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Objective Abnormal muscle response (AMR) is widely used as an indicator of the degree and effect of surgery during microvascular decompression (MVD) for hemifacial spasm (HFS). However, the positive rate of AMR during operation is quite different because of individual differences and single recording of muscle, which can not predict surgical outcomes. We present an improved method to record from multiple muscles innervated by multiple branches of the facial nerve to enlarge the AMR positive rate. Methods A total of 96 HFS patients in our hospital from January 2017 to June 2019, underwent MVD with intraoperative AMR monitoring. Ipsilateral frontalis, orbicularis oculi, orbicularis oris and mentalis were simultaneously monitored for AMR in stimulating the affected zygomatic branch of facial nerve in all cases. The effect of MVD for facial nerve was analyzed based on the disappearance of intraoperative AMR and the postoperative result. Results The AMR positive rate of frontalis was 43.75% (42/96), of orbicularis oculi was 38.54% (37/96), of orbicularis oris was 64.58% (62/96) and of mentalis was 78.13% (75/96). Total AMR positive rate was further improved to 97.92% (94/96) when the 4 muscles were monitored simultaneously. The AMR positive rates between multiple muscles monitoring group and any single muscle monitoring groups were significantly different (P = 0.000, for all). The AMR positive rates of orbicularis oris and mentalis were higher than that of frontalis (P = 0.000, 0.006) and orbicularis oculi (P = 0.000, 0.000). The postoperative results were statistically different between AMR complete disappearance group and AMR persistence group (Fisher exact probability: P = 0.043). Conclusions The method of multibranch facial muscles monitoring can effectively increase the AMR positive rate. AMR disappearance after the operation can evaluate the effect of facial nerve decompression and judge the prognosis. DOI:10.3969/j.issn.1672⁃6731.2020.11.010

Abstract. Background:. Extra-corporeal video telescope operating monitor system provides a necessary instrument to perform high-precision neurosurgical procedures that could substitute or supplement the traditional surgical microscope. The present study was designed to evaluate a compact high-definition two-dimensional exoscope system for assisting in surgical removal of large vestibular schwannoma (VS), as an alternative to a binocular surgical microscope. Methods:. Patients with Koos grade 3 and grade 4 VS undergoing surgery were enrolled in this prospective cohort study between January 2013 and June 2018. The demographics and tumor characteristics (size, Koos grade, composition [cystic or solid mass]) were matched between the two groups of patients. The following outcome measurements were compared between the two groups: duration of surgery, volume of blood loss, extent of tumor resection, number of operating field adjustments, pre- and post-operative facial and cochlear nerve function evaluated at 3 months post-surgery, complications and surgeons’ comfortability. Results:. A total of 81 patients received tumor resection through the retrosigmoid approach under either an exoscope (cases, n = 39) or a surgical microscope (control, n = 42). Patients in the two groups had comparable tumor location (P = 0.439), Koos grading (P = 0.867), and composition (P = 0.891). While no significant differences in the duration of surgery (P = 0.172), extent of tumor resection (P = 0.858), facial function (P = 0.838), and hearing ability (P = 1.000), patients operated on under an exoscope had less blood loss (P = 0.036) and a fewer field adjustments (P

