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Jia-Ping Zheng, Chu-Zhong Li and Guo-Qiang Chen

OBJECTIVE

The aim of the present study was to investigate the practical value of a multimaterial and multicolor 3D-printed model in anatomical teaching, surgical training, and preoperative planning of transnasal endoscopic surgery for pituitary adenoma.

METHODS

Multimodality neuroimaging data were obtained in a 42-year-old healthy male volunteer and a 40-year-old female patient with an invasive nonfunctional pituitary adenoma. Three 3D-printed models were produced: a monomaterial and monocolor model, a monomaterial and multicolor model, and a multimaterial and multicolor model. The effects on anatomical teaching and surgical training for exposing the vidian nerve were assessed by 12 residents, and the training effect was validated on cadavers. The practical values for preoperative planning were evaluated by 6 experienced neurosurgeons. All evaluations were based on 5-point Likert questionnaires.

RESULTS

The multimaterial and multicolor model was superior to the monomaterial models in surgical training for exposing the vidian nerve (Fisher test; p < 0.05). In addition, the multimaterial and multicolor model was superior to the monomaterial models in anatomical teaching and preoperative planning (Friedman test; p < 0.05).

CONCLUSIONS

Multimaterial and multicolor 3D printing technology makes it convenient and efficient to produce a practical model for simulating individualized and complex anatomical structures in the sellar region. Furthermore, the multimaterial model can provide a more realistic manipulative experience for surgical training and facilitate the preoperative planning.

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Wen-qing Huang, Shi-ju Zheng, Qing-sheng Tian, Jian-qing Huang, Yu-xia Li, Qing-zhong Xu, Zi-jun Liu and Wen-cui Zhang

✓ The authors present a statistical survey of the general incidence, age distribution, and preferential sites of 25,122 tumors of the central nervous system (CNS), from 12 centers in China. Of these tumors, 22,457 were intracranial and the rest intraspinal.

Of the 22,457 intracranial neoplasms collected, tumors of neuroepithelial tissue comprised 43.85%, meningiomas 16.58%, tumors of nerve sheath cells 9.5%, pituitary adenoma 9.52%, congenital tumors 8.46%, secondary tumors 6.8%, vascular malformations and tumors 3.82%, and primary sarcomas 0.72%. Neuroepithelial and meningeal tumors occurred first and second in all series, but the other tumors varied in frequency. There was a higher incidence of nerve-sheath tumors in southern than in northern regions. The age distribution of Chinese patients with tumors of the CNS was lower than that of Caucasians: nearly two-thirds (64.57%) had the clinical onset of their tumor between the ages of 31 and 40 years, with the peak incidence at 35 years. Nearly 20% of tumors of the CNS occurred before 20 years of age. The male:female ratio was 1.53:1; the only tumor with a definite preponderance of females over males was the meningioma.

Intraspinal tumors derived from nerve sheaths comprised 47.13% of all tumors within the spinal canal. Meningiomas were second with an incidence of 14.06%, then followed congenital tumors (12.06%) and neoplasms of neuroepithelial tissue (10.83%). Secondary tumors, vascular malformations and neoplasms, and sarcoma were next in order of frequency with 4.6%, 4.5%, and 4.16%, respectively.

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Nader Pouratian, Zhong Zheng, Ausaf A. Bari, Eric Behnke, W. Jeff Elias and Antonio A. F. DeSalles

Object

Due to the lack of internal anatomical detail with traditional MR imaging, preoperative stereotactic planning for the treatment of tremor usually relies on indirect targeting based on atlas-derived coordinates. The object of this study was to preliminarily investigate the role of probabilistic tractography–based thalamic segmentation for deep brain stimulation (DBS) targeting for the treatment of tremor.

Methods

Six patients undergoing bilateral implantation of DBS electrodes in the thalamus for the treatment of upper-extremity tremor were studied. All patients underwent stereotactic surgical implantation using traditional methods (based on indirect targeting methodologies and intraoperative macrostimulation findings) that were programmed for optimal efficacy, independent of tractography-based segmentations described in this report. Connectivity-based thalamic segmentations were derived by identifying with which of 7 cortical target regions each thalamic voxel had the highest probability of connectivity. The authors retrospectively analyzed the location of the optimal contact for treatment of tremor with connectivity-based thalamic segmentations. Findings from one institution (David Geffen School of Medicine at UCLA) were validated with results from 4 patients at another institution (University of Virginia Health System).

