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Long Wang, Xiang'en Shi, Fangjun Liu and Hai Qian

Fusiform dilation of the internal carotid artery (FDICA) is an infrequent vascular complication following resection of suprasellar lesions in the pediatric population, and its course appears to be benign without apparent clinical symptoms. However, data correlating symptomatic FDICA with bypass surgery are scarce. The authors here report 2 symptomatic cases that were treated using internal maxillary artery bypass more than 5 years after total removal of a craniopharyngioma at an outside institution. Both cases of FDICA were resected to relieve the mass effect and to expose the craniopharyngioma. The postoperative course was uneventful, and radiological imaging revealed graft conduit patency. To the authors' knowledge, this is the first reported use of extracranial to intracranial bypass to treat FDICA following removal of a suprasellar lesion. Their findings suggest that bypass surgery is a useful therapeutic approach for symptomatic cases of FDICA and total removal of recurrent craniopharyngioma. Moreover, the indications for surgical intervention and treatment modalities are discussed in the context of previous relevant cases.

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Xiaofeng Deng, Yan Zhang, Long Xu, Bo Wang, Shuo Wang, Jun Wu, Dong Zhang, Rong Wang, Jia Wang and Jizong Zhao

OBJECT

Cerebral arteriovenous malformations (AVMs) are congenital malformations that may grow in the language cortex but usually do not lead to aphasia. In contrast, language dysfunction is a common presentation for patients with a glioma that involves language areas. The authors attempted to demonstrate the difference in patterns of language cortex reorganization between cerebral AVMs and gliomas by blood oxygen level–dependent (BOLD) functional MRI (fMRI) evaluation.

METHODS

The authors retrospectively reviewed clinical and imaging data of 63 patients with an unruptured cerebral AVM (AVM group) and 38 patients with a glioma (glioma group) who underwent fMRI. All the patients were right handed, and all their lesions were located in the left cerebral hemisphere. Patients were further categorized into 1 of the 2 following subgroups according to their lesion location: the BA subgroup (overlying or adjacent to the inferior frontal or the middle frontal gyri [the Broca area]) and the WA subgroup (overlying or adjacent to the supramarginal, angular, or superior temporal gyri [the Wernicke area]). Lateralization indices of BOLD signal activations were calculated separately for the Broca and Wernicke areas. Statistical analysis was performed to identify the difference in patterns of language cortex reorganization between the 2 groups.

RESULTS

In the AVM group, right-sided lateralization of BOLD signal activations was observed in 23 patients (36.5%), including 6 with right-sided lateralization in the Broca area alone, 12 in the Wernicke area alone, and 5 in both areas. More specifically, in the 34 patients in the AVM-BA subgroup, right-sided lateralization of the Broca area was detected in 9 patients (26.5%), and right-sided lateralization of the Wernicke area was detected in 4 (11.8%); in the 29 patients in the AVM-WA subgroup, 2 (6.9%) had right-sided lateralization of the Broca area, and 13 (44.8%) had right-sided lateralization of the Wernicke area. In the glioma group, 6 patients (15.8%) showed right-sided lateralization of the Wernicke area, including 2 patients in the glioma-BA subgroup and 4 patients in the glioma-WA subgroup. No patient showed right-sided lateralization of the Broca area. Moreover, although the incidence of right-sided lateralization was higher in cases of low-grade gliomas (5 in 26 [19.2%]) than in high-grade gliomas (1 in 12 [8.3%]), no significant difference was detected between them (p = 0.643). Compared with the AVM group, the incidence of aphasia was significantly higher (p < 0.001), and right-sided lateralization of language areas was significantly rarer (p = 0.026) in the glioma group.

CONCLUSIONS

Right-sided lateralization of BOLD signal activations was observed in patients with a cerebral AVM and in those with a glioma, suggesting that language cortex reorganization may occur with both diseases. However, the potential of reorganization in patients with gliomas seems to be insufficient compared with patients AVMs, which is suggested by clinical manifestations and the fMRI findings. Moreover, this study seems to indicate that in patients with an AVM, a nidus near the Broca area mainly leads to right-sided lateralization of the Broca area, and a nidus near the Wernicke area mainly leads to right-sided lateralization of the Wernicke area.

