Tianhao Wang, Yongfei Zhao, Yan Liang, Haocong Zhang, Zheng Wang, and Yan Wang
The aim of this paper was to analyze the incidence and risk factors of proximal junctional kyphosis (PJK) in patients with ankylosing spondylitis (AS) who underwent pedicle subtraction osteotomy.
The records of 83 patients with AS and thoracolumbar kyphosis who underwent surgery at the authors’ institution between 2007 and 2013 were reviewed. The patients were divided into 2 groups based on the presence or absence of PJK. The radiographic measurements, including proximal junctional angle (PJA), sagittal parameters, and pelvic parameters of these 2 groups, were compared at different time points: before surgery and 2 weeks, 12 months, and 2 years after surgery. Oswestry Disability Index scores were also evaluated.
Overall, 14.5% of patients developed PJK. Before surgery, the mean PJAs in the 2 groups were 13.6° and 8.5°, respectively (p = 0.008). There were no significant differences in age, sex, and body mass index between groups. Patients with PJK had a larger thoracolumbar kyphotic angle (50.8° ± 12.6°) and a greater sagittal vertical axis (21.7 ± 4.3 cm) preoperatively than those without PJK. The proportion of patients with PJK whose fusion extended to the sacrum was 41.2% (7/17), which is significantly greater than the proportion of patients with PJK whose lowest instrumented vertebra was above the sacrum. Oswestry Disability Index scores did not significantly increase in the PJK group compared with the non-PJK group.
The authors found that PJK occurs postoperatively in patients with AS with an incidence of 14.5%. Risk factors of PJK include larger preoperative sagittal vertical axis, PJA, and osteotomy angle. Reducing the osteotomy angle in some severe cases and extending fusion to a higher, flatter level would be also beneficial in decreasing the risk of PJK.
Le-Bao Yu, Xin-Jian Yang, Qian Zhang, Shao-Sen Zhang, Yan Zhang, Rong Wang, and Dong Zhang
Recurrent aneurysms after coil embolization remain a challenging issue. The goal of the present study was to report the authors’ experience with recurrent aneurysms after coil embolization and to discuss the radiographic classification scheme and recommended management strategy.
Aneurysm treatments from a single institution over a 6-year period were retrospectively reviewed. Ninety-seven aneurysms that recurred after initial coiling were managed during the study period. Recurrent aneurysms were classified into the following 5 types based on their angiographic characteristics: I, pure recanalization inside the aneurysm sac; II, pure coil compaction without aneurysm growth; III, new aneurysm neck formed without coil compaction; IV, new aneurysm neck formed with coil compaction; and V, newly formed aneurysm neck and sac.
Aneurysm recurrences resulted in rehemorrhages in 6 cases (6.2%) of type III–V aneurysms, but in none of type I–II aneurysms. There was a significantly higher proportion of ophthalmic artery aneurysms and complex internal carotid artery aneurysms presenting as types I and II than presented as the other 3 types (63.3% vs 16.4%, p < 0.001). In contrast, for posterior communicating artery aneurysms and anterior communicating artery aneurysms, a higher proportion of type III–V aneurysms was observed than for the other 2 types, but without a significant difference in the multivariate model (56.7% vs 23.3%). In addition, giant (> 25 mm) aneurysms were more common among type I and II lesions than among type III and IV aneurysms (36.7% vs 9.0%, p = 0.001), which exhibited a higher proportion of small (< 10 mm) lesions (65.7% vs 13.3%, p < 0.001). A single reembolization procedure was sufficient to occlude 80.0% of type I recurrences and 83.3% of type II recurrences from coil compaction but only 65.6% of type III–V recurrences from aneurysm regrowth.
Aneurysm size and location represent the determining factors of the angiographic recurrence types. Type I and II recurrences were safely treated by reembolization, whereas type III–V recurrences may be best managed surgically when technically feasible.
Bo Xiao, Fang-Fang Wu, Hong Zhang, and Yan-Bin Ma
When treating patients with a spontaneous supratentorial massive (≥ 70 ml) intracerebral hemorrhage (ICH), the results of surgery are gloomy. A worsening pupil response has been observed in patients preoperatively, despite blood pressure control and diuretic administration. Because open surgery needs time for decompression to occur, the authors conducted a prospective randomized study to determine whether patients who have suffered a massive ICH can benefit from a more urgently performed decompressive procedure.
