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Ang Deng, Hong-Qi Zhang, Ming-Xing Tang, Shao-Hua Liu, Yu-Xiang Wang, and Qi-Le Gao

OBJECTIVE

The objective of this study was to evaluate the clinical efficacy of posterior-only surgical correction of dystrophic scoliosis in patients with neurofibromatosis Type 1 (NF1) using a multiple anchor point method (MAPM).

METHODS

From 2005 to 2014, 31 patients (mean age 13.5 years old, range 10–22 years old) suffering from dystrophic scoliosis associated with NF1 underwent posterior-only surgical correction using a MAPM. The apex of the deformity was thoracic (n = 25), thoracolumbar (n = 4), and lumbar (n = 2). The mean preoperative coronal Cobb angle was 69.1° (range 48.9°–91.4°). The mean Cobb angle on the side-bending radiograph of the convex side was 58.2° (range 40°–79.8°). The mean flexibility and apical vertebral rotation (AVR) were 15.6% (range 8.3%–28.2%) and 2.5° (range 2°–3°), respectively. The mean angle of sagittal kyphosis was 58.3° (range 34.1°–79.6°).

RESULTS

The mean follow-up period was 53 months (range 12–96 months). The mean postoperative coronal Cobb angle was 27.4° (range 16.3°–46.7°). Postoperatively, the mean AVR and angle of sagittal kyphosis were 1.2° (range 1°–2°) and 22.4° (range 4.2°–36.3°), respectively. All patients showed good correction of all indices postoperatively. The mean postoperative correction rate was 58.7% (range 46.3%–74.1%). At the final follow-up evaluation, the corrective loss rate of the Cobb angle was only 2.3%. Only 1 patient required revision surgery. No severe complications such as spinal cord, neural, or large vascular injury occurred during the operation.

CONCLUSIONS

Posterior-only surgical correction of dystrophic scoliosis in patients with NF1 using a MAPM could yield satisfactory clinical efficacy of correction and fusion.

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Wenhua Chen, Wei Xing, Zhongming He, Ya Peng, Caoye Wang, and Qi Wang

OBJECTIVE

The study aimed to assess the diagnostic accuracy of 320-detector row nonsubtracted and subtracted volume CT angiography (VCTA) in detecting small cerebral aneurysms (< 3 mm) compared with 3D digital subtraction angiography (3D DSA).

METHODS

Six hundred sixty-two patients underwent 320-detector row VCTA and 3D DSA for suspected cerebral aneurysms. Five neuroradiologists independently reviewed VCTA and 3D DSA images. The 3D DSA was considered the reference standard, and the sensitivity, specificity, and accuracy of nonsubtracted and subtracted VCTA in depicting small aneurysms were analyzed. A p value < 0.05 was considered a significant difference.

RESULTS

According to 3D DSA images, 98 small cerebral aneurysms were identified in 90 of 662 patients. Nonsubtracted VCTA depicted 90 small aneurysms. Ten small aneurysms were missed, and 2 small aneurysms were misdiagnosed. The missed small aneurysms were located almost in the internal carotid artery, near bone tissue. The sensitivity, specificity, and accuracy of nonsubtracted VCTA in depicting small aneurysms were 89.8%, 99.2%, and 96.5%, respectively, on a per-aneurysm basis. Subtracted VCTA depicted 97 small aneurysms. Three small aneurysms were missed, and 2 small aneurysms were misdiagnosed. The sensitivity, specificity, and accuracy of subtracted VCTA in depicting small aneurysms were 96.9%, 99.2%, and 98.6%, respectively, on a per-aneurysm basis. There was no difference in accuracy between subtracted VCTA and 3D DSA (p = 1.000). However, nonsubtracted VCTA had significantly less sensitivity than 3D DSA and subtracted VCTA (p = 0.039 and 0.016, respectively).

CONCLUSIONS

Subtracted 320-detector row VCTA is sensitive enough to replace 3D DSA in the diagnosis of small cerebral aneurysms (< 3 mm). The accuracy rate of nonsubtracted VCTA was lower than that of subtracted VCTA and 3D DSA, especially in the assessment of small internal carotid artery aneurysms adjacent to the skull base.

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Qi Wang, Chi Wang, Xiaobo Zhang, Fanqi Hu, Wenhao Hu, Teng Li, Yan Wang, and Xuesong Zhang

OBJECTIVE

The aim of this study was to investigate whether bone mineral density (BMD) measured in Hounsfield units (HUs) is correlated with proximal junctional failure (PJF).