Hypothalamic-pituitary-adrenal axis dysfunction may lead to the occurrence of critical illness-related corticosteroid insufficiency. Critical illness-related corticosteroid insufficiency can easily occur after traumatic brain injury, but few studies have examined this occurrence. A multicenter, prospective, cohort study was performed to evaluate the function of the hypothalamic-pituitary-adrenal axis and the incidence of critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. One hundred and forty patients with acute traumatic brain injury were enrolled from the neurosurgical departments of three tertiary-level hospitals in China, and the critical illness-related corticosteroid insufficiency incidence, critical-illness-related corticosteroid insufficiency-related risk factors, complications, and 28-day mortality among these patients was recorded. Critical illness-related corticosteroid insufficiency was diagnosed in patients with plasma total cortisol levels less than 10 μg/dL (275.9 nM) on post-injury day 4 or when serum cortisol was insufficiently suppressed (less than 50%) during a dexamethasone suppression test on post-injury day 5. The results demonstrated that critical illness-related corticosteroid insufficiency occurred during the sub-acute phase of traumatic brain injury in 5.6% of patients with mild injury, 22.5% of patients with moderate injury, and 52.2% of patients with severe injury. Traumatic brain injury-induced critical illness-related corticosteroid insufficiency was strongly correlated to injury severity during the sub-acute stage of traumatic brain injury. Traumatic brain injury patients with critical illness-related corticosteroid insufficiency frequently presented with hemorrhagic cerebral contusions, diffuse axonal injury, brain herniation, and hypotension. Differences in the incidence of hospital-acquired pneumonia, gastrointestinal bleeding, and 28-day mortality were observed between patients with and without critical illness-related corticosteroid insufficiency during the sub-acute phase of traumatic brain injury. Hypotension, brain-injury severity, and the types of traumatic brain injury were independent risk factors for traumatic brain injury-induced critical illness-related corticosteroid insufficiency. These findings indicate that critical illness-related corticosteroid insufficiency is common during the sub-acute phase of traumatic brain injury and is strongly associated with poor prognosis. The dexamethasone suppression test is a practical assay for the evaluation of hypothalamic-pituitary-adrenal axis function and for the diagnosis of critical illness-related corticosteroid insufficiency in patients with traumatic brain injury, especially those with hypotension, hemorrhagic cerebral contusions, diffuse axonal injury, and brain herniation. Sub-acute infection of acute traumatic brain injury may be an important factor associated with the occurrence and development of critical illness-related corticosteroid insufficiency. This study protocol was approved by the Ethics Committee of General Hospital of Tianjin Medical University, China in December 2011 (approval No. 201189).

There are landmarks on the course of the anterior choroidal artery (AChoA), such as the original point (OP) and the plexal point (PP), as documented in previous articles. In these previous articles, the AChoA was the terminal branch of the internal carotid artery (ICA), which had two segments throughout its course. The first cisternal segment began from the origin and ended at the point where the artery reached the choroidal fissure (the PP). The second segment consisted of one or more branches, which passed through the choroidal fissure and entered the choroid plexus. However, we found another angiographic landmark, named the most external point (MEP), along the course of the AChoA in the anteroposterior (AP) view. There was a sharp turn at the outermost limit of the course of the AChoA, and then the AChoA progressed inward and upward. We defined the outermost limit as the MEP of the AChoA. This study describes two rare cases of distal AChoA aneurysms associated with arteriovenous malformation (AVM) and Moyamoya disease that developed intraventricular hemorrhage, and we used the parent artery occlusion (PAO) technique to embolize the distal AChoA lesions at the MEP. The patients recovered well without any neurological complications.

Objective To study the efficacy and safety of hematoma puncture catheter drainage under CT real-time guide for treatment of intracerebral hemorrhage (ICH). Methods A total of 80 ICH patients with hematoma volume 15-30 ml were given conservative treatment (control group, 40 cases including 6 cases with hematoma volume 15-20 ml and 34 cases with hematoma volume > 20-30 ml) and hematoma puncture and catheter drainage under CT real-time guide (operation group, 40 cases with hematoma volume > 20-30 ml). Conscious states were evaluated by Glasgow Coma Scale (GCS) on admission and 3 d after onset. Neurological deficits of patients were evaluated by National Institutes of Health Stroke Scale (NIHSS) on admission and discharge. Hospitalization days and complications (including rebleeding, epilepsy, intracranial infection, severe pulmonary infection and bleeding caused by digestive tract stress ulcer) were recorded. Results The GCS scores 3 d after onset (P = 0.000) and NIHSS scores on discharge (P = 0.000) of 2 groups were significantly lower than those on admission. The GCS score of operation group was significantly higher (P = 0.003) and NIHSS score was significantly lower (P = 0.000) than that of control group. The hospitalization time of operation group was significantly lower than those of control group [(10.53 ± 2.64) d vs. (17.30 ± 4.92) d; t = 7.673, P = 0.000]. Complications including rebleeding, intracranial infection, severe pulmonary infection and bleeding caused by digestive tract stress ulcer did not occur in patients of 2 groups. Conclusions For supratentorial hemorrhage patients withhematoma volume 15-30 ml, in comparison with conservative treatment, operation with hematoma puncture and catheter drainage under CT real-time guide can save hospitalization days, relieve edema peak response and improve the prognosis. DOI: 10.3969/j.issn.1672-6731.2018.11.007