Overall, 36 eligible patients admitted 6 or fewer hours post-ictus were enrolled in the study. In Group A, 12 patients underwent CT-based hematoma puncture and partial aspiration in the emergency department (ED) and subsequent evacuation via a craniectomy; in Group B, 24 patients underwent hematoma evacuation via a craniectomy only. Pupil responses were categorized into 5 grades (Grade 0, bilaterally fixed; Grade 1, unilaterally fixed with the fixed pupil > 7 mm; Grade 2, unilaterally fixed with the fixed pupil ≤ 7 mm; Grade 3, a unilaterally sluggish response; and Grade 4, a bilaterally brisk response). Grades were obtained on admission, at surgical decompression (defined as the point at which liquid hematoma began to flow out in Group A and at dural opening in Group B), and at completion of craniectomy. The Barthel Scale was used to assess survivors' functional outcome at 12 months. Comparisons were made between Groups A and B. Logistic regression analysis was used to evaluate the positive likelihood ratio of all variables for survival and function (Barthel Scale score of ≥ 35 at 12 months).
Decompressive surgery was undertaken approximately 60 minutes earlier in Group A than B. A worsening pupil reflex before decompression was observed in no Group A patient and in 9 Group B patients. At the time of decompression pupil response was better in Group A than B (p < 0.05). Although only approximately one-third of the hematoma volume documented on initial CT scanning had been drained before the craniectomy in Group A, when partial aspiration was followed by craniectomy, better pupil-response results were obtained in Group A at the completion of craniectomy, and survival rate and 12-month Barthel Scale score were better as well (p < 0.05). Logistic regression analysis revealed that one variable, a minimum pupil grade of 3 at the time of decompression, had the highest predictive value for survival at 12 months (8.0, 95% CI 2.0–32.0), and a pupil grade of 4 at the same time was the most valuable predictor of a Barthel Scale score of 35 or greater at 12 months (15.0, 95% CI 1.9–120.9).
Patients with massive spontaneous supratentorial ICHs may benefit from more urgent surgical decompression. The results of logistic regression analysis implied that, to improve long-term functional outcome, decompression should be performed in patients before herniation occurs. Due to the fact that most of these patients have signs of herniation when presenting to the ED and because conventional surgical decompression requires time to take effect, this combination of surgical treatment provides a feasible and effective surgical option.
Apolipoprotein E and myelopathy
Hong-liang Zhang, Ping Liu, and Shuai Yan
Si Zhang, Xiang Wang, Xuesong Liu, Yan Ju, and Xuhui Hui
The authors retrospectively analyzed data on brainstem gangliogliomas treated in their department and reviewed the pertinent literature to foster understanding of the preoperative characteristics, management, and clinical outcomes of this disease.
In 2006, the authors established a database of treated lesions of the posterior fossa. The epidemiology findings, clinical presentations, radiological investigations, pathological diagnoses, management, and prognosis for brainstem gangliogliomas were retrospectively analyzed.
Between 2006 and 2012, 7 patients suffering from brainstem ganglioglioma were treated at the West China Hospital of Sichuan University. The mean age of the patients, mean duration of symptoms prior to diagnosis, and mean duration of follow-up were 28.6 years, 19.4 months, and 38.1 months, respectively. The main presentations were progressive cranial nerve deficits and cerebellar signs. Subtotal resection was achieved in 2 patients, and partial resection in 5. All tumors were pathologically diagnosed as WHO Grade I or II ganglioglioma. Radiotherapy and adjuvant chemotherapy were not administered. After 21–69 months of follow-up, patient symptoms were resolved or stable without aggravation, and MRI showed that the size of residual lesions was unchanged without progression or recurrence.
The diagnosis of brainstem ganglioglioma is of great importance given its favorable prognosis. The authors recommend the maximal safe resection followed by close observation without adjuvant therapy as the optimal treatment for this disease.
Jun Yan, Jing Wen, Roodrajeetsing Gopaul, Chao-Yuan Zhang, and Shao-wen Xiao
There have been many multidisciplinary approaches to the treatment of vein of Galen malformations. Endovascular embolization is the first option for treatment. However, the effects of the treatment remain controversial. The aim of this study is to assess the efficacy and safety of endovascular embolization to treat patients with vein of Galen malformations.
