2017年 · 第33卷第10期

Moyamoya disease is a chronic ischemic cerebrovascular disease characterized by progressive stenosis or occlusion of multiple large intracranial arteries with the formation of moyamoya-like compensatory vessels at the base of the brain and the pial meninges. Moyamoya disease mostly occurs in East Asian populations, and the prevalence rates in Japan and South Korea are lower than 7/100,000. Although there is no national census data for this disease in China, the regional reports are basically similar^[1,2,3]Whereas western countries are lower, so moyamoya disease is a truly rare disease^[1,2,3]。 Nevertheless, the study of moyamoya disease has important clinical significance: (1) The social burden is heavy. Moyamoya disease has two peak onset age: children and young and middle aged. Compared with the elderly patients, its higher disability rate causes greater economic and social psychological burden. (2) The timing and efficacy of treatment are uncertain. Improvement of cerebral perfusion by surgical cerebral blood flow reconstruction is the only effective treatment for moyamoya disease, which can definitively reduce the risk of new stroke and improve neurological deficit symptoms (recommended grade B)^[4]。 However, due to the lack of understanding of the disease and the weakness of clinical evaluation methods, a large number of first-diagnosis patients with hidden symptoms in the early stage of the disease are missed or treated, and the efficacy of severe cerebral ischemia symptoms such as hemiplegia or dementia in the late stage of the disease is not ideal, which makes the surgical efficacy of moyamoya disease questioned for a long time. (3) Basic research is difficult. Although recent studies have found that moyamoya disease may be related to genes and various environmental factors, the etiology is still unclear, and the pathogenesis is complex, so an ideal animal model has not been constructed. However, brain tissue specimens are difficult to obtain due to ethical problems, which makes the basic and clinical research of moyamoya disease difficult. (4) The reference of foreign research is poor. The incidence of moyamoya disease and the geographical distribution of clinical symptoms suggest that the reference value of foreign research results for Chinese population is limited.

After a century of development, neuroendoscopic technology has been widely used in many sub-specialties of neurosurgery. Currently, endoscopic neurosurgery is one of the most important and active subspecialties in minimally invasive neurosurgery. It mainly covers ventriculoscopic surgery characterized by third ventriculostomy (ETV) for the treatment of hydrocephalus and various types of cyst fistula, endoscopic nasal skull base surgery to remove skull base lesions, endoscopic transcranial keyhole approach, endoscopic trans-channel (endoport) surgery, endoscopic spinal surgery and endoscopic combined microscopic surgery. Among them, ventriculoscopic surgery and endoscopic transnasal skull base surgery are currently the most widely carried out. Endoscopic transcranial keyhole approach, endoscopic transcanal surgery and endoscopic spinal surgery are already being carried out gradually and orderly and will become important subspecialties. In this paper, the present situation, existing problems and prospects of the application of endoscopy in various subspecialties of neurosurgery are discussed, in order to promote the application of neuroendoscopy in neurosurgery.

With the development of neuroendoscopic technique, endoscopic transnasal sphenoidal enlargement approach for the treatment of skull base tumors has gradually been adopted clinically. However, postoperative cerebrospinal fluid leakage is the most common complication of this approach, and reliable skull base reconstruction techniques are necessary for successful surgery^[1]。 This article retrospectively analyzed the clinical data of 20 patients who underwent endoscopic transnasal sphenoidal enlargement surgery and skull base reconstruction in the Department of Neurosurgery of the First Affiliated People's Hospital of Shanghai Jiaotong University from October 2013 to December 2015, and explored the effectiveness of multi-layer skull base reconstruction technique using artificial dura mater, fat, fascia lata, nasal septal bone fragments and nasal septal mucosal flap as materials.

tethered cord syndrome (TCS) is a syndrome in which various factors cause longitudinal traction of the spinal cord, low cone position, pathophysiological changes of the spinal cord, and neurological dysfunction and deformity. Surgery is its most effective treatment. With the advancement of technology, the surgery for TCS presents a trend of transformation from classical surgery to microsurgery and endoscopic surgery^[1]。 Microtethered release has been recognized as a standard surgical procedure for the treatment of TCS because of its small trauma, accurate positioning, low nerve injury rate and clear curative effect. As a new surgical procedure, neuroendoscopic surgery has shown great potential in clinical research for TCS. The clinical data of 124 patients with TCS were retrospectively studied to compare the surgical outcome, operation time, hospital stay and complications of microscopic surgery and neuroendoscopic surgery.

In the past, many scholars have reported the anatomical studies of vascular nerves in the skull base, but most of them are studied from the perspective of microscopic craniotomy, and the anatomical features of the skull base observed by naked eye or microscope are reported. In recent years, extended endoscopic endonasal approach (EEEA) skull base surgery has shown many advantages^[1]However, there are relatively few detailed anatomical studies in this area in China. The anatomical features of anterior skull base, sellar region, slope and craniocervical junction were revealed by EEEA skull base surgery.