A moderate stress such as cold water swimming can raise the tolerance of the body to potentially injurious events. However, little is known about the mechanism of beneficial effects induced by moderate stress. In this study, we used a classic rat model of traumatic brain injury to test the hypothesis that cold water swimming preconditioning improved the recovery of cognitive functions and explored the mechanisms. Results showed that after traumatic brain injury, pre-conditioned rats (cold water swimming for 3 minutes at 4°C) spent a significantly higher percent of times in the goal quadrant of cold water swim, and escape latencies were shorter than for non-pretreated rats. The number of circulating endothelial progenitor cells was significantly higher in pre-conditioned rats than those without pretreatment at 0, 3, 6 and 24 hours after traumatic brain injury. Immunohistochemical staining and Von Willebrand factor staining demonstrated that the number of CD34+ stem cells and new blood vessels in the injured hippocampus tissue increased significantly in pre-conditioned rats. These data suggest that pretreatment with cold water swimming could promote the proliferation of endothelial progenitor cells and angiogenesis in the peripheral blood and hippocampus. It also ameliorated cognitive deficits caused by experimental traumatic brain injury.

Objective To investigate the significance of abnormal muscle response (AMR) monitoring during microvascular decompression (MVD) for hemifacial spasm (HFS) in confirming the responsible blood vessel, improving the prognosis and reducing postoperative complications. Methods A total of 34 HFS patients underwent AMR monitoring during MVD. Results The AMR of mentalis was recorded in all 34 patients by electrically stimulating zygomatic branch of facial nerve before anesthesia. Compared with preoperation, the AMR latency after operation was significantly longer [(16.12 ± 3.17) ms vs (14.75 ± 3.32) ms, P = 0.015] and amplitude was significantly reduced [(0.11 ± 0.03）mV vs (0.13 ± 0.03) mV, P = 0.027]. AMR was disappeared in 32 cases (94.12% ) after the removal of responsible blood vessel. There was one patient (2.94%) whose AMR disappeared momentarily after the incision of endocranium and disappeared completely after the removal of responsible blood vessel, while AMR still existed in one case (2.94%) after the removal of responsible blood vessel. Responsible blood vessels included anterior inferior cerebellar artery (N = 30, 88.24%), posterior inferior cerebellar artery (N = 3, 8.82%) and basilar artery (N = 1, 2.94%), which oppressed the root of facial nerve (N = 22, 64.71%), the distal part (N = 8, 23.53%), and both the root and distal part (N = 4, 11.76%). After operation, facial spasm disappeared. Thirty-one cases were cured, 2 cases evidently remitted, and one case inefficacious. The total effective rate was 97.06%. Conclusions Continuously intraoperative monitoring of AMR contributes to confirming the responsible blood vessel, completing decompression for facial nerve more thoroughly, improving the prognosis, reducing delayed healing up, at the same time enhancing neurosurgeons' confidence and reducing operation time. DOI: 10.3969/j.issn.1672-6731.2016.05.010

Background Epithelioid hemangioendothelioma is an uncommon low-grade malignant tumor with various biological behaviors. This paper retrospectively analyzed the clinical data of 2 cases with epithelioid hemangioendothelioma which were confirmed by histopathological features, and reviewed relevant literatures, so as to summarize clinical and radiological features, diagnosis and differential diagnosis, treatment and prognosis of this disease. Methods and Results The tumor in Case 1 was cystic accompanied with hemorrhage. Hematoma clearance, decompressive craniectomy and total removal of the tumor were performed. The tumor in Case 2 was misdiagosed as meningioma firstly, and craniotomy was implemented to remove the tumor. But 8 months later, the tumor relapsed. The tumor was vascularized in operation and subtotally removed with moderate blood loss. Postoperative pathological diagnosis revealed epithelioid hemangioendothelioma in both cases. Immunohistochemical staining showed the tumor cells were positive for CD34, FⅧ RAg in Case 1, while CD31, vimentin (Vim) and Fli-1 in Case 2, and both negative for cytokeratin (CK) and epithelial membrane antigen (EMA). Case 1 was followed up for one year, and no recurrence was found. Case 2 received postoperative auxiliary radiotherapy, but tumor metastasis was found 3 months later. Conclusions Epithelioid hemangioendothelioma is a unique vascular tumor characterized by proliferation of epithelioid or histiocytoid endothelial cells. The histopathological features and biological behaviors are intermediate between hemangioma and angioscarcoma, and its intracranial occurrence is extremely rare. A preoperative diagnosis is usually difficult because of lacking characteristic clinical and radiological features. Diagnosis mainly depends on histopathology and immunohistochemistry. Gross resection is currently the firstline treatment for these tumors. Otherwise, adjuvant therapies are required. The prognosis of this disease has not yet been well defined DOI: 10.3969/j.issn.1672-6731.2015.09.012

