2018年 · 第34卷第02期

In the world, reducing the high disability and death rate of severe traumatic brain injury (sTBI) has been the direction of medical efforts. China has a vast territory, and the differences in region, economy, culture and concept lead to great differences in the clinical treatment of sTBI. Especially for some trauma centers below the county level, there is still a lot of room for improvement in the treatment of sTBI. In order to standardize care and guide treatment, the Brain Trauma Foundation (BTF) published the latest treatment guidelines for sTBI in 2016, the Guidelines for the Treatment of Severe Craniocerebral Trauma (Fourth Edition)^[1]。 Immediately, information platforms such as Chinese Journal of Neurosurgery successively released relevant interpretations of the new guidelines in 2017^[2]。 This article combines the new guidelines and the author's experience and lessons on clinical management of sTBI for more than 30 years, and focuses on the practical problems encountered by clinicians in the whole medical management of sTBI and the specific measures taken, with the purpose of promoting and promoting the standardization of medical management of sTBI in China.

The annual incidence rate of glioma in China is (3~6.4) /100,000, and the annual death number reaches 30,000^[1,2]。 The incidence rate of malignant glioma is 5.8/100,000, and the 5-year mortality rate is second only to pancreatic cancer and lung cancer among systemic tumors^[3]。 Among the primary malignant central nervous system (CNS) tumors, glioblastoma (GBM, WHO grade IV) has the highest incidence, accounting for 46.6%, about 3.20/100,000; Followed by diffuse astrocytoma with an incidence of 0.51/100,000^[4]。

Posterior cerebral artery aneurysms accounted for only 0.7% ~2.3% of all intracranial aneurysms^[1,2]。 Due to the tortuous running of the posterior cerebral artery and the complex anatomical relationships around it, surgical treatment of such aneurysms tends to be at higher risk. With the development of endovascular therapy techniques and the improvement of materials, more and more such aneurysms are treated by endovascular routes. Compared with traditional surgical treatment, endovascular treatment has a lower complication rate, according to domestic and foreign literature^{[3,4,5,6,7,8,9]}。 Endovascular therapy includes embolization of aneurysms alone and embolization of combined tumor-bearing arteries. For P1 segment aneurysm, the author used simple embolization of the aneurysm to preserve the tumor-bearing artery; For P2 segment and its distal aneurysms, because most of them have the characteristics of dissecting aneurysms in imaging manifestations, in order to prevent postoperative recurrence, most surgeons use the simultaneous embolization of aneurysms combined with tumor-bearing arteries. This article retrospectively enrolled 20 patients with ruptured aneurysms of P1 segment of posterior cerebral artery and its distal end admitted to the Department of Neurosurgery of Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine from March 2010 to June 2016. According to the clinical characteristics of this disease, the safety and effectiveness of endovascular treatment were analyzed in combination with the literature.

Hydrocephalus is a common complication of subarachnoid hemorrhage (SAH), especially hydrocephalus caused by ruptured aneurysm, which mostly occurs within 72 hours after hemorrhage. The literature reported that the incidence of hydrocephalus can reach 12% ~41%^[1]Among them, about 50% of patients with combined hydrocephalus can resolve their own symptoms within 24 h, while 15% to 30% of patients can gradually develop chronic hydrocephalus, but the type of hydrocephalus is still unclear^[1,2,3,4,5]。 In the past, the treatment measures for hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH) were mostly ventriculo-peritoneal shunt (VPS), but the shunt brought the discomfort of foreign body placement to patients and could produce various adverse reactions. endoscopic third ventriculostomy (ETV) has the advantages of no foreign body placement, simple operation and low complication rate. At present, it has replaced traditional shunt surgery as the first choice method for the treatment of obstructive hydrocephalus. Studies show that the success rate is 70% ~80%^[6,7]。 Because the treatment of hydrocephalus by ETV is simple, mature, less invasive, no foreign body is needed in the body, and CSF hydrodynamics is more in line with physiological requirements than VPS, it is widely accepted^[8]。 ETV can obtain good curative effect on obstructive hydrocephalus and communicating hydrocephalus (including normal pressure hydrocephalus)^[9,10]This provides a theoretical basis for the treatment of aSAH combined with hydrocephalus by ETV. This study analyzed the clinical data of 26 patients with hydrocephalus after aSAH who underwent ETV to investigate the efficacy and safety of ETV in the treatment of hydrocephalus after aSAH.

Hypertensive cerebral hemorrhage accounts for 10% ~15% of cerebrovascular diseases, has high disability rate and high mortality rate, and is considered to be the most devastating type of stroke^[1]。 The basal ganglia area is the most common site of bleeding. The lateral fissure-insular approach is a surgical method to enter deep lesions from natural anatomical spaces, which can reduce the traction and damage to brain tissue and blood supply arteries, so it has the advantage of minimally invasive treatment of hypertensive hemorrhage in the basal ganglia region. Water separation technique is a kind of separation technique in which warm physiological saline is injected into a fissure interface to be separated in the cranium by a syringe with a blunt needle, and the fissure is extended to facilitate further identification and separation of the interface^[2]。 Lateral fissure separation and hematoma boundary exposure are key steps in surgical separation of hypertensive hemorrhage in basal ganglia region through lateral fissure-insular approach. This study retrospectively included 29 patients with hypertensive hemorrhage in the basal ganglia area admitted to the Department of Neurosurgery of Jinhua Central Hospital from January 2012 to August 2013. All patients were treated by microsurgery through lateral fissure-insula approach, and the lateral fissure separation and hematoma boundary exposure were performed by water separation technique during the operation, with satisfactory results, which are reported below.