Results

Of 12 electrodes implanted using traditional methodologies, all but one resulted in efficacious tremor control. Connectivity-based thalamic segmentation consistently revealed discrete thalamic regions having unique connectivity patterns with distinct cortical regions. Although the authors initially hypothesized that the most efficacious DBS contact for controlling tremor would colocalize with the thalamic region most highly connected with the primary motor cortex, they instead found it to highly colocalize with those thalamic voxels demonstrating a high probability of connectivity with premotor cortex (center-to-center distance: 0.36 ± 0.55 mm). In contrast to the high degree of colocalization with optimal stimulation site, the precise localization of the premotor cortex–defined thalamic region relative to the anterior and posterior commissures was highly variable. Having defined a connectivity-based target for thalamic stimulation in a cohort of patients at David Geffen School of Medicine at UCLA, the authors validated findings in 4 patients (5 electrodes) who underwent surgery at a different institution (University of Virginia Health System) by a different surgeon.

Conclusions

This report identifies and provides preliminary external validation of a novel means of targeting a patient-specific therapeutic thalamic target for the treatment of tremor based on individualized analysis of thalamic connectivity patterns. This novel thalamic targeting approach is based on identifying the thalamic region with the highest probability of connectivity with premotor and supplementary motor cortices. This approach may prove to be advantageous over traditional preoperative methods of indirect targeting, providing patient-specific targets that could improve the precision, efficacy, and efficiency of deep brain stimulation surgery. Prospective evaluation and development of methodologies to make these analyses more widely available to neurosurgeons are likely warranted.

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Bing Zhao, Hua Yang, Kuang Zheng, Zequn Li, Ye Xiong, Xianxi Tan, Ming Zhong and the AMPAS Study Group

OBJECTIVE

An increasing number of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have received endovascular treatment. Endovascular treatment of poor-grade aSAH, however, is based on single-center retrospective studies, and predictors of long-term outcome have not been well defined. Using results from a multicenter prospective registry, the authors aimed to develop preoperative and postoperative prognostic models to predict poor outcome after endovascular treatment of poor-grade aSAH.

METHODS

A Multicenter Poor-grade Aneurysm Study (AMPAS) was a prospective and observational registry of consecutive patients with poor-grade aSAH. From October 2010 to March 2012, 366 patients were enrolled in the registry, and 136 patients receiving endovascular treatment were included in this study. Outcome was assessed by modified Rankin Scale (mRS) score at 12 months, and poor outcome was defined as an mRS score of 4, 5, or 6. Prognostic models were developed in multivariate logistic regression models. The area under receiver operating characteristic curves (AUC) was used to assess the model's discriminatory ability, and Hosmer-Lemeshow goodness-of-fit tests were used to assess the calibration.

RESULTS

At 12 months, 64 patients (47.0%) had a poor outcome: 9 (6.6%) had an mRS score of 4, 6 (4.4%) had an mRS score of 5, and 49 (36.0%) had died. Univariate analyses showed that older age (p = 0.001), female sex (p = 0.044), lower Glasgow Coma Scale score (p < 0.001), a World Federation of Neurosurgical Societies (WFNS) grade of V (p < 0.001), higher Fisher grade (p < 0.001), modified Fisher grade (p < 0.001), and wider neck aneurysm (p = 0.026) were associated with a poor outcome. There was a trend toward a worse outcome in patients with anterior communicating artery aneurysms (p = 0.080) and in those with incompletely occluded aneurysms (p = 0.063). After endovascular treatment, the presence of cerebral infarction (p = 0.039), symptomatic vasospasm (p = 0.039), and pneumonia (p = 0.006) were associated with a poor outcome. Multivariate analyses showed that the preoperative prognostic model including age, a WFNS grade of V, modified Fisher grade, and aneurysm neck size had excellent discrimination with an AUC of 0.86 (95% CI 0.80–0.92, p < 0.001), and a postoperative model that included these predictors as well as postoperative pneumonia had excellent discrimination (AUC = 0.87, 95% CI 0.81–0.93, p < 0.001). Both models had good calibration (p = 0.941 and p = 0.653, respectively).

CONCLUSIONS

Older age, WFNS Grade V, higher modified Fisher grade, wider neck aneurysm, and postoperative pneumonia were independent predictors of poor outcome after endovascular treatment of poor-grade aSAH. The preoperative model had almost the same discrimination as the postoperative model. Endovascular treatment should be carefully considered in patients with poor-grade aSAH with ruptured wide-neck aneurysms.

▪ CLASSIFICATION OF EVIDENCE Type of question: prognostic; study design: retrospective cohort trial; evidence: Class I.

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Peng-Fan Yang, Hui-Jian Zhang, Jia-Sheng Pei, Qiao Lin, Zhen Mei, Zi-Qian Chen, Yan-Zeng Jia, Zhong-Hui Zhong and Zhi-Yong Zheng

OBJECT

The objectives of this study were to describe a novel minimal-access subtemporal approach for selective resection of the amygdala and hippocampus in patients with medically refractory mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis, and to analyze the related outcomes.

METHODS

The authors analyzed data from all cases involving patients with unilateral MTLE due to hippocampal sclerosis who were treated with selective amygdalohippocampectomy via the posterior subtemporal approach through a relatively small craniotomy, without a neuronavigation system, at their institution during the period from September 2010 to September 2012. Data were obtained on baseline characteristics, preoperative evaluations of unilateral mesial temporal sclerosis, surgical complications, and Engel class seizure outcomes. All patients underwent memory testing, IQ testing, and language testing.

RESULTS

The mean duration of follow-up was 33.6 months (range 24–48 months). There were no deaths and no cases of significant postoperative morbidity. One patient had a mild complication. At 2-year follow-up, 19 patients were seizure free (Engel Class I outcome). Verbal memory scores obtained at 3 months and at 2 years after surgery were significantly lower than preoperative scores for patients who underwent surgery on the left side of the brain (p < 0.05). Pictorial memory scores were higher following surgery compared with before surgery regardless of whether patients underwent left- or right-sided brain surgery. There was also improvement in performance IQ and total IQ following surgery in both groups. For patients who underwent right-sided brain surgery, verbal comprehension and semantic fluency testing scores were significantly higher at both 3 months and 2 years after surgery than before surgery. For patients who underwent left-sided brain surgery, scores on all language tests were significantly lower at 3 months after surgery than before surgery. Verbal comprehension testing scores returned to the preoperative level at 2 years after surgery.

CONCLUSIONS

The posterior subtemporal approach through a relatively small craniotomy allows adequate exposure and safe resection of mesial temporal structures and effectively reduces medically intractable MTLE. It preserves IQ but may have a detrimental effect on verbal memory and language ability.

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Baotian Zhao, Chao Zhang, Xiu Wang, Yao Wang, Chang Liu, Jiajie Mo, Zhong Zheng, Kai Zhang, Xiao-qiu Shao, Wenhan Hu and Jianguo Zhang

Focal cortical dysplasia type II (FCD II) is a common histopathological substrate of epilepsy surgery. Here, the authors propose a sulcus-centered resection strategy for this malformation, provide technical details, and assess the efficacy and safety of this technique. The main purpose of the sulcus-centered resection is to remove the folded gray matter surrounding a dysplastic sulcus, particularly that at the bottom of the sulcus. The authors also retrospectively reviewed the records of 88 consecutive patients with FCD II treated with resective surgery between January 2015 and December 2018. The demographics, clinical characteristics, electrophysiological recordings, neuroimaging studies, histopathological findings, surgical outcomes, and complications were collected. After the exclusion of diffusely distributed and gyrus-based lesions, 71 patients (30 females, 41 males) who had undergone sulcus-centered resection were included in this study. The mean (± standard deviation) age of the cohort was 17.78 ± 10.54 years (38 pediatric patients, 33 adults). Thirty-five lesions (49%) were demonstrated on MRI; 42 patients (59%) underwent stereo-EEG monitoring before resective surgery; and 37 (52%) and 34 (48%) lesions were histopathologically proven to be FCD IIa and IIb, respectively. At a mean follow-up of 3.34 ± 1.17 years, 64 patients (90%) remained seizure free, and 7 (10%) had permanent neurological deficits including motor weakness, sensory deficits, and visual field deficits. The study findings showed that in carefully selected FCD II cases, sulcus-centered resection is an effective and safe surgical strategy.

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Yong Zhang, Xiang-Yang Bao, Lian Duan, Wei-Zhong Yang, De-Sheng Li, Zheng-Shan Zhang, Cong Han, Feng Zhao, Qian Zhang and Qian-Nan Wang

OBJECTIVE

The object of this study was to summarize the long-term effect of encephaloduroarteriosynangiosis (EDAS) for the treatment of pediatric moyamoya disease (MMD) and to investigate factors influencing the clinical outcomes of EDAS.

METHODS

Clinical features, angiographic findings, and clinical outcomes were analyzed among MMD patients younger than 18 years who had been treated with EDAS between 2002 and 2007 at the authors’ institution. The Kaplan-Meier method was used to estimate stroke risk after EDAS. Predictors of neurological outcome were assessed.

RESULTS

One hundred fifteen patients were identified. The mean age at symptom onset was 7.3 ± 4.0 years. The incidence of familial MMD was 11.3%. The female/male ratio was 1:1.16. A total of 232 EDAS procedures were performed, and the incidence of postoperative complications was 3%. Postoperative digital subtraction angiography was performed in 54% of the patients, and about 80% of the hemispheres showed good or excellent results. Neovascularization showed significant correlations with delay time (from symptom onset to first operation), Suzuki stage, and preoperative stroke (all p < 0.05). Clinical follow-up was available in 100 patients with a mean follow-up of 124.4 ± 10.5 months. Ten-year cumulative survival was 96.5% after surgery, and the risk of stroke was 0.33%/person-year. An independent life with no significant disability was reported by 92% of the patients. A good outcome correlated with a low Suzuki stage (p = 0.001). Older children and those without preoperative stroke had better clinical outcomes (p < 0.05).

CONCLUSIONS

On the basis of long-term follow-up data, the authors concluded that EDAS is a safe and effective treatment for pediatric MMD, can reduce the risk of subsequent neurological events, and can improve quality of life. The risk of ischemia-related complications was higher in younger patients, and older children showed better outcomes. Compensation was greater with more prominent cerebral ischemia. The long-term clinical outcome largely depended on the presence and extent of preoperative stroke.

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Baotian Zhao, Chao Zhang, Xiu Wang, Yao Wang, Jiajie Mo, Zhong Zheng, Lin Ai, Kai Zhang, Jianguo Zhang, Xiao-qiu Shao and Wenhan Hu

OBJECTIVE

The aim of this study was to characterize the clinical and electrophysiological findings of epilepsy originating from the orbitofrontal cortex (OFC) as well as its surgical outcomes.

METHODS

The authors retrospectively reviewed 27 consecutive cases of patients with drug-resistant orbitofrontal epilepsy (OFE) who underwent tailored resective surgery after a detailed presurgical workup. Demographic features, seizure semiology, imaging characteristics, resection site, pathological results, and surgical outcomes were analyzed. Patients were categorized according to semiology. The underlying neural network was further explored through quantitative FDG-PET and ictal stereo-electroencephalography (SEEG) analysis at the group level. FDG-PET studies between the semiology group and the control group were compared using a voxel-based independent t-test. Ictal SEEG was quantified by calculating the energy ratio (ER) of high- and low-frequency bands. An ER comparison between the anterior cingulate cortex (ACC) and the amygdala was performed to differentiate seizure spreading patterns in groups with different semiology.

RESULTS

Scalp electroencephalography (EEG) and MRI were inconclusive to a large extent. Patients were categorized into the following 3 semiology groups: the frontal group (n = 14), which included patients with hyperactive automatisms with agitated movements; the temporal group (n = 11), which included patients with oroalimentary or manual automatisms; and the other group (n = 2), which included patients with none of the abovementioned or indistinguishable manifestations. Patients in the frontal and temporal groups (n = 23) or in the frontal group only (n = 14) demonstrated significant hypometabolism mainly across the ipsilateral OFC, ACC, and anterior insula (AI), while patients in the temporal group (n = 9) had hypometabolism only in the OFC and AI. The ER results (n = 15) suggested distinct propagation pathways that allowed us to differentiate between the frontal and temporal groups. Pathologies included focal cortical dysplasia, dysembryoplastic neuroepithelial tumor, cavernous malformation, glial scar, and nonspecific findings. At a minimum follow-up of 12 months, 19 patients (70.4%) were seizure free, and Engel class II, III, and IV outcomes were observed in 4 patients (14.8%), 3 patients (11.1%), and 1 patient (3.7%), respectively.

CONCLUSIONS

The diagnosis of OFE requires careful presurgical evaluation. Based on their electrophysiological and metabolic evidence, the authors propose that varied semiological patterns could be explained by the extent of involvement of a network that includes at least the OFC, ACC, AI, and temporal lobe. Tailored resections for OFE may lead to a good overall outcome.