Intracranial enterogenous cyst is a kind of benign disease. This paper retrospectively analyzed the clinical data of 4 cases with enterogenous cysts, which were confirmed by surgery, pathology and combined with relevant literature to summarize the causes, clinical features, diagnosis and treatment of this disease. It is common in middle-aged women and occurs in the midline region. It is difficult to distinguish intracranial enterogenous cyst from other intracranial cysts, because there are no characteristic changes in imaging or clear diagnostic criteria. It increases the difficulty of preoperative diagnosis and misdiagnosis rate. Diagnosis depends on intraoperative findings and pathological examination. Total resection is the only curative means. doi: 10.3969/j.issn.1672-6731.2014.04.014

Background With the development of image fusion technology in clinical application, the fusion of 11C-methionine (11C-Met) PET and MRI is also used in clinic. Based on different image results in 11C-Met PET and MRI of gliomas, this article aims to evaluate the application value of integration of MRI and 11C-Met PET in preoperative assessment, intraoperative neuronavigation and tumor resection of glioma surgery. Methods Twenty-five patients with gliomas were examined with both MRI and 11C-Met PET before operation. Based on the integrated 11C-Met PET/MRI images, the neuronavigation workstation performed tumor delineation and calculated the tumor volume. Histological classification of tumors was performed according to WHO grades. The percentages of discrepancy-PET (vPET not included in vMRI) and discrepancy-MRI (vMRI not included in vPET) were evaluated on the fusion images. Results Therewere 3 11C-Met PET/MRI integration patterns emerged after analysis of volumetric data. One group included 15 cases (one was WHO Ⅱ, six were WHO Ⅲ and eight were WHO Ⅳ) with vMRI included in vPET with a low discrepancy-MRI. The second one included 2 patients with WHOⅢ gliomas with vPET included in vMRI with a low discrepancy-PET. The third group included 8 cases (six were WHOⅡ and two were WHO Ⅲ) with vMRI-different-from-vPET. Conclusion 11C-Met PET is able to accurately delineate tumor boundary and sensitively target the region of high proliferation or metabolism. Different 11C-Met PET/MRI integration patterns can be assigned in tumor classfication and are favorable for making surgery plans.

Objective To discuss the application of the intraoperative magnetic resonance imaging (iMRI) ⁃ based neuronavigation system in transnasal ⁃ sphenoidal surgery for pituitary adenoma. Methods Thirty ⁃ eight pituitary adenomas were resected via nasal ⁃ sphenoidal approach with assistance of the American GE Signa 1.5T intraoperative magnetic resonance system associating German Brain LAB neuronavigation system. The clinical materials, iMRI quality and its influence on the surgical process and results were analyzed. Results Intraoperative scanning was performed 2 or 3 times in each patient, averaging (2.11 + 0.41) times. The scanning time was 3-5 min, and adding the packaging and transporting process, the whole procedure required 15-20 min. Posing the position, fixing the head rest and navigation registering took 32-40 min in all. So the total operation may last 47-60 min, averaging (51.20 + 0.66) min. The iMRI was used to scan and collect pictures. Residual tumor tissue was revealed in 11 cases. Eight of the 11 cases underwent total resection according to the new neuronavigation plan. The other 3 cases under⁃ went subtotal resection because the adenomas were tenacious and adhered closely to the surrounding significant structures. By using this iMRI system, the total resection rate (TRR) of adenoma increased from 71.05% (27/38) to 92.10% (35/38). It was raised by 21.05% (8/38; χ2 = 4.290, P = 0.018). There was no iMRI related complication occurred. Conclusion The application of iMRI ⁃ based neuronavigation technology in transnasal ⁃ sphenoidal operations for pituitary adenoma provides objective evidence for the guidance of surgical procedure and real time assessment of surgical results, which may lead to higher TRR and avoid deviation of navigation caused by brain⁃drift in transnasal⁃sphenoidal operation. DOI：10.3969/j.issn.1672⁃6731.2012.02.022

Objective A microanatomical study was performed to observe the relationship between trigeminal nerve, superior cerebellar arteries (SCA) and superior petrosal veins (SPV), in order to provide anatomical reference for the clinical application of microvascular decompression. Methods Simulating operation technique, a retrosigmoid keyhole craniotomy was made and the bone window was controlled within 2.00 cm × 2.50 cm. Thirty sides of 15 cadaver heads (embalmed and injected) were dissected under 4 to 24 magnification via operating microscope. Opened the calvaria and removed dura mater and cerebrum tissue, the tentorium of cerebellum and brainstem were exposed. Trigeminal nerve, SCA and SPV were dissected carefully under microscope. The related anatomical variations were observed and analysed. Results Retrosigmoid keyhole approach presented a clear visualization of trigeminal nerve, trochlear nerve, SPV, and SCA and the branches. The site and the route of cranial nerves were regular, the vascular structures were somewhat variable related to nerves which can be contacted or compressed. SCA of 11 specimens (36.67%) contacted with trigeminal nerve. The suprameatal tubercle was developed variably, but in all specimens it obstructed the exposure of Meckel's cavity under microscope. Of the 30 superior petrosal sinus (SPS) examined in 15 cadaver heads, the SPV entered into the sinus as a single venous stem in 24 sides and as 2 stems in the remaining 6 sides. There were 22.22% (8/36) of SPV entered into SPS at the lateral side of the medial margin of internal auditory meatus (IAM), 63.89% (23/36) of the SPV entered into the SPS between the medial margin of the IAM and the lateral margin of the trigeminal nerve of Meckel's cavity, and 13.89% (5/36) of the SPV entered into the SPS at a point medial to the lateral margin of the trigeminal nerve. Five different types were identified based on the relative sites between trigeminal nerve and SPV, including noncontact type, contact type, branch riding type, arachnoid adhesion type and perforating nerve type. Conclusion The SCA and SPV have close relationship with trigeminal nerve. Compression of the SCA is the primary etiological factor for trigeminal neuralgia in most cases. SPV is the most frequently encountered venous structure during microvascular decompression operation and exists significant variation in position, form, branch and distribution area. Maneuvering the SPV individually may aid surgical exposure and may reduce the probability of potential venous complications. DOI：10.3969/j.issn.1672-6731.2010.06.017

Abstract Background Chronic subdural haematoma (CSDH) is a common condition in the elderly that often requires neurosurgical management. For small CSDH, evidence has emerged that statins may reduce haematoma volume and improve outcomes, presumably by reducing local inflammation and promoting vascular repair. We wish to extend this evidence in a study that aims to determine the efficacy and safety of atorvastatin combined with low-dose dexamethasone in patients with CSDH. Methods The second ATorvastatin On Chronic subdural Hematoma (ATOCH-II) study is a multi-centre, randomized, placebo-controlled, double-blind trial which aims to enrol 240 adult patients with a conservative therapeutic indication for CSDH, randomly allocated to standard treatment with atorvastatin 20 mg combined with low-dose dexamethasone (or matching placebos) daily for 28 days, and with 152 days of follow-up. The primary outcome is a composite good outcome defined by any reduction from baseline in haematoma volume and survival free of surgery at 28 days. Secondary outcomes include functional outcome on the modified Rankin scale (mRS) and modified Barthel Index at 28 days, surgical transition and reduction in haematoma volumes at 14, 28 and 90 days. Discussion This multi-centre clinical trial aims to provide high-quality evidence on the efficacy and safety of the combined treatment of atorvastatin and low-dose dexamethasone to reduce inflammation and enhance angiogenesis in CSDH. Trial registration ChiCTR, ChiCTR1900021659 . Registered on 3 March 2019, http://www.chictr.org.cn/showproj.aspx?proj=36157 .