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Xiaofeng Deng, Zihao Zhang, Yan Zhang, Dong Zhang, Rong Wang, Xun Ye, Long Xu, Bo Wang, Kai Wang and Jizong Zhao

OBJECT

The authors compared the image quality and diagnostic sensitivity and specificity of 7.0-T and 3.0-T MRI and time-of-flight (TOF) MR angiography (MRA) in patients with moyamoya disease (MMD).

METHODS

MR images of 15 patients with ischemic-type MMD (8 males, 7 females; age 13–48 years) and 13 healthy controls (7 males, 6 females; age 19–28 years) who underwent both 7.0-T and 3.0-T MRI and MRA were studied retrospectively. The main intracranial arteries were assessed by using the modified Houkin’s grading system (MRA score). Moyamoya vessels (MMVs) were evaluated by 2 grading systems: the MMV quality score and the MMV area score. Two diagnostic criteria for MMD were used: the T2 criteria, which used flow voids in the basal ganglion on T2-weighted images, and the TOF criteria, which used the high-intensity areas in the basal ganglion on source images from TOF MRA. All data were evaluated by 2 independent readers who were blinded to the strength field and presence or absence of MMD. Using conventional angiography as the gold standard, the sensitivity and specificity of 7.0-T and 3.0-T MRI/MRA in the diagnosis of MMD were calculated. The differences between 7.0-T and 3.0-T MRI and MRA were statistically compared.

RESULTS

No significant differences were observed between 7.0-T and 3.0-T MRA in MRA score (p = 0.317) or MRA grade (p = 0.317). There was a strong correlation between the Suzuki’s stage and MRA grade in both 3.0-T (rs = 0.930; p < 0.001) and 7.0-T (rs = 0.966; p < 0.001) MRA. However, MMVs were visualized significantly better on 7.0-T than on 3.0-T MRA, suggested by both the MMV quality score (p = 0.001) and the MMV area score (p = 0.001). The correlation between the Suzuki’s stage and the MMV area score was moderate in 3.0-T MRA (rs = 0.738; p = 0.002) and strong in 7.0-T MRA (rs = 0.908; p < 0.001). Moreover, 7.0-T MR images showed a greater capacity for detecting flow voids in the basal ganglion on both T2-weighted MR images (p < 0.001) and TOF source images (p < 0.001); 7.0-T MRA also revealed the subbranches of superficial temporal arteries much better. Receiver operating characteristic curve analysis showed that, according to the T2 criteria, 7.0-T MRI/MRA was more sensitive (sensitivity 1.000; specificity 0.933) than 3.0-T MRI/MRA (sensitivity 0.692; specificity 0.933) in diagnosing MMD; based on the TOF criteria, 7.0-T MRI/MRA was more sensitive (1.000 vs 0.733, respectively) and more specific (1.000 vs 0.923, respectively) than 3.0-T MRI/MRA.

CONCLUSIONS

Compared with 3.0-T MRI/MRA, 7.0-T MRI/MRA detected and delineated MMVs more clearly and provided higher diagnostic sensitivity and specificity, although it did not show significant improvement in depicting main intracranial arteries. The authors speculate that 7.0-T MRI/MRA is a promising technique in the diagnosis of MMD because it is noninvasive compared with conventional angiography and it is more sensitive than 3.0-T MRI/MRA.

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Chi Long Ho, Chee Meng Wang, Kah Keow Lee, Ivan Ng and Beng Ti Ang

Object

This study addresses the changes in brain oxygenation, cerebrovascular reactivity, and cerebral neurochemistry in patients following decompressive craniectomy for the control of elevated intracranial pressure (ICP) after severe traumatic brain injury (TBI).

Methods

Sixteen consecutive patients with isolated TBI and elevated ICP, who were refractory to maximal medical therapy, underwent decompressive craniectomy over a 1-year period. Thirteen patients were male and 3 were female. The mean age of the patients was 38 years and the median Glasgow Coma Scale score on admission was 5.