Cerebrospinal fluid rhinorrhea is a fracture of the skull base or skull defect caused by various reasons, resulting in the outflow of cerebrospinal fluid from the nasal cavity with rupture of the dura and arachnoid membranes. The leakage has different clinical manifestations with different sizes, and can be divided into spontaneous, iatrogenic, traumatic and neoplastic cerebrospinal fluid rhinorrhea. With the increasing application of neuroendoscopic nasal treatment of sellar region diseases, the incidence of iatrogenic cerebrospinal fluid rhinorrhea has also increased. Cerebrospinal fluid rhinorrhea can be treated by craniotomy and skull base repair, neuroendoscopic nasal repair or a combination of two methods. Craniotomy for skull base repair is more invasive, slow postoperative recovery and high failure rate. The advantage of neuroendoscopic nasal repair is that it can look for leaks under direct vision. Compared with craniotomy and tile surgery, its repair is more accurate and the success rate of surgery is higher. From January 2012 to June 2016, the Department of Neurosurgery of the First Affiliated Hospital of Shenzhen University treated 17 patients with cerebrospinal fluid rhinorrhea nasally under neuroendoscopy, and the curative effect was good, which is reported below.

Glioblastoma multiforme, referred to as glioblastoma for short, is the most common malignant tumor of the nervous system. The occurrence probability of glioblastoma is not the same in different parts, and it is most likely to occur in the white matter near the posterior horn of the lateral ventricle^[1]。 Glioblastoma occurring in the spinal cord is rare, accounting for 1% ~5% of all glioblastomas and 1.5% of all spinal cord tumors^[2]。 In terms of diagnosis, spinal glioblastoma is easily confused with spinal cord grade II and III astrocytoma and ependymoma, and its differential diagnosis is difficult. Spinal glioblastoma is not different in cell morphology from glioblastoma in the brain, but it is not the same in principle of treatment. At present, there are few reports on this disease in the literature, there are few large-scale clinical trials for this disease, and the level of evidence for the diagnosis and treatment of spinal glioblastoma in relevant guidelines is also low^[3]。 This paper summarizes the data of 5 patients with spinal glioblastoma and reviews the relevant literature to improve the understanding of spinal glioblastoma.

With the development of endovascular therapy techniques and embolization materials, endovascular therapy has become the first choice for intracranial aneurysm. However, postoperative recurrence is still a difficult problem to be solved in endovascular treatment of aneurysms. Uniform and dense packing of coils can effectively reduce recurrence, but for complex intracranial aneurysms, especially irregular aneurysms, it is still difficult to achieve uniform and dense embolization and reduce postoperative recurrence. From October 2011 to October 2016, 33 cases of irregular ruptured intracranial aneurysms were treated by double microcatheter combined with staggered basket embolization in the Department of Neurosurgery of the Provincial Hospital affiliated to Anhui Medical University, with satisfactory results. The retrospective report is as follows.

Cranioplasty is a common procedure in neurosurgery. Studies have shown that early cranioplasty can improve the blood perfusion of brain tissue at the skull defect, thus improving the quality of life of patients^[1,2]。 However, although cranial repair surgery is simple and easy to perform, there are still complications such as secondary intracranial hematoma, subcutaneous effusion, loosening and lifting of titanium plate in the later stage, and exposure of titanium plate caused by scalp infection and ulcer. Among them, titanium plate exposure caused by various reasons is the most difficult, which may not only lead to the failure of cranial repair surgery, but also require secondary surgery to remove titanium plate, and increase the pain and economic burden of patients. This study included 22 patients with titanium plate exposure after cranioplasty admitted to the Department of Neurosurgery of the 180th Hospital of the People's Liberation Army from June 2008 to June 2016. The causes and preventive measures of titanium plate exposure were retrospectively analyzed, which are reported as follows.

Craniopharyngioma often adheres closely to important structures such as pituitary stem, internal carotid artery, optic nerve, optic chiasma, endplate and hypothalamus, which makes surgery difficult. Different surgical approaches have different degrees of tumor exposure, vascular neuroprotection and hydrocephalus remission^[1]。 This study retrospectively analyzed the clinical data of 31 children with craniopharyngioma resected by anterior longitudinal fissure microsurgery from January 2010 to November 2015 in the Department of Neurosurgery of Guizhou Provincial People's Hospital.

During the treatment of patients with severe cerebral hemorrhage, adequate fluid rehydration can increase the effective circulating blood volume, but also easily lead to increased intracranial pressure and neurogenic pulmonary edema (NPE). Therefore, fluid rehydration should be limited in clinical treatment. However, restriction of fluid rehydration and insufficient fluid intake may lead to cerebral infarction. Therefore, fluid management in patients with severe cerebral hemorrhage is an important link in the treatment. In the past, the traditional method of fluid management was central venous pressure (CVP) monitoring, but there were many drawbacks. pulse index continuous cardiac output (PICCO) monitoring is a new technology for fluid management in recent years. Previous studies have confirmed that PICCO monitoring can effectively manage fluids and improve the treatment rate of patients with severe cerebral hemorrhage^[1]。 However, there are few comparative studies on the effects of PICCO and CVP in the monitoring of severe cerebral hemorrhage. Therefore, this paper applies PICCO technology to fluid management of patients with severe cerebral hemorrhage, and compares the effect with traditional CVP monitoring and treatment, which is reported as follows.

Surgical clipping or endovascular therapy are the main methods of intracranial ruptured aneurysms at present, and the question of "optimal surgical timing" has been controversial both at home and abroad^[1]。 This article retrospectively analyzed the clinical data of patients with ruptured intracranial aneurysms treated by the Department of Neurosurgery of Chifeng University Affiliated Hospital from January 2009 to December 2016, and explored the prognosis of patients with intracranial aneurysms with different Hunt-Hess grades treated with different surgical opportunities. The results are reported below.

During lateral ventricular drainage, drainage tube blockage often occurs. The anti-blockage lateral ventricular drainage system (patent number: ZL2016 2 1006553,9) designed by the Department of Neurosurgery of Longhai (Brain Department) Hospital in Kaifeng City has the advantages of repeated flushing and aspiration of the lateral ventricular drainage system without opening the drainage system, which solves the blockage problem of most drainage tubes, and has achieved good clinical efficacy. It is now introduced as follows.

Sellar tumors are mainly pituitary adenomas in adults, only about 10% are tumors of other nature, and primary undifferentiated sarcoma of the sellar region is even more rare^[1]。 There are literature reports of undifferentiated sarcoma in the sellar region after radiotherapy in patients with pituitary adenoma^[1]。 This article retrospectively analyzed the clinical data of a patient with undifferentiated sarcoma in the sellar area admitted to the Department of Neurosurgery, Brain Hospital, Weifang People's Hospital in April 2015 and reviewed the relevant literature.

Neuromuscular maltumor, also known as benign salamander tumor, is a rare clinical disease. It is caused by ectopic growth of normal embryonic tissue, and mostly involves peripheral nerves such as sciatic nerve and brachial plexus^[1]。 Many patients have pediatric onset and clinical manifestations are sensory or motor function deficits of affected nerves. Neuromuscular maltumas involving cranial nerves are more rare. At present, there are 22 cases reported abroad. The vestibulocochlear nerve is the most frequently involved, followed by the oculomotor nerve^[2]。 It has not been reported in domestic literature. This paper reports a case of cerebellopontine angle neuromuscular maltumas, and discusses its clinical features in combination with literature.

PatientFemale, 24 years old, 27 weeks pregnant, refugee from South Sudan. On 18 April 2014, he was flown by United Nations helicopter to the 12th batch of peacekeeping medical teams in South Sudan from Jinan Military Region because he was "unconscious for 30 hours after being hit in the head by a bullet". Physical examination of the patient at admission: normal basic vital signs, light coma, Glasgow Coma Scale (GCS) 8, no abnormalities in bilateral pupils. A tangential injury of 7 cm ×3 cm was seen on the left temporal roof of the skull (FIG. 1A), a small amount of brain tissue and cerebrospinal fluid outflow can be seen locally. Right limb tingling unresponsive, right Babinski sign positive. A plain radiograph of the skull showed a triangular defect of the left parietal bone, with a large number of bone fragments in the skull below the defect, and the fracture extending to the forehead in a groove-like manner (FIG. 1B)。

Hemangioblastoma is a rare benign tumor of the central nervous system. It originates from the embryonic residual tissue of mesodermal cells. It is a vascular-rich and localized tumor, which occurs in the cerebellum, spinal cord and brainstem. The onset of most hemangioblastomas is sporadic, but about 25% of them belong to a clinical manifestation of von Hippel-Lindau (VHL) disease with a familial predisposition. brainstem hemangioblastomas (BSHs) account for about 2% to 10% of brainstem tumors^[1,2]Compared with cerebellar hemangioblastoma, the diagnosis and treatment of hemangioblastoma is unique. With the advancement of medical imaging, intraoperative auxiliary technology, radiotherapy and molecular biology technology, there are new understandings about the diagnosis and treatment of BSH, which are summarized below.

intracerebral hemorrhage (ICH) is a serious neurological disease, and its mortality and disability rate are higher than those of ischemic stroke^[1]。 It has been reported that the 30-day mortality rate of ICH patients is 30% to 50%, and nearly 50% of patients die within 2 weeks of onset^[2]。 Initial hematoma volume and hematoma location are the risk factors that significantly affect the prognosis of ICH patients. Hematoma enlargement is present in 40% of ICH patients and is an independent predictor of worsening disease and poor prognosis^[3]。 However, there is no unified diagnostic criteria at present, and it mainly relies on CT angiography (CTA) and CT examination. Therefore, it is of great clinical significance to study the first CT and CTA images of ICH patients. In recent years, many studies have confirmed that some specific manifestations in CTA and CT are associated with hematoma enlargement, such as spot sign^[4]leakage sign,^[5]blend sign,^[6]Black hole sign (black hole sign)^[7]To provide a more effective method for diagnosing high-risk ICH patients with enlarged hematoma. This paper analyzes the potential correlation between the specific manifestations of hematoma in ICH patients in CTA and CT and the early hematoma enlargement, in order to provide timely and effective clinical intervention for ICH patients with hematoma enlargement, so as to reduce the mortality rate and improve the prognosis.