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Peng Li, Fu Zhao, Jing Zhang, Zhenmin Wang, Xingchao Wang, Bo Wang, Zhijun Yang, Jun Yang, Zhixian Gao, and Pinan Liu

OBJECT

The aim of this study was to evaluate the clinical features of spinal schwannomas in patients with schwannomatosis and compare them with a large cohort of patients with solitary schwannomas and neurofibromatosis Type 2 (NF2).

METHODS

The study was a retrospective review of 831 patients with solitary schwannomas, 65 with schwannomatosis, and 102 with NF2. The clinical, radiographic, and pathological data were extracted with specific attention to the age at onset, location of tumors, initial symptoms, family history, and treatment outcome.

RESULTS

The male-to-female ratio of patients with schwannomatosis (72.3% vs 27.7%) was significantly higher than that of patients with solitary schwannomas (53.3% vs 46.7%) and NF2 (54.0% vs 46.0%), respectively (chi-square test, p = 0.012). The mean age at the first spinal schwannoma operation of patients with NF2 (24.7 ± 10.2 years) was significantly younger than that of patients with solitary schwannomas (44.8 ± 13.2 years) and schwannomatosis (44.4 ± 14.1 years; 1-way ANOVA, p < 0.001). The initial symptoms were similar among the 3 groups, with pain being the most common. The distribution of spinal tumors among the 3 groups was significantly different. The peak locations of spinal schwannomas in patients with solitary schwannomas were at C1–3 and T12–L3; in schwannomatosis, the peak location was at T12-L5. A preferred spinal location was not evident for intradural-extramedullary tumors in NF2. Only a slight prominence in the lumbar area could be observed. The patients in the 3 groups obtained similar benefits from the operation; the recovery rates in the patients with solitary schwannomas, NF2, and schwannomatosis were 50.1%, 38.0%, and 53.9%, respectively. The prognosis varied among spinal schwannomas in the patients with schwannomatosis. Up until the last date of follow-up, most patients with schwannomatosis (81.5%) had undergone a single spinal operation, but 12 patients (18.5%) had undergone multiple spinal operations. Patients with nonsegmental schwannomatosis or those with early onset disease seemed to have a poor prognosis; they were more likely to undergo multiple spinal operations. Small cauda equina nodules were common in patients with schwannomatosis (46.7%) and NF2 (86.9%); these small schwannomas appeared to have relatively static behavior. Two patients suspicious for schwannomatosis were diagnosed with NF2 with the detection of constitutional NF2 mutations; 1 had unilateral vestibular schwannoma, and the other had suspicious bilateral trigeminal schwannomas.

CONCLUSIONS

The clinical features of spinal schwannomas vary among patients with solitary schwannomas, NF2, and schwannomatosis. Spinal schwannomas of patients with NF2 appear to be more aggressive than those in patients with solitary schwannomas and schwannomatosis. Spinal schwannomas of schwannomatosis predominate in the lumbar area, and most of them can be treated successfully with surgery. The prognosis varies among spinal schwannomas of schwannomatosis; some patients may need multiple operations due to newly developed schwannomas. Sometimes, it is difficult to differentiate schwannomatosis from NF2 based on clinical manifestations. It is prudent to perform close follow-up examinations in patients with undetermined schwannomatosis and their offspring.

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Xin-Yi Gao, Qiao Li, Jing-Run Li, Qian Zhou, Jian-Xun Qu, and Zhen-Wei Yao

OBJECTIVE

The authors conducted a study to noninvasively and nonradioactively reveal moyamoya disease (MMD) intracerebral perfusion and perfusion territory supplied by the unilateral internal carotid artery (ICA) and external carotid artery (ECA) and bilateral vertebral arteries (VAs) before surgery and to further identify risk factors for preoperative hemorrhage in adult MMD.

METHODS

Forty-three consecutive adult patients with bilateral MMD underwent unenhanced T1-weighted MRI, territorial arterial spin labeling (t-ASL), and unenhanced 3D time-of-flight MRA (3D-TOF-MRA). Clinical factors, including age, sex, hypertension, diabetes mellitus, hyperlipidemia, current smoking status, and history of taking aspirin, were gathered and stratified. Univariate logistic regression analyses were used to examine the relationship between various risk factors and the occurrence of preoperative hemorrhage. Stepwise multivariate logistic regression analyses were used to determine independent risk factors of preoperative hemorrhage in MMD.

RESULTS

Among the 86 MMD hemispheres, t-ASL revealed 137 perfusion territory shifts in 79 hemispheres. Five distinct categories of perfusion territory shifts were observed on t-ASL maps. The subtypes of perfusion territory shift on t-ASL maps were further subdivided into 2 different categories, group A and group B, in combination with findings on 3D-TOF-MRA. A perfusion territory shift attributable solely to the secondary collaterals was a potential independent risk factor for preoperative hemorrhage (p = 0.026; 95% CI 1.201–18.615; OR 4.729). After eliminating the influence of the secondary collaterals, the primary collaterals had no significant effect on the risk of preoperative hemorrhage (p = 0.182).