Ventriculo-peritoneal shunt is the most commonly used method for the treatment of hydrocephalus. Postoperative complications include shunt obstruction, infection and overshunt, among which shunt obstruction is the most common^[1]。 Obstruction can result from blockage, detachment, or rupture of the shunt device. At present, the diagnosis of shunt obstruction is mainly through clinical manifestations, imaging data and squeezing or puncturing the reservoir, but ultimately surgical exploration is required to confirm the diagnosis. Therefore, preoperative diagnosis of shunt obstruction is very important for clinical work. In this study, magnetic resonance phase cinematic imaging (Pc cine MRI) was used to examine the flow of cerebrospinal fluid (CSF) in the shunt, in order to provide a new method for the diagnosis of ventricular-peritoneal shunt obstruction.

Klippel-Feil syndrome is a group of congenital malformations characterized by cervical spine formation and segmentation disorders, which can be combined with developmental abnormalities of other systems such as the nervous system. Since Love and Kernohan first reported Klippel-Feil syndrome with dermoid cysts in 1936, the correlation between dermoid cysts and epidermoid cysts in the posterior fossa and Klippel-Feil syndrome has been gradually recognized. These cysts are usually located in the midline of the posterior fossa and can extend to the upper cervical vertebra, and a few can even extend to the upper thoracic segment^[1]。 Klippel-Feil syndrome with posterior cranial fossa dermoid cysts are more frequent, but epidermoid cysts are rare. Previous surgical treatment of posterior fossa epidermoid cysts and subcutaneous cysts complicated with Klippel-Feil syndrome usually used suboccipital midline approach, which affected the stability of cervical spine and was difficult to fix. In May 2013, the Department of Neurosurgery, the Third Affiliated Hospital of the Third Military Medical University admitted a patient with giant posterior fossa epidermoid cyst complicated with Klippel-Feil syndrome. The imaging findings were atypical. According to the clinical characteristics of the patient, the surgeon used occipital transtentorial approach to remove the cyst, and the effect was good. The specific reports are as follows.

Angioma is a rare disease derived from lymphatic vessels and blood vessels, also known as angiolymphangioma, which includes lymphangioma and hemangioma^[1,2]。 Angiomas are divided into two types: primary and secondary^[3]。 Angiomas tend to occur in the head and neck, and occur in the spinal canal is extremely rare^[1]。 This disease lacks specific clinical symptoms and signs, and can be diagnosed according to its pathological manifestations. Current treatment methods of angioma include surgical resection, radiotherapy, injection of sclerosing agent, etc^[4]。 In May 2016, a case of T was admitted to the Department of Neurotumor Surgery, Bethune First Hospital, Jilin University_10～12Patients with intraspinal epidural angioma are now reported as follows.

Subarachnoid hemorrhage (SAH) is a common cerebrovascular disease, and 85% of SAH is caused by ruptured aneurysms. Intracranial aneurysms can occur at any age, more in women than in men^[1,2]。 Pregnant women have unique hemodynamic characteristics and hormonal changes, which may be related to the occurrence, development and rupture of aneurysms^[3,4]。 The rupture of intracranial aneurysm during pregnancy and delivery can directly endanger the life of pregnant women, and can also lead to fetal distress and even intrauterine fetal death. The management of intracranial aneurysm in pregnant women should not only follow the diagnosis and treatment guidelines of neurosurgical specialty diseases, but also be careful of the potential harm brought to the fetus by corresponding treatment. The incidence of intracranial aneurysm rupture during pregnancy and delivery is low, and there is currently no standardized diagnosis and treatment guidelines specifically for this type of disease; Although the guidelines on aneurysmal subarachnoid hemorrhage (aSAH) have been issued in many countries, the diagnosis and treatment of intracranial aneurysms during pregnancy and delivery have not been solved. This article reviews the diagnosis and treatment of ruptured intracranial aneurysm during pregnancy and delivery, in order to provide evidence for neurosurgeons and obstetricians and gynecologists to diagnose and treat this kind of disease.

traumatic brain injury (TBI) occupies the second place in the incidence of systemic trauma, and the residual mortality occupies the first place. The preliminary statistical results included in the TBI database of 47 hospitals in China showed that among the patients with acute TBI, the mortality rate of severe TBI was 27.23%, and the death + plant survival + severe disability rate was 53.17%^[1,2]。 In recent years, although various medical monitoring and treatment technologies have been greatly developed, the treatment effect of TBI has not improved significantly.