METHODS

A retrospective study of 104 patients with adult degenerative lumbar disease was performed. All patients underwent posterior instrumented fusion of 4 or more segments and were followed up for at least 2 years. Patients were divided into two groups on the basis of whether they had mechanical complications of PJF. Age, sex ratio, BMI, follow-up time, upper instrumented vertebra (UIV), lower instrumented vertebra, and vertebral body osteotomy were recorded. The spinopelvic parameters were measured on early postoperative radiographs. The HU value of L1 trabecular attenuation was measured on axial and sagittal CT scans. Statistical analysis was performed to compare the difference of continuous and categorical variables. Receiver operating characteristic (ROC) curve analysis was used to obtain attenuation thresholds. A Kaplan-Meier curve and log-rank test were used to analyze the differences in PJF-free survival. Multivariate analysis via a Cox proportional hazards model was used to analyze the risk factors.

RESULTS

The HU value of L1 trabecular attenuation in the PJF group was lower than that in the control group (p < 0.001). The spinopelvic parameter L4–S1 lordosis was significantly different between the groups (p = 0.033). ROC curve analysis determined an optimal threshold of 89.25 HUs (sensitivity = 78.3%, specificity = 80.2%, area under the ROC curve = 0.799). PJF-free survival significantly decreased in patients with L1 attenuation ≤ 89.25 HUs (p < 0.001, log-rank test). When L1 trabecular attenuation was ≤ 89.25 HUs, PJF-free survival in patients with the UIV at L2 was the lowest, compared with patients with their UIV at the thoracolumbar junction or above (p = 0.028, log-rank test).

CONCLUSIONS

HUs could provide important information for surgeons to make a treatment plan to prevent PJF. L1 trabecular attenuation ≤ 89.25 HUs measured by spinal CT scanning could predict the incidence of PJF. Under this condition, the UIV at L2 significantly increases the incidence of PJF.

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Jian-tao Liang, Yu-hai Bao, Hong-qi Zhang, Li-rong Huo, Zhen-yu Wang, and Feng Ling

Object

The authors conducted a study to assess the clinical pattern, radiological features, therapeutic strategies, and long-term outcomes in patients with intramedullary spinal cord cavernomas (ISCCs) based on a large case series.

Methods

This retrospective study identified 96 patients (60 males, 36 females) surgically (81 cases) or conservatively (15 cases) treated for ISCCs between May 1993 and November 2007. Each diagnosis was based on MR imaging and spinal angiography evidence. For all surgically treated patients, the diagnosis was verified pathologically. The neurological outcomes pre- and postoperatively, as well as long-term follow-up, were assessed using the Aminoff-Logue Disability Scale.

Results

The mean age at the onset of symptoms was 34.5 years (range 9–80 years). Of the lesions, 68 (71%) were located in the thoracic spine, 25 (26%) in the cervical spine, and only 3 (3%) in the lumbar spine. The median symptom duration was 19.7 months. The clinical behavior of the lesion was a slow progression in 73 cases and an acute decline in 23 cases. Long-term follow-up data (mean 45.8 months, range 10–183 months) were available for 75 patients (64 surgical cases and 11 conservative cases). In the surgical group, a complete resection was achieved in 60 patients, and incomplete resection was detected in 4 patients after operation. At the end of the follow-up period in the operative group, 23 patients (36%) improved, 35 (55%) remained unchanged, and 6 (9%) worsened. In the nonoperative group, 5 patients improved, 6 patients remained unchanged, and none worsened.

Conclusions

For differential diagnosis, spinal angiography was necessary in some cases. For most symptomatic lesions, complete microsurgical resection of the symptomatic ISCC is safe and prevents rebleeding and further neurological deterioration. However, in patients whose lesions were small and located ventrally in the spinal cord, one can also opt for a rigorous follow-up, considering the high surgical risk.

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Chao-hu Wang, Song-Tao Qi, Jun Fan, Jun Pan, Jun-Xiang Peng, Jing Nie, Yun Bao, Ya-Wei Liu, Xi’an Zhang, and Yi Liu

OBJECTIVE

Nuclear β-catenin, a hallmark of active canonical Wnt signaling, can be histologically detected in a subset of cells and cell clusters in up to 94% of adamantinomatous craniopharyngioma (ACP) samples. However, it is unclear whether nuclear β-catenin–containing cells within human ACPs possess the characteristics of tumor stem cells, and it is unknown what role these cells have in ACP.

METHODS

Primary ACP cells were cultured from 12 human ACP samples. Adamantinomatous CP stem cell–like cells (CSLCs) showing CD44 positivity were isolated from the cultured primary ACP cells by performing magnetic-activated cell sorting. The tumor sphere formation, cell cycle distribution, stemness marker expression, and multidifferentiation potential of the CD44− cells and the CSLCs were analyzed.