CONCLUSIONS

t-ASL could reveal comprehensive MMD cerebral blood perfusion and the vivid perfusion territory shifts fed by the unilateral ICA and ECA and bilateral VAs in a noninvasive, straightforward, nonradioactive, and nonenhanced manner. 3D-TOF-MRA could subdivide t-ASL perfusion territory shifts according to their shunt arteries. A perfusion territory shift attributable to the secondary collaterals is a potential independent risk factor for preoperative hemorrhage in MMD patients. A perfusion territory shift fed by the primary collaterals may not have a strong effect on preoperative hemorrhage in MMD patients. These findings make the combined modalities of t-ASL and 3D-TOF-MRA a feasible tool for MMD disease assessment, management, and surgical strategy planning.

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Shaowei Jiang, Ya Peng, Chao-hui Jing, Ai-hua Fei, Hai-rong Wang, Cheng-jin Gao, Miao Chen, Yi Li, and Shuming Pan

OBJECTIVE

This study aimed to assess whether patients with acute ischemic stroke (AIS) and large infarct lesions benefit from reperfusion management. To determine the efficacy of different recanalization managements on AIS patients with Alberta Stroke Program Early CT Score (ASPECTS) < 6, the authors retrospectively analyzed hospitalized patients with AIS.

METHODS

Eighty-nine patients with AIS and ASPECTS < 6 were screened from 13,285 hospitalized patients treated by thrombolysis, thrombectomy, or conventional care in two stroke medical centers. Logistic regression or Fisher’s exact test was performed for comparison of the outcome and risk events between patients treated by thrombectomy (or thrombolysis) and conventional care. The modified Rankin Scale (mRS) score was used to assess the major clinical outcome of patients 3 months after disease onset. Disease outcome was also examined by analyzing symptom improvement at discharge. In particular, mortality and symptomatic intracranial hemorrhage (sICH) were evaluated as risk factors.

RESULTS

This study included 21 patients who received thrombolysis, 36 patients receiving thrombectomy, and 32 patients receiving conventional treatment. Among these 3 treatments, only the thrombectomy group clearly showed the most encouraging clinical outcome (mRS score 0–2; p < 0.05, Fisher’s exact test) and marked improvement (OR 25.84, 95% CI 2.44–273.59) compared with conventional treatment. It is noteworthy that the mortality rate of the thrombectomy and thrombolysis group was similar to that of the conventional group, and thrombectomy and thrombolysis increased the risk of sICH in comparison with conventional care (p < 0.05, Fisher’s exact test).

CONCLUSIONS

Patients with AIS and ASPECTS < 6 definitely benefited from thrombectomy with higher sICH risk, whereas thrombolysis management showed similar efficacy to the control group.

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Myung Ji Kim, So Hee Park, Kyung Won Chang, Yuhee Kim, Jing Gao, Maya Kovalevsky, Itay Rachmilevitch, Eyal Zadicario, Won Seok Chang, Hyun Ho Jung, and Jin Woo Chang

OBJECTIVE

Magnetic resonance imaging–guided focused ultrasound (MRgFUS) provides real-time monitoring of patients to assess tremor control and document any adverse effects. MRgFUS of the ventral intermediate nucleus (VIM) of the thalamus has become an effective treatment option for medically intractable essential tremor (ET). The aim of this study was to analyze the correlations of clinical and technical parameters with 12-month outcomes after unilateral MRgFUS thalamotomy for ET to help guide future clinical treatments.

METHODS

From October 2013 to January 2019, data on unilateral MRgFUS thalamotomy from the original pivotal study and continued-access studies from three different geographic regions were collected. Authors of the present study retrospectively reviewed those data and evaluated the efficacy of the procedure on the basis of improvement in the Clinical Rating Scale for Tremor (CRST) subscore at 1 year posttreatment. Safety was based on the rates of moderate and severe thalamotomy-related adverse events. Treatment outcomes in relation to various patient- and sonication-related parameters were analyzed in a large cohort of patients with ET.

RESULTS

In total, 250 patients were included in the present analysis. Improvement was sustained throughout the 12-month follow-up period, and 184 (73.6%) of 250 patients had minimal or no disability due to tremor (CRST subscore < 10) at the 12-month follow-up. Younger age and higher focal temperature (Tmax) correlated with tremor improvement in the multivariate analysis (OR 0.948, p = 0.013; OR 1.188, p = 0.025; respectively). However, no single statistically significant factor correlated with Tmax in the multivariate analysis. The cutoff value of Tmax in predicting a CRST subscore < 10 was 55.8°C. Skull density ratio (SDR) was positively correlated with heating efficiency (β = 0.005, p < 0.001), but no significant relationship with tremor improvement was observed. In the low-temperature group, 1–3 repetitions to the right target with 52°C ≤ Tmax ≤ 54°C was sufficient to generate sustained tremor suppression within the investigated follow-up period. The high-temperature group had a higher rate of balance disturbances than the low-temperature group (p = 0.04).

