2017年 · 第33卷第03期

brainstem gliomas (BSG) are a group of gliomas originating in the midbrain, pons and medulla oblongata. Before the 1980s, BSG was considered a group of homogeneous diseases. At that time, the brainstem was still a restricted area for surgery, which resulted in a lack of adequate understanding of the pathological characteristics of BSG. In addition, the tumor itself was insensitive to radiotherapy and chemotherapy, so the overall prognosis of BSG was extremely poor^[1]。 In recent 30 years, with the continuous development of neuroimaging technology, molecular biology and tumor genomics, people have gradually recognized that BSG is a group of highly heterogeneous diseases. First, BSG as a whole has different molecular genetic properties from cerebral hemispheric gliomas; Secondly, in BSG, tumors in different age groups and different sites have different pathogenesis, growth characteristics and prognosis^{[2,3,4,5,6,7,8,9,10,11,12]}。 From the surgical point of view, although the surgical safety and resection degree of BSG have been significantly improved in recent 30 years with the development of microneurosurgical techniques, neuroimaging techniques, neuronavigation techniques and neuroelectrophysiology techniques, the brainstem is still the site with the highest surgical risk in the central nervous system. Moreover, the tumors in different parts and different growth patterns in the brainstem have their own characteristics in the selection of surgical plan, surgical complications and perioperative nursing. The heterogeneity and complexity of BSG itself determine that it needs comprehensive treatment with multidisciplinary involvement. At present, there are no multidisciplinary research and treatment teams around BSG in domestic medical units. In addition, geographical differences in medical technology have led to a still lack of unified understanding of BSG. Therefore, it is necessary to formulate an expert consensus on BSG standardized diagnosis and treatment for the reference and application of medical institutions and medical staff in clinical work.

Since the existence of human activities, trauma has appeared and increased gradually with the development of human society. Among them, the incidence of craniocerebral trauma ranks second only to limb injury, while the mortality rate ranks first. Especially for severe craniocerebral trauma, the mortality rate is still about 30% so far, and almost all surviving patients have different degrees of neurological dysfunction, which brings a heavy burden to society and family. How to reduce the mortality and disability rate of patients with craniocerebral trauma is still an important issue for neurosurgeons^[1,2,3,4]。

At present, the commonly used keyhole procedures include supraorbital keyhole approach, pterional keyhole approach and infratemporal keyhole approach, all of which need to increase the space of brain tissue traction by releasing cerebrospinal fluid. Some patients with cerebral edema and intracranial hypertension have difficulty in releasing cerebrospinal fluid, so ventricular puncture and external drainage are required, but it is often difficult to locate the ventricle during operation. Among the patients who underwent keyhole surgery from March 2013 to February 2016 in the Department of Neurosurgery, Huangdao Campus, Affiliated Hospital of Qingdao University, 19 patients underwent intraoperative ultrasound-guided puncture of the lateral ventricle, and obtained good results, which are reported below.

Arachnoid cyst is a benign space-occupying lesion in the cranium, which is more common in the middle cranial fossa. Arachnoid cyst complicated with chronic subdural hematoma is rare in clinical practice, and few bulk cases are reported in literature. The pathogenesis of this disease is unknown, but external factors such as craniocerebral trauma are important inducers. This study retrospectively analyzed the clinical characteristics and treatment results of 6 patients with arachnoid cyst complicated with chronic subdural hematoma admitted to the Department of Neurosurgery of the First Affiliated Hospital of Guangxi Medical University from October 2007 to November 2015, and combined with domestic and foreign literature reports as follows.

Intracranial schwannoma, also known as Schwann cell tumor, is most commonly found in the trigeminal and vestibular nerves, while intraparenchymal schwannoma, which is not related to cranial nerves, is very rare clinically^[1]。 The imaging and pathological manifestations of this disease have certain characteristics. Fully understanding and timely and accurate diagnosis are helpful for the formulation of clinical treatment plan and the prognosis of patients. This article retrospectively analyzed the clinical data of two patients with intraparenchymal schwannoma confirmed by pathological and immunohistochemical examination from October 2007 to March 2015 in the Department of Neurosurgery, Jiaxing Second Hospital, Zhejiang Province. Combined with relevant literatures, the mechanism, imaging manifestations, clinical manifestations, pathological characteristics, treatment methods and prognosis of this tumor were discussed.

Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with giant lymphadenopathy, was first reported by Rosai and Dorfman in 1969. RDD is a rare benign histiocytic disease that occurs in children or adolescents, and the proportion of men and women is roughly equal. 43% of RDD occurred outside the lymph nodes^[1]It can occur in almost all organs. The incidence of RDD is high in the peripheral system, and currently known sites include bone, skin, soft tissue, upper respiratory tract, pancreas, salivary glands, eye and orbit, digestive system, mammary gland^{[2,3,4,5,6,7,8]}。 The mean age of patients with intracranial RDD was 40.6 years, accounting for less than 7% of all RDD patients^[9]。 Primary CNS RDD is rare, 6 cases have been reported in the literature so far. The clinical and imaging manifestations of intracranial RDD are mostly similar to meningiomas^[10]。 In October 2015, a case of primary multiple intraparenchymal RDD was admitted to the Department of Neurosurgery of Huashan Hospital affiliated to Fudan University, which is reported in the literature as follows.