Results

Six months following TBI, 11 patients had a poor outcome (Group 1, Glasgow Outcome Scale [GOS] Score 1–3), whereas the remaining 5 patients had a favorable outcome (Group 2, GOS Score 4 or 5). Decompressive craniectomy resulted in a significant reduction (p < 0.001) in the mean ICP and cerebrovascular pressure reactivity index to autoregulatory values (< 0.3) in both groups of patients. There was a significant improvement in brain tissue oxygenation (PbtO2) in Group 2 patients from 3 to 17 mm Hg and an 85% reduction in episodes of cerebral ischemia. In addition, the durations of abnormal PbtO2 and biochemical indices were significantly reduced in Group 2 patients after decompressive craniectomy, but there was no improvement in the biochemical indices in Group 1 patients despite surgery.

Conclusions

Decompressive craniectomy, when used appropriately in protocol-driven intensive care regimens for the treatment of recalcitrant elevated ICP, is associated with a return of abnormal metabolic parameters to normal values in patients with eventually favorable outcomes.

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Xiang-Yang Wang, Li-Yang Dai, Hua-Zi Xu and Yong-Long Chi

Object.

Experimental burst fracture models are often developed by using either single or incremental impacts. In both protocols, the weight-drop technique produces the impact. However, to the authors' knowledge in no study have researchers attempted to compare the equivalence of the spine burst fracture produced using the different impact protocols. This study was performed to investigate whether the single and incremental trauma approaches produce equivalent degrees of severity in thoracolumbar burst fractures.

Methods.

Twenty bovine thoracolumbar spines comprising three vertebrae were divided evenly into the single impact and incremental impact groups. The specimens in the incremental impact group were subjected to three axial compressive impacts of increasing energy (78.4, 107.8, and 137.2 J), whereas specimens in the other group were subjected to a single impact (137.2 J). Before and after the final trauma, multidirectional flexibility of each specimen was measured under flexion/extension, right/left lateral bending, and right/left axial rotation, thus quantifying the instability of the fracture. The flexibility parameters were then compared between the two groups.

Results.

A significant increase in flexibility parameters was found after the final trauma in both groups, indicating the instability of the spine (p < 0.01). No significant differences in flexibility parameters were observed in either intact status or injured status between the two groups (p > 0.05).

Conclusions.

In this study the authors have confirmed that the single and incremental impact protocols produced a similar degree of severity in producing an in vitro bovine burst fracture. The results of this study support the use of the incremental impact protocol in future experimental biomechanical studies.

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Xiang-Yang Wang, Li-Yang Dai, Hua-Zi Xu and Yong-Long Chi

Object

Recurrent kyphosis has been commonly seen after posterior short-segment pedicle instrumentation for a thoracolumbar fracture, but studies on this issue are relatively scarce, and the clinical significance of recurrent deformity is uncertain. No study has addressed the associations between the reduction of a burst fracture vertebra and the final recurrent kyphosis after implant removal. The aim of this study was to investigate the recurrent kyphosis after short-segment pedicle screw fixation in thoracolumbar burst fractures and to evaluate the effect of the degree of a vertebral reduction on the recurrent kyphotic deformity after implant removal.

Methods

Twenty-seven patients who had undergone posterior short-segment pedicle screw fixation for thoracolumbar junction burst fractures (T12–L2) were investigated retrospectively. The minimum follow-up period was 2 years (mean 2.7 years). Pain status was evaluated using the Denis pain scale. Changes in the anterior vertebral height ratio, vertebral wedge angle, upper intervertebral angle, lower intervertebral angle, Cobb angle, regional angle, and sagittal index were measured preoperatively, postoperatively, before implant removal, and at final follow-up. The correlation between the reduction of a fractured vertebra and the recurrent kyphotic deformity was also analyzed.

