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Extraventricular choroid plexus papilloma in the brainstem

Case report

Anqi Xiao, Jianguo Xu, Xin He, and Chao You

Choroid plexus papilloma (CPP) is extremely rare in the brainstem. The authors report the case of a 10-year-old boy with a lesion in the pons that was misdiagnosed as a glioma preoperatively. The boy underwent partial resection of the lesion, which was diagnosed as a CPP based on histopathological findings. The authors review the MRI findings in this case and conclude that the presence of a well-defined boundary and no obvious cerebral edema are valuable features for distinguishing brainstem CPP from glioma. Although previous reports of parenchymal CPPs have described enhancement on contrast-enhanced T1-weighted MR images, the lesion in this case did not demonstrate significant enhancement. The authors note that the diagnosis of extraventricular CPP cannot be ruled out in a case of brainstem tumor without marked enhancement.

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Cerebral paragonimiasis: a retrospective analysis of 27 cases

Yong Xia, Yan Ju, Jing Chen, and Chao You

OBJECT

The authors retrospectively analyzed the clinical characteristics, existing problems, and treatment experiences in recently diagnosed cerebral paragonimiasis (CP) cases and sought to raise awareness of CP and to supply reference data for early diagnosis and treatment.

METHODS

Twenty-seven patients (22 male and 5 female; median age 20.3 years, range 4–47 years) with CP were diagnosed between September 2008 and September 2013. These diagnoses were confirmed by IgG enzyme-linked immunosorbent assays. Follow-up was performed in 24 cases for a period of 6–56 months.

RESULTS

Cerebral paragonimiasis accounted for 21.6% of paragonimiasis cases (27 of 125). The average duration from onset to praziquantel treatment was 69 days. All patients resided in rural areas. Twenty patients had positive lung results, which included visible lung lesions in 14 cases. The lesions were surgically removed in 8 of these cases. Twenty-four patients had high eosinophil counts (≥ 0.08 × 109/L), and eosinophilic meningitis was noted in 17 cases. The rate of misdiagnosis and missed diagnosis was 30.4%. Most symptoms were markedly improved after treatment, but mild movement disorders combined with impaired memory and personality changes remained in a small number of patients.

CONCLUSIONS

Clinicians should be alert to the possibility of CP in young patients (4–16 years) with the primary symptoms of epilepsy and hemorrhage. Early diagnosis and timely treatment can reduce the need for surgery and further impairments to brain function. Liquid-based cytological examination of CSF and peripheral blood eosinophil counts can aid in differentiating CP from similar lesions.

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Growing skull fracture stages and treatment strategy

Clinical article

Xue-song Liu, Chao You, Ma Lu, and Jia-gang Liu

Object

A growing skull fracture (GSF) is a rare but significant late complication of skull fractures, usually occurring during infancy and early childhood. Delayed diagnosis and improper treatment could exacerbate this disease. The aim of this study was to introduce a new hypothesis about, describe the stages of, and discuss the treatment strategy for GSF.

Methods

The authors performed a retrospective review of 27 patients with GSF, who were grouped according to 3 different GSF stages.

Results

Over a period of 20 years, 27 patients with GSF (16 males and 11 females) were treated in the authors' department. The mean follow-up period was 26.5 months. Six patients were in the prephase of GSF (Stage 1), 10 patients in the early phase (Stage 2), and 11 in the late phase (Stage 3). All patients underwent duraplasty. All 6 patients at Stage 1 and 5 patients at Stage 2 underwent craniotomy without cranioplasty. Five patients at Stage 2 and all of the patients at Stage 3 underwent cranioplasty with autologous bone and alloplastic materials, respectively. Among all patients, 5 underwent ventriculoperitoneal shunt placement.

Symptoms in all patients at Stages 1 and 2 were alleviated or disappeared, and the cranial bones developed without deformity during follow-up. Among patients with Stage 3 GSF, no obvious improvement in neurological deficits was observed. Three patients underwent additional operations because of cranial deformation or infection.

