoscope or alternatively 30° one. A neuronavigation system was used to measure the exposed area of the floor of 4th ventricle, the maximum exposure range, the length of the floor of 4th ventricle, the shortest distance from the midpoint of posterior arch of atlas to the opening of the aqueduct in the 4th ventricle and to the jugular foramen on both sides, respectively. Results: All the anatomic structures within the 4th ventricle and partial anatomic landmarks around brainstem were identified by means of the midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach. The exposed area of the floor of 4th ventricle is 459.68 ± 73.71 mm2. However, the total exposed area is 1601.70 ± 200.76 mm2. The length of the floor of 4th ventricle is 36.08 ± 2.63 mm. The shortest distance from the midpoint of posterior arch of atlas to the opening of the aqueduct in the 4th ventricle is 63.87 ± 2.97 mm, to the jugular foramen on both sides, respectively, is 40.11 ± 2.47 mm/40.30 ± 2.31 mm. Conclusions: Midline suboccipital endoscopic transcerebellomedullary fissure keyhole approach can basically meet the medial and lateral route of the transcerebellomedullary fissure approach. A tumor within the 4th ventricle or near the jugular tubercle extending into the 4th ventricle through the cerebellomedullary fissure can be removed by this approach.

Microsurgical and Endoscopic Posterior Transcortical Keyhole Approach to the Atrium of the Lateral Ventricle: A Cadaveric Study.

OBJECTIVE Accessing large lesions located in the atrium of the lateral ventricle without causing a neurologic deficit can be challenging. The aim of this study was to evaluate a modification of the posterior transcortical approach that may create sufficient exposure to the atrium of the lateral ventricle with less injury to the brain cortex and fibers using a technique that combines a microscope with an endoscope. MATERIAL AND METHODS Craniotomy procedures performed using the posterior transcortical keyhole approach were simulated on 10 adult cadaveric heads (20 hemispheres). The anatomical structures in the lateral ventricle were observed through the microscope and endoscope. Three distance measurements on the intraparietal sulcus were recorded. RESULTS The anatomical structures related to the atrium of the lateral ventricle, including the calcar avis, corpus callosum bulb, caudate nucleus, pulvinar, and glomus, were clearly observed under the microscope. Via the endoscope, a wider visualization of anatomical structures could be obtained. The distance from the intersection of the intraparietal sulcus and postcentral sulcus to the cerebral longitudinal fissure was 35.36 ± 1.06 mm, the depth of the intraparietal sulcus was 19.16 ± 1.03 mm, and the distance from the bottom of the intraparietal sulcus to the lateral ventricle was 21.31 ± 1.32 mm. CONCLUSIONS The microsurgical posterior transcortical keyhole approach could provide an ideal exposure to the atrium and the posterior part of the body of the lateral ventricle. The endoscopic posterior transcortical keyhole approach demonstrated a wider viewing range compared with the microscope. An endoscopic-controlled or -assisted surgery may reduce damage to normal brain tissue, facilitate total resection of the lesion, and improve the surgical outcome.

Spontaneous acute hemorrhage of intraspinal canal cellular schwannoma with paraplegia: A case report.

Abstract Cellular schwannoma, an unusual histological subtype of schwannoma, is a benign hypercellular variant of a peripheral nerve sheath tumor. We report a 48-year-old woman with sudden onset of paraplegia. The complete surgical resection was achieved. This is the first report about intraspinal canal cellular schwannoma following spontaneous acute hemorrhage and paraplegia.