Results

After the initial surgical correction, the reduced vertebral body (VB) height (anterior vertebral height ratio and vertebral wedge angle) remained stable until final follow-up, whereas the intervertebral disc space (the upper and lower intervertebral angles) collapsed, resulting in a progressive kyphotic deformity (Cobb angle, regional angle, and sagittal index). No significant correlation was found between the final kyphosis and pain scale, but the 8 patients with a sagittal index > 15° showed a higher incidence of moderate to severe pain (P3–5 on the Denis pain scale) compared with the remaining 19 patients with a sagittal index < 15°. Significant positive correlation was found between recurrent kyphosis and vertebral wedge angle (r = 0.850, p < 0.001) and the reduced vertebral height (r = −0.727, p < 0.001).

Conclusions

Given that the correction loss occurs primarily through disc space collapse, the amount of the final kyphotic deformity was predictable by the degree of the fractured vertebral reduction as seen on the lateral x-ray study. Surgeons who perform posterior reduction and fixation procedures should pay more attention to reducing the fractured vertebral wedge angle to its intact condition, rather than the segmental angular parameters. If the wedge angle of the fractured VB is unacceptable after reduction, additional reconstruction of the anterior column may be necessary.

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J. J. Verlaan and F. C. Oner

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Xian-xin Qiu, Chen-hong Wang, Zhi-xiong Lin, Na You, Xing-fu Wang, Yu-peng Chen, Long Chen, Shui-yuan Liu and De-zhi Kang

OBJECT

Peritumoral brain edema (PTBE) is a common phenomenon associated with high-grade gliomas (HGGs). In this study, the authors investigated the expression of Notch delta-like ligand 4 (DLL4) and its correlation with PTBE and prognosis in patients with an HGG.

METHODS

Tumors from 99 patients with HGG were analyzed for DLL4 expression using immunohistochemistry. PTBE on preoperative MR images and the relationship between PTBE and DLL4 expression were evaluated. The effect of DLL4 on patient prognosis was assessed by using Kaplan-Meier survival and Cox proportional hazard models.

RESULTS

Immunohistochemistry results revealed that the expression of DLL4 was distributed primarily within the cytoplasm of tumor vascular endothelial cells and seldom detected in tumor cells. DLL4 expression was correlated positively with the degree of edema (r = 0.845 and p < 0.001, Spearman’s test). In addition, DLL4 was an independent predictor of prognosis in patients with HGGs (p = 0.001).

CONCLUSIONS

DLL4 expression was correlated positively with the degree of PTBE and was an independent unfavorable prognostic indicator in patients with HGG.

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Shi-hao Zheng, Jin-lan Huang, Ming Chen, Bing-long Wang, Qi-shui Ou and Sheng-yue Huang

OBJECTIVE

Glioma is the most common form of brain tumor and has high lethality. The authors of this study aimed to elucidate the efficiency of preoperative inflammatory markers, including neutrophil/lymphocyte ratio (NLR), derived NLR (dNLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), and prognostic nutritional index (PNI), and their paired combinations as tools for the preoperative diagnosis of glioma, with particular interest in its most aggressive form, glioblastoma (GBM).

METHODS

The medical records of patients newly diagnosed with glioma, acoustic neuroma, meningioma, or nonlesional epilepsy at 3 hospitals between January 2011 and February 2016 were collected and retrospectively analyzed. The values of NLR, dNLR, PLR, LMR, and PNI were compared among patients suffering from glioma, acoustic neuroma, meningioma, and nonlesional epilepsy and healthy controls by using nonparametric tests. Correlations between NLR, dNLR, PLR, LMR, PNI, and tumor grade were analyzed. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic significance of NLR, dNLR, PLR, LMR, PNI, and their paired combinations for glioma, particularly GBM.