Conclusions

The authors identify the stages of GSF according to a new hypothesis. They conclude that accurately diagnosing and treating GSF during Stages 1 and 2 leads to a better prognosis.

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Intradiploic hemangioma with repeated hemorrhage in a child with hemophilia

Case report

Weiying Zhong, Guoping Li, Siqing Huang, Haifeng Chen, and Chao You

Intraosseous hemangioma is an uncommon benign vascular tumor, which is most frequently found in middle-aged female patients. The clinical course is usually insidious and the outcome excellent after total resection. The authors report a case of a calvarial hemangioma in a child with hemophilia who experienced a catastrophic postoperative hematoma and discuss the mechanism, clinical features, and treatment of this condition.

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The factors associated with hemorrhagic presentation in children with untreated brain arteriovenous malformation: a meta-analysis

Xiaolin Ai, Zengpanpan Ye, Jianguo Xu, Chao You, and Yan Jiang

OBJECTIVE

Rupture of arteriovenous malformations (AVMs) would result in high mortality and prevalence of disability in pediatric patients. Decisions regarding the treatment of AVMs need to weigh the risk of rupture over the course of their natural history against the possibility of creating a lesion during treatment. Multiple factors have been proposed to predict hemorrhagic presentation of pediatric patients with AVMs. The aim of this meta-analysis was to evaluate the predictors of hemorrhagic presentation in pediatric patients with AVMs.

METHODS

The authors searched the PubMed and EMBASE databases. Studies reporting the predictors of hemorrhagic presentation in children with untreated brain AVMs were included. The predictive ability of identified predictors was assessed by odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A higher risk of hemorrhagic presentation was found in AVMs with smaller size (< 3 cm, OR 2.97, 95% CI 1.94–4.54, p < 0.00001), deep venous drainage (OR 2.28, 95% CI 1.55–3.36, p < 0.0001), a single draining vein (OR 2.23, 95% CI 1.27–3.92, p = 0.005), a single feeder (OR 3.72, 95% CI 1.31–10.62, p = 0.01), a deep location (OR 1.82, 95% CI 1.22–2.72, p = 0.004), an infratentorial location (OR 2.25, 95% CI 1.19–4.26, p = 0.01), and diffuse morphology (OR 8.94, 95% CI 3.01–26.55, p < 0.0001). In addition, the AVMs with draining vein ectasia (OR 0.35, 95% CI 0.13–0.97, p = 0.04) and high Spetzler-Martin (SM) grade (OR 0.53, 95% CI 0.36–0.78, p = 0.001) had a lower risk of hemorrhagic presentation in pediatric patients.

CONCLUSIONS

Smaller AVMs, deep venous drainage, a single draining vein, a single feeder, deep/infratentorial location, diffuse morphology, and high SM grade were identified as positive predictors for hemorrhagic presentation. Particularly, patients with diffuse AVMs have a higher risk of hemorrhagic presentation than other factors and may need active treatments. However, factors such as age, sex, draining vein stenosis, and associated aneurysms were not associated with hemorrhagic presentation.

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Decompressive craniectomy in hemorrhagic cerebral venous thrombosis: clinicoradiological features and risk factors

Si Zhang, Hexiang Zhao, Hao Li, Chao You, and Xuhui Hui

OBJECTIVE

Decompressive craniectomy (DC) is a life-saving treatment for severe hemorrhagic cerebral venous thrombosis (CVT). However, the correlations between the clinicoradiological features and surgical outcomes of this disease are not well established. Therefore, the authors endeavored to analyze the potential risk factors for this more severe subtype of CVT and to provide more evidence regarding the benefits of DC in patients with hemorrhagic CVT.

METHODS

The clinical features, radiological findings, and surgical outcomes of patients with severe hemorrhagic CVT who had undergone DC treatment in the period from January 2005 to March 2015 were retrospectively analyzed, and the risk factors for this disease were evaluated.

RESULTS

Fifty-eight patients, 39 females (67.2%) and 19 males (32.8%), with a mean age of 39.7 ± 12.5 years, were included in this study. The mean duration from symptom onset to surgery was 3.3 ± 1.9 days, and 21 patients experienced acute courses. On neuroimaging, the mean mass lesion volume was 114.7 ± 17.7 ml. Nine patients had bilateral lesions, and 7 patients had deep CVT. According to their hemorrhagic proportion, cases were divided into hemorrhage-dominated (27 [46.6%]) and edema-dominated (31 [53.4%]) groups. After 6 months of follow-up, 56.9% of patients had achieved a favorable outcome, and 8 patients had died. The hemorrhage-dominated lesions (p = 0.026) and deep cerebral venous involvement (p = 0.026) were significantly associated with a poor outcome.

CONCLUSIONS

In patients suffering from severe hemorrhagic CVT, DC is an effective life-saving treatment that is associated with favorable outcomes. Hemorrhage-dominated lesions and deep cerebral venous involvement have a significant impact on the outcome of this disease.

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Letter to the Editor. The surgical outcomes of symptomatic moyamoya disease in adults

Zengpanpan Ye, Xiaolin Ai, and Chao You

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Letter to the Editor. Impaired glymphatic pathway as potential contributing factor in amyloid beta accumulation and enhanced neuroinflammation after IVH

Si Zhang and Chao You

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Letter to the Editor. Imaging predictor for rebleeding after surgery in intracerebral hemorrhage

Zhiyuan Yu, Rui Guo, Jun Zheng, Hao Li, Chao You, and Lu Ma

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Association of APOE ε4 with progressive hemorrhagic injury in patients with traumatic intracerebral hemorrhage

Xueyan Wan, Chao Gan, Chao You, Ting Fan, Suojun Zhang, Huaqiu Zhang, Sheng Wang, Kai Shu, Xiong Wang, and Ting Lei

OBJECTIVE

The intracranial hematoma volume in patients with traumatic brain injury is a key parameter for the determination of the management approach and outcome. Apolipoprotein E (APOE) ε4 is reported to be a risk factor for larger hematoma volume, which might contribute to a poor outcome. However, whether APOE ε4 is related to progressive hemorrhagic injury (PHI), a common occurrence in the clinical setting, remains unclear. In this study, the authors aimed to investigate the association between the APOE genotype and occurrence of PHI.

METHODS

This prospective study included a cohort of 123 patients with traumatic intracerebral hemorrhage who initially underwent conservative treatment. These patients were assigned to the PHI or non-PHI group according to the follow-up CT scan. A polymerase chain reaction and sequencing method were carried out to determine the APOE genotype. Multivariate logistic regression analysis was applied to identify predictors of PHI.

RESULTS

The overall frequency of the alleles was as follows: E2/2, 0%; E2/3, 14.6%; E3/3, 57.8%; E2/4, 2.4%; E3/4, 22.8%; and E4/4, 2.4%. Thirty-four patients carried at least one allele of ε4. In this study 60 patients (48.8%) experienced PHI, and the distribution of the alleles was as follows: E2/2, 0%; E2/3, 5.7%; E3/3, 22.8%; E2/4, 2.4%; E3/4, 16.3%; and E4/4, 1.6%, which was significantly different from that in the non-PHI group (p = 0.008). Additionally, the late operation rate in the PHI group was significantly higher than that in the non-PHI group (24.4% vs 11.4%, p = 0.002). Multivariate logistic regression identified APOE ε4 (OR 5.14, 95% CI 2.40–11.62), an elevated international normalized ratio (OR 3.57, 95% CI 1.61–8.26), and higher glucose level (≥ 10 mmol/L) (OR 3.88, 95% CI 1.54–10.77) as independent risk factors for PHI. Moreover, APOE ε4 was not a risk factor for the coagulopathy and outcome of the patients with traumatic intracerebral hemorrhage.

CONCLUSIONS

The presence of APOE ε4, an elevated international normalized ratio, and a higher glucose level (≥ 10 mmol/L) are predictors of PHI. Additionally, APOE ε4 is not associated with traumatic coagulopathy and patient outcome.