Glioma is the most common primary intracranial tumor, with an annual incidence rate of about 4/100,000~5/100,000^[1]。 High-grade glioma has a poor prognosis, with a median overall survival of 14.4 months for glioblastoma^[2]。 With the continuous development of imaging technology, the evaluation criteria of therapeutic response for neurotumors are also constantly updated. In the 1990s, CT began to be used in clinical practice on a large scale. Macdonald et al. proposed a criterion for evaluating the treatment response of high-grade glioma based on CT scan, namely the Macdonald criterion (Table 1)。 This standard uses CT-enhanced lesions and two-dimensional response evaluation standard to measure the size of lesions, which provides an objective basis for the evaluation of tumor treatment response. The Macdonald criteria also refer to the use of corticosteroids in the course of treatment and the neurological status of patients. Because MRI has better resolution than CT, later Macdonald criteria are mostly based on enhanced MRI scans. Since this standard has been applied in clinical practice, it has been widely used in the treatment evaluation of high-grade glioma clinical trials.

glioblastoma (GBM) is the most common primary intracranial malignant tumor in adults^[1]。 In the United States, approximately 10 000 people are newly diagnosed with GBM each year. It is estimated that the incidence of GBM worldwide is approximately 3.5 per 100,000 people. For newly diagnosed patients with GBM, even with aggressive treatment, that is, adjuvant chemotherapy and radiotherapy after surgical resection to the maximum extent, the median survival time of patients is only 12 to 18 months^[2,3]。 Despite first-line drug therapy, nearly all patients experienced tumor recurrence, with an average time to tumor progression of about 6 to 11 months^[4]。 Bevacizumab (BEV) was provisionally approved in the United States for the treatment of recurrent GBM, but the European Food and Drug Agency refused approval due to its lack of controlled trials^[5]。 The most commonly used cytotoxic drugs are alkylating agents such as nitrosoureas [lomustine (CCNU) or carmustine (BCNU)] and methylbenzylhydrazine, or concomitantly temozolomide (TMZ) for the treatment of GBM^[6]。 The chemotherapy response rate was less than 10%, and the progression-free survival (PFS) of 6 months was less than 20%^[7]。 Due to the lack of effective treatment, the overall survival (OS) after recurrence is usually short, rarely exceeding 3 to 5 months^[8]。

Magnetic resonance diffusion tensor imaging (DTI) is an advanced and sophisticated noninvasive magnetic resonance technique developed on the basis of diffusion weighted imaging (DWI) and is a non-invasive method for characterizing microtissue in vivo^[1]。 At present, the application of DTI technology in craniocerebral lesions tends to be mature, and the application research in spinal cord lesions has also become a hot spot. This article reviews the application of DTI in spinal cord tumors.

Holmes tremor (HT) is also known as midbrain tremor, red nucleus tremor, thalamic tremor, and myorhythmic tremor. Tremor caused by midbrain lesions was first reported by Benedikt in 1889^[1], until the first case of HT was described in detail by Holmes in 1904^[2]。 HT is an extrapyramidal disease, mostly caused by brainstem, cerebellum and thalamus lesions, of which thalamus is the most commonly involved part. Its pathogenesis is not clear at present, but it is generally believed that the cerebellum-erythroid-thalamus pathway and the substantia nigra-striatum pathway are damaged. Its etiology includes stroke, tumor, cerebrovascular malformation, craniocerebral trauma, multiple sclerosis and infection, among which stroke is the most common^[3,4]。 HT is rare in clinical practice, and most of the domestic and foreign literatures are retrospective case reports. At present, there is no corresponding treatment guideline. This article reviews the progress of clinical treatment of HT.

Epilepsy is the most common chronic neurological disorder, with about 65 million patients worldwide^[1]。 Epilepsy is an abnormal discharge of brain neurons, which can cause sensory and motor dysfunction of human body, and even change behavior or consciousness, which brings a huge burden to patients and their families. It must be treated in time and effectively. Anti-epileptic drugs are the main means of treating epilepsy, but after a period of standardized drug treatment, about 1/3 of patients still can't be effectively controlled^[2]This type of epilepsy is called medically intractable epilepsy (MIE) and requires surgery or neuromodulation treatment. Since the first case of vagus nerve stimulation (VNS) was performed by Penry and Dean in 1988^[3]Since its successful implementation, invasive Vagus Nerve Stimulation (i-VNS) has been approved by the United States Food and Drug Administration (FDA) in 1994 and 1997. More than 85,000 patients worldwide have undergone the procedure^[4], is an adjuvant treatment approved by the FDA that can be applied to patients with intractable epilepsy ≥12 years old^[5]。 This article summarizes the recent research progress of i-VNS in the treatment of intractable epilepsy as follows.

In 1991, Benabid et al.^[1]After stimulation of the ventral intermediate nucleus of the thalamus by deep brain stimulation (DBS), it was found that tremor was effectively improved in patients with Parkinson's disease (PD). Subsequently Limousin et al.^[2]When the subthalamic nucleus (STN) was used as the stimulation target, in addition to tremor, the symptoms such as stiffness and abnormal movement were well controlled. At present, STN-DBS has gradually replaced damage surgery as one of the common methods for surgical treatment of PD because of its definite, safe and reversible curative effect. Although this technology has been developed for decades, its mechanism of action is still being explored. In recent years, it has been found that the local field potentials (LFPs) recorded by DBS electrode are of great significance in studying the mechanism of action of DBS and the pathophysiological changes of PD. It has the following characteristics: (1) LFPs is correlated with the clinical symptoms of PD patients. (2) During DBS operation, LFPs signal can be directly recorded by DBS electrode. (3) LFPs can continue to collect signals without the interference of DBS electrical stimulation. (4) LFPs signal was regulated by the intensity of electrical stimulation. (5) After implantation of DBS electrode for a period of time, LFPs signal can still be recorded and still controlled by the intensity of electrical stimulation. (6) In PD animal models, the closed-loop stimulation mode with LFPs neuronal discharge and oscillation as feedback signals was superior to the traditional open-loop stimulation mode in improving symptoms^[3]。 This article reviews the association between different frequency bands of LFPs and different symptoms of PD and the preliminary mechanism of DBS in the treatment of PD as follows.