RESULTS

A total of 750 patients with glioma (Grade I, 81 patients; Grade II, 208 patients; Grade III, 169 patients; Grade IV [GBM], 292 patients), 44 with acoustic neuroma, 271 with meningioma, 102 with nonlesional epilepsy, and 682 healthy controls were included in this study. Compared with healthy controls and patients with acoustic neuroma, meningioma, or nonlesional epilepsy, the patients with glioma had higher values of preoperative NLR and dNLR as well as lower values of LMR and PNI, whereas PLR was higher in glioma patients than in healthy controls and patients with nonlesional epilepsy. Subgroup analysis revealed a positive correlation between NLR, dNLR, PLR, and tumor grade but a negative correlation between LMR, PNI, and tumor grade in glioma. For glioma diagnosis, the area under the curve (AUC) obtained from the ROC curve was 0.722 (0.697–0.747) for NLR, 0.696 (0.670–0.722) for dNLR, 0.576 (0.549–0.604) for PLR, 0.760 (0.738–0.783) for LMR, and 0.672 (0.646–0.698) for PNI. The best diagnostic performance was obtained with the combination of NLR+LMR and dNLR+LMR, with AUCs of 0.777 and 0.778, respectively. Additionally, NLR (AUC 0.860, 95% CI 0.832–0.887), dNLR (0.840, 0.810–0.869), PLR (0.678, 0.641–0.715), LMR (0.837, 0.811–0.863), and PNI (0.740, 0.706–0.773) had significant predictive value for GBM compared with healthy controls and other disease groups. As compared with the Grade I–III glioma patients, the GBM patients had an AUC of 0.811 (95% CI 0.778–0.844) for NLR, 0.797 (0.763–0.832) for dNLR, 0.662 (0.622–0.702) for PLR, 0.743 (0.707–0.779) for LMR, and 0.661(0.622–0.701) for PNI. For the paired combinations, NLR+LMR demonstrated the highest accuracy.

CONCLUSIONS

The NLR+LMR combination was revealed as a noninvasive biomarker with relatively high sensitivity and specificity for glioma diagnosis, the differential diagnosis of glioma from acoustic neuroma and meningioma, GBM diagnosis, and the differential diagnosis of GBM from low-grade glioma.

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Long Wang, Shuaibin Lu, Li Cai, Hai Qian, Rokuya Tanikawa and Xiang’en Shi

OBJECTIVE

The rapid innovation of the endovascular armamentarium results in a decreased number of indications for a classic surgical approach. However, a middle cerebral artery (MCA) aneurysm remains the best example of one for which results have favored microsurgery over endovascular intervention. In this study, the authors aimed to evaluate the experience and efficacy regarding surgical outcomes after applying internal maxillary artery (IMA) bypass for complex MCA aneurysms (CMCAAs).

METHODS

All IMA bypasses performed between January 2010 and July 2018 in a single-center, single-surgeon practice were screened.

RESULTS

In total, 12 patients (9 males, 3 females) with CMCAAs managed by high-flow IMA bypass were identified. The mean size of CMCAAs was 23.7 mm (range 10–37 mm), and the patients had a mean age of 31.7 years (range 14–56 years). The aneurysms were proximally occluded in 8 cases, completely trapped in 3 cases, and completely resected in 1 case. The radial artery was used as the graft vessel in all cases. At discharge, the graft patency rate was 83.3% (n = 10), and all aneurysms were completely eliminated (83.3%, n = 10) or greatly diminished (16.7%, n = 2) from the circulation. Postoperative ischemia was detected in 2 patients as a result of graft occlusion, and 1 patient presenting with subarachnoid hemorrhage achieved improved modified Rankin Scale scores compared to the preoperative status but retained some neurological deficits. Therefore, neurological assessment at discharge showed that 9 of the 12 patients experienced unremarkable outcomes. The mean interval time from bypass to angiographic and clinical follow-up was 28.7 months (range 2–74 months) and 53.1 months (range 19–82 months), respectively. Although 2 grafts remained occluded, all aneurysms were isolated from the circulation, and no patient had an unfavorable outcome.

CONCLUSIONS

The satisfactory result in the present study demonstrated that IMA bypass is a promising method for the treatment of CMCAAs and should be maintained in the neurosurgical armamentarium. However, cases with intraoperative radical resection or inappropriate bypass recipient selection such as aneurysmal wall should be meticulously chosen with respect to the subtype of MCA aneurysm.