This paper includes a retrospective analysis of a sample of 667 patients who underwent endovascular embolization to treat vein of Galen malformations. The data were obtained through a literature search of PubMed databases. The authors also evaluate the efficacy and safety of the treatment. Mortality within the follow-up period is analyzed. Pooled estimates of proportions with corresponding 95% CIs were calculated using raw (i.e., untransformed) proportions (PRAW).
In the 34 studies evaluated, neonates accounted for 44% of the sample (95% CI 31%-57%; I2 = 92.5%), infants accounted for 41% (95% CI 30%–51%; I2 = 83.3%), and children and adults accounted for 12% (95% CI 7%–16%; I2 = 52.9%). The meta-analysis revealed that complete occlusion was performed in 57% (95% CI 48%–65%; I2 = 68.2%) of cases, with partial occlusion in 43% (95% CI 34%–51%; I2 = 70.7%). The pooled proportion of patients showing a good outcome was 68% (95% CI 61%–76%; I2 = 77.8%), while 31% showed a poor outcome (95% CI 24%–38%; I2 = 75.6%). The proportional meta-analysis showed that postembolization mortality and complications were reported in 10% (95% CI 8%–12%; I2 = 42.8%) and 37% (95% CI 29%–45%; I2 = 79.1%), respectively. Complications included cerebral hemorrhage, cerebral ischemia, hydrocephalus, leg ischemia, and vessel perforation.
The successful treatment of vein of Galen malformations remains a complex therapeutic challenge. The authors’ analysis of clinical history and research literature suggests that vein of Galen malformations treated with endovascular embolization can result in an acceptable mortality rate, complications, and good clinical outcome. Future large-scale, multicenter, randomized trials are necessary to confirm these findings.
Wei Pan, Jia-li Zhao, Jin Xu, Ming Zhang, Tao Fang, Jing Yan, Xin-hong Wang, and Quan Zhou
The purpose of this study was to compare the preoperative radiographic features of degenerative lumbar spondylolisthesis (DLS) with and without local coronal imbalance (LCI) and to investigate the surgical outcomes of transforaminal lumbar interbody fusion (TLIF) in the treatment of DLS with LCI at the spondylolisthesis level. DLS with scoliotic disc wedging and/or lateral listhesis at the same involved segment, as well as LCI, constitutes a distinct subgroup. However, previous studies concerning surgical outcomes focused mainly on sagittal profiles. There is a paucity of valid data regarding lumbar coronal alignment and patient-reported outcomes (PROs) after surgery in DLS with LCI.
The authors reviewed consecutive patients who received TLIF for L4/5 DLS between 2009 and 2018. Patients were assigned to the LCI and non-LCI groups based on preoperative radiographs. Demographics, radiographic parameters related to both sagittal and coronal alignment, and PROs were compared between the 2 groups.
There were 21 patients in the LCI and 80 in the non-LCI group. Compared with the non-LCI group, the LCI group was characterized by lower preoperative lumbar lordosis on sagittal alignment (38.3° vs 43.7°, p < 0.05), higher lumbar Cobb angle on coronal alignment (12.4° vs 5.1°, p < 0.05), and worse lumbar coronal balance (18.5 mm vs 6.8 mm, p < 0.05). After surgery, lumbar alignment in the sagittal and coronal planes was significantly improved in the LCI group, whereas no significant changes occurred in the non-LCI group. Scores on the preoperative Oswestry Disability Index and the visual analog scale for back pain and leg pain scores were significantly higher in the LCI group, whereas no differences were found between the 2 groups in the postoperative evaluation (p > 0.05).
DLS with LCI constitutes a distinct subgroup characterized by coronal malalignment and loss of whole lumbar lordosis, which may result in worse PROs. The TLIF procedure allows the reconstruction of the coronal and sagittal lumbar profile and achievement of satisfactory PROs.
Lei Zhao, Shuo Zhang, Li Gong, Yan Qu, and Lijun Heng
Maffucci syndrome is an extremely rare disorder characterized by benign enchondromas, skeletal deformities, and cutaneous lesions composed of abnormal blood vessels. Enchondromas rarely arise in the cranial bones. Interdural pituitary transposition is an effective way to gain access to the posterior clinoid, without affecting the function of the pituitary gland. Here, the authors present a case of a posterior clinoid process enchondroma in a patient with Maffucci syndrome. The tumor was resected via an interdural pituitary transposition fashion. Four months postoperatively, the patient’s oculomotor function had recovered to normal and the function of the pituitary gland was preserved intact.
The video can be found here: https://youtu.be/EYgVwVZuC4g.