RESULTS

Compared with the CD44− cells, the cultured human CSLCs formed tumor spheres and expressed CD44 and CD133; moreover, these cells demonstrated nuclear translocation of β-catenin. In addition, the CSLCs demonstrated osteogenic and adipogenic differentiation capacities compared with the CD44− cells. The CSLCs also displayed the capacity for tumor initiation in human–mouse xenografts.

CONCLUSIONS

These results indicate that CSLCs play an important role in ACP development, calcification, and cystic degeneration.

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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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Hua-Qiao Tan, Ming-Hua Li, Pei-Lei Zhang, Yong-Dong Li, Jian-Bo Wang, Yue-Qi Zhu, and Wu Wang

Object

Placement of covered stents has emerged as a promising therapeutic option for cerebrovascular diseases. However, the medium- and long-term efficacy and safety of covered stents in the treatment of these diseases remain unclear. The purpose of this study was to evaluate the medium-term clinical and angiographic outcomes of covered stent placement for the treatment of intracranial aneurysms.

Methods

The authors' institutional review board approved the study. Thirty-four patients (13 females and 21 males; mean age 41.9 years) with 38 intracranial aneurysms were treated with the Willis covered stent. Clinical and angiographic follow-up were performed at 3 months, at 6–12 months, and annually thereafter. The initial procedural and follow-up outcomes were collected and analyzed retrospectively.

Results

Forty-two covered stents were successfully implanted into the target artery in 33 patients with 37 aneurysms, and 1 covered stent navigation failed in 1 patient. A complete aneurysm exclusion was initially achieved in 24 patients with 28 aneurysms, and a minor endoleak occurred in 9 patients with 9 aneurysms. Postoperatively, 2 patients died of complications related to the procedure. Angiographic and clinical follow-up data are available in 30 patients. The angiographic follow-up (17.5 ± 9.4 months [mean ± SD]) exhibited complete occlusion in 28 patients with 31 aneurysms, and incomplete occlusion in 2 aneurysms, with an asymptomatic in-stent stenosis in 3 patients (10%). The clinical follow-up (26.7 ± 13 months [mean ± SD]) demonstrated that 16 patients (53.3%) experienced a full recovery, and 14 patients (46.7%) improved. No aneurysm rupture, thromboembolic events, or neurological deficits resulting from closure of a perforating vessel by covered stent placement occurred.

Conclusions

Endovascular reconstruction with the Willis covered stent represents a safe, durable, and curative treatment option for selected intracranial aneurysms, yielding an excellent medium-term patency of the parent artery and excellent clinical outcomes.

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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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Wei Dong Zhu, Qi Huang, Xi Ye Li, Hong Sai Chen, Zhao Yan Wang, and Hao Wu

OBJECT

Cavernous hemangioma of the internal auditory canal (IAC) is an extremely rare type of tumor, and only 50 cases have been reported in the literature prior to this study. The aim in this study was to describe the symptomatology, radiological features, and surgical outcomes for patients with cavernous hemangioma of the IAC and to discuss the diagnostic criteria and treatment strategy for the disease.

METHODS

The study included 6 patients with cavernous hemangioma of the IAC. All patients presented with sensorineural hearing loss and tinnitus, and 2 also suffered from vertigo. Five patients reported a history of facial symptoms with hemispasm or palsy: 3 had progressive facial weakness, 1 had a hemispasm, and 1 had a history of recovery from sudden facial paresis. All patients underwent CT and MRI to rule out intracanalicular vestibular schwannomas and facial nerve neuromas. Five patients had their tumors surgically removed, while 1 patient, who did not have facial problems, was followed up with a wait-and-scan approach.

RESULTS

All patients had a presurgical diagnosis of cavernous hemangioma of the IAC, which was confirmed pathologically in the 5 patients who underwent surgical removal of the tumor. The translabyrinthine approach was used to remove the tumor in 4 patients, while the middle cranial fossa approach was used in the 1 patient who still had functional hearing. Tumors adhered to cranial nerves VII and/or VIII and were difficult to dissect from nerve sheaths during surgeries. Complete hearing loss occurred in all 5 patients. In 3 patients, the facial nerve could not be separated from the tumor, and primary end-to-end anastomosis was performed. Intact facial nerve preservation was achieved in 2 patients. Patients were followed up for at least 1 year after treatment, and MRI showed no evidence of tumor regrowth. All patients experienced some level of recovery in facial nerve function.

CONCLUSIONS

Cavernous hemangioma of the IAC can be diagnosed preoperatively through analysis of clinical features and neuroimaging. Early surgical intervention may preserve the functional integrity of the facial nerve and provide a better outcome after nerve reconstruction. However, preservation of functional hearing may not be achieved, even with the retrosigmoid or middle cranial fossa approaches. The translabyrinthine approach seems to be the most appropriate approach overall, as the facial nerve can be easily located and reconstructed.