CONCLUSIONS

The authors analyzed the data of 250 patients with the aim of improving practices for patient screening and determining treatment endpoints. These results may improve the safety, efficacy, and efficiency of MRgFUS thalamotomy for ET.

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Xinghuo Wu, Kirkham B. Wood, Yong Gao, Shuai Li, Jing Wang, Ting Ge, Boming Zhao, Zengwu Shao, Shuhua Yang, and Cao Yang

OBJECTIVE

This study aimed to compare the clinical results of using posterior fixation and fusion with or without anterior decompression to treat os odontoideum with atlantoaxial dislocation.

METHODS

Twenty-five consecutive patients with os odontoideum were included in this study. Sixteen patients with reducible atlantoaxial dislocation were treated by single-level posterior fusion and stabilization; the other 9 were treated with posterior fusion and stabilization combined with transoral decompression. Pre- and postoperative CT scans and MR images were obtained.

RESULTS

Twenty-four patients were followed for 24–54 months (average 36.5 months). Postoperative CT scans indicated that all pedicle screws were placed satisfactorily except in 2 cases, in which the screws slightly penetrated the transverse foramen. Postoperative MR images demonstrated that sufficient decompression of the spinal cord was obtained in all patients. Complications included 1 case each of pedicle screw breakage, pharynx ulcer, and persistent pharynx discomfort. Statistical analysis of all cases revealed that mean Japanese Orthopaedic Association scores improved from a preoperative score of 10.2 (range 7–13) to a postoperative score of 15.6 (range 11–18).

CONCLUSIONS

Patients who have os odontoideum with a reducible atlantoaxial dislocation can be effectively treated with single-level posterior fusion and stabilization. Combined transoral decompression and posterior fusion and stabilization is recommended for those with irreducible atlantoaxial dislocation.

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Guang Yang, Zhendong Liu, Lu Wang, Xin Chen, Xiaoxiong Wang, Qi Dong, Daming Zhang, Zhao Yang, Qi Zhou, Jingxian Sun, Linmeng Xue, Xinzhuang Wang, Ming Gao, Lili Li, Ran Yi, Gareev Ilgiz, Jing Ai, and Shiguang Zhao

OBJECTIVE

It has been reported that microRNA-195 (miR-195) protects against chronic brain injury induced by chronic brain hypoperfusion. However, neither the expression profile of miR-195 nor its potential role during acute ischemic stroke has been investigated. In this study, the authors’ aim was to verify the mechanism of miR-195 in acute ischemic stroke.

METHODS

The plasma levels of miR-195 expression were assessed using real-time PCR in 96 patients with acute ischemic stroke, and the correlation with the National Institutes of Health Stroke Scale score was evaluated. In addition, cerebral infarct volume, neurological score, and levels of miR-195 and CX3CL1/CX3CR1 mRNA and protein expression were assessed in mice subjected to middle cerebral artery occlusion (MCAO) with or without intra-cerebroventricular infusion of lentiviral vector. The inflammatory cytokines tumor necrosis factor–α (TNFα), interleukin (IL)–1β, and IL-6 of mouse brains after MCAO and BV2 cells treated with oxygen-glucose deprivation were measured using enzyme-linked immunosorbent assay, and apoptotic proteins were examined by Western blotting. Direct targeting of CX3CL1/CX3CR1 by miR-195 was determined by immunoblotting and dual luciferase assay.

RESULTS

In ischemic stroke patients, miR-195 was significantly downregulated and expression levels of miR-195 in these patients negatively correlated with the National Institutes of Health Stroke Scale score. In mice after MCAO, miR-195 overexpression decreased infarct volume, alleviated neurological deficits, and most importantly, suppressed an inflammatory response. Meanwhile, miR-195 suppressed the expression of the inflammatory cytokines TNFα, IL-1β, and IL-6 in vitro and in vivo. The authors further discovered that both CX3CL1 and CX3CR1 are direct targets of miR-195, but miR-195 exerts neuroprotective roles mainly through inhibiting CX3CR1-mediated neuroinflammation and subsequent neuronal cell apoptosis.

CONCLUSIONS

Taken together, these findings suggest that miR-195 promotes neuronal cell survival against chronic cerebral ischemic damage by inhibiting CX3CR1-mediated neuroinflammation. This indicates that miR-195 may represent a novel target that regulates neuroinflammation and brain injury, thus offering a new treatment strategy for cerebral ischemic disorders.

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Yuan Wang, Bolin Liu, Tianzhi Zhao, Binfang Zhao, Daihua Yu, Xue Jiang, Lin Ye, Lanfu Zhao, Wenhai Lv, Yufu Zhang, Tao Zheng, Yafei Xue, Lei Chen, Eric Sankey, Long Chen, Yingxi Wu, Mingjuan Li, Lin Ma, Zhengmin Li, Ruigang Li, Juan Li, Jing Yan, Shasha Wang, Hui Zhao, Xude Sun, Guodong Gao, Yan Qu, and Shiming He

OBJECTIVE

Although enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.

METHODS

A multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.

RESULTS

The median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1–3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51–15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1–2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29–1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56–6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).

CONCLUSIONS

This multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.

Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn)