The iteration of cerebral revascularization has been accompanied by the evolution of the concept of complex intracranial aneurysms. Cerebral revascularization has gradually changed the treatment strategy of intracranial aneurysms. This article focuses on the treatment principles and common microsurgical techniques of intracranial aneurysms, the conceptual changes and treatment difficulties of complex intracranial aneurysms, the development trend of cerebral revascularization and its application in the treatment of complex intracranial aneurysms, and the prospect of cerebral revascularization in the treatment of complex intracranial aneurysms. It aims to promote the high-quality application of cerebral revascularization in the treatment of intracranial aneurysms.
Cerebral revascularization is constantly being updated and iterated, but there are still many challenges: how to regulate the bypass flow quantitatively, how to reconstruct cerebral artery perforator vessels with diameter less than 0.5 mm, etc.. This paper reviews the birth of revascularization and the development of cerebral revascularization, focusing on the basic principle and innovative technology of cerebral revascularization, application and effect of cerebral revascularization in the treatment of complex intracranial aneurysms, current situation and development trend of cerebral revascularization iteration. The aim is to promote the iteration of cerebral revascularization and its application in the treatment of complex intracranial aneurysms.
Intracranial-intracranial bypass is a crucial treatment for complex intracranial aneurysms, as it not only achieves aneurysm eradication but also ensures perfusion to the bypassed vascular territory. To ensure bypass vessels patency and postoperative neurological recovery in patients with aneurysm, it is necessary to consider multiple characteristics of the aneurysm, donor artery and recipient artery. This comprehensive evaluation enables the selection of appropriate surgical decisions and bypass techniques. In recent years, with the advancement of intracranial-intracranial bypass, several new options including donor artery and recipient artery, anastomosis techniques, graft vessels, and auxiliary techniques have been added for neurosurgeons to choose from. This review aims to introduce the technical advances, surgical experience of intracranial-intracranial bypass for complex intracranial aneurysms, with the intention of facilitating clinical application of intracranial-intracranial bypass.
Cerebral vascular bypass is a key method for the treatment of complex intracranial aneurysms. After nearly 60 years of exploration, its application range now covers the whole cerebral vascular region. With the advent of detachable coils and the mature application of related assistance techniques, endovascular intervention treatment is highly favored in the treatment of routine intracranial aneurysms due to its minimally invasive and rapid characteristics. The introduction of flow diverter (FD) has further ushered in a new era in the treatment of intracranial aneurysms. This article reviews the history and development of cerebral vascular bypass in the treatment of intracranial aneurysms, elaborates on the application and promotion of flow diverter, and discusses the limitations of endovascular intervention treatment in the flow diversion era. It also explores the application and prospects of a comprehensive cerebral vascular bypass system, reaffirming the application value of the whole-region cerebral vascular bypass technique.
Objective: To explore the surgical procedures and indications of intracranial-intracranial bypass for the treatment of complex aneurysms in the basilar artery (BA). Methods and Results: A retrospective analysis was conducted on the clinical data and treatment process of 6 patients with complex BA aneurysms who underwent intracranial-intracranial bypass from April 2017 to April 2023 in Tianjin Huanhu Hospital. Among the 6 aneurysms, 3 were vertebro basilar dolichoectasia aneurysms, one was an aneurysm in the upper segment of BA combined with severe stenosis at the proximal of the aneurysm, and 2 were giant dissecting aneurysms of the BA. Among them, 5 were ruptured aneurysms, with one case of Hunt-Hess grade Ⅴ, one case of grade Ⅳ, 2 cases of grade Ⅲ, and one case of grade Ⅱ, while the remaining one case was an unruptured aneurysm. One patient underwent petrous segment of internal carotid artery (ICA)-radial artery (RA)-posterior cerebral artery (PCA) bypass combined with aneurysm clipping, 4 patients underwent V3 segment of vertebral artery (VA)-RA-PCA bypass combined with aneurysm trapping, and one patient underwent middle cerebral artery (MCA)-RA-PCA bypass combined with aneurysm trapping. Four patients had good prognosis, with modified Rankin Scale (mRS) 0 to 3, one case scored 4 and one case died one week after surgery. Conclusions: For complex aneurysms of the BA that cannot be treated with conventional methods, intracranial-intracranial bypass provides a good option. It is necessary to select the appropriate surgical procedure based on the actual situation in clinical practice.
Background: Complex intracranial aneurysms are one of the most difficult cerebrovascular diseases to treat, and even experienced cerebrovascular surgeons face great challenges. Intracranial-intracranial bypass with interposition graft has its unique surgical indications and technical points, but there is a lack of research reports in the literature at home and abroad. Methods: Six patients with complex intracranial aneurysms who were cured by intracranial-intracranial bypass with interposition graft from January 2015 to December 2023 in The First Medical Center of PLA General Hospital were enrolled, DSA was used to evaluate the patency of postoperative grafts and aneurysm development, modified Rankin Scale (mRS) was used to evaluate the neurological prognosis, and the procedure-related complications such as cerebral infarction, intracranial hemorrhage, scalp nonunion, and forearm nerve dysfunction were recorded. Results: All 6 patients successfully completed intracranial-intracranial bypass with interposition graft, with superficial temporal artery (STA) in 5 cases and radial artery (RA) in one case. The grafts were embedded between the proximal and distal parent arteries in 2 cases, and the grafts were bridged between the distal donor and proximal donor in 2 cases, one case was reconstructed in a "Y" shape between the artery and the recipient artery, one case was reconnected proximally to the donor artery, and the distal end was anastomosed with the branch end-to-end. Postoperative DSA showed all aneurysms disappeared and the grafts were unobstructed. The average postoperative follow-up was 23.67 months, and there was no recurrence of aneurysms and grafts occlusion, and the mean mRS score was 0.33 at the last follow-up. There were no surgery-related complications after surgery. Conclusions: Intracranial-intracranial bypass with interposition graft is an effective method for the treatment of complex intracranial aneurysms, which has the technical advantages of strong flexibility, abundant variants and wide range of indications, and can provide more abundant, safe and effective individualized treatment strategies for cerebrovascular surgeons.
Objective: To explore the long-term outcome of intracranial-intracranial side-to-side bypass for complex intracranial aneurysms. Methods: Five patients with complex intracranial aneurysms underwent intracranial-intracranial side-to-side bypass performed by the same surgeon at The First Hospital of China Medical University from January 2015 to December 2023 were included. Two cases involved the A2 segment of anterior cerebral artery (ACA) and 3 cases involved the M2 segment of middle cerebral artery (MCA). Indocyanine green angiography (ICGA) was used intraoperatively, and CTA or DSA was used postoperatively to evaluate aneurysm occlusion and blood flow reconstruction. The modified Rankin Scale (mRS) was used to evaluate the neurological prognosis at one week, 3 months and the last follow-up. CT/ MRI examination was completed on the first day, one week and 3 months after operation to evaluate whether hemorrhagic or ischemic complications occurred. Results: Five cases of complex intracranial aneurysms were all occluded accurately. Two cases underwent A3-A3 side-to-side anastomosis, and 3 cases underwent M2-M2 side-to-side anastomosis, among which one case added M1-radial artery (RA)-M2 intracranial-intracranial bypass with RA as graft on the basis of M2-M2 side-to-side anastomosis. During the operation, ICGA confirmed that the side-to-side anastomosis and M1-RA-M2 bypass were unobstructed in 5 cases. The postoperative follow-up time was 23 (14, 71) months. No aneurysm was found in cerebrovascular imaging examination one week and 3 months after operation in 5 patients, and 9 to 12 months after operation in 3 patients. Five side-to-side anastomosis stomas and one M1-RA-M2 graft were all unobstructed. At one week after operation, the mRS increased by 0-3 score compared with that before operation (4 score maintained unchanged before and after operation in one case, 2 score increased in one case, and 3 score increased in one case). In 2 unruptured cases, the mRS score was 1 score at one week after operation, and there was no change from that before operation. At 3 months after operation, the mRS scores of 5 cases were decreased (2 cases with 0 score, one case with 2 score, and 2 cases with 3 score); one case was lost at the last follow-up, and the mRS scores of other 4 cases decreased further (2 cases with 0 score, one case with 1 score, and one case with 2 score). No cerebral hemorrhage or cerebral ischemia occurred in the follow-up. Conclusions: Intracranial-intracranial side-to-side bypass has good short-term and long-term patency and stable long-term clinical effect. It is a reliable technique for surgical treatment of complex intracranial aneurysms.
Objective: To explore the efficacy and safety of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms. Methods and Results: A total of 32 patients with complex intracranial aneurysms who were hospitalized for treatment at Huashan Hospital, Fudan University from January 2015 to December 2023 were included. Surgical methods included in-situ bypass, reimplantation, reanastomosis and bypass with interposition graft. For middle cerebral artery (MCA) aneurysms (n = 16), there were 5 cases of in-situ bypass, one case of reimplantation, 3 cases of reanastomosis, and 7 cases of bypass with interposition graft. For anterior cerebral artery (ACA) aneurysms (n = 8), there were 5 cases of in-situ bypass and 3 cases of reimplantation. For anterior communicating artery (ACoA) aneurysms (n = 2), both cases were in-situ bypass. For posterior circulation aneurysms (n = 6), there were 3 cases of in-situ bypass, 2 cases of reanastomosis, and one case of bypass with interposition graft. The intraoperative graft vessels patency rate was 100%. Among the 23 patients who participated in follow-up imaging for more than 6 months postoperatively, no obvious recurrence was indicated by imaging. Among the 28 patients who participated in modified Rankin Scale (mRS) follow-up, there was one case of 5, 5 cases of 3, 2 cases of 2, one case of 1, and 19 cases of 0. Postoperative hemorrhagic complications occurred in 3 cases (9.37%), and ischemic complications occurred in 10 cases (31.25%), with no patients requiring unplanned secondary surgery for complication treatment. Conclusions: Intracranial-intracranial bypass has good efficacy and safety for the treatment of complex intracranial aneurysms and has unique advantages in the microsurgical treatment of complex intracranial aneurysms.
Objective: To explore the efficacy and advantages of intracranial-intracranial bypass for the treatment of complex intracranial aneurysms. Methods: A total of 9 patients with complex intracranial aneurysms who underwent intracranial-intracranial bypass in Xiangya Hospital of Central South University from February 2014 to May 2020 were included, and were treated with grafts bypass or reimplantation of recipient arteries. All cases underwent CTA or DSA to detect the patent of grafts, whether aneurysms were completely clipped or resected and aneurysms recurrence occurred during the follow-up. Modified Rankin Scale (mRS) was used to evaluate the neurological prognosis at discharge and during the follow-up. Results: Radial artery (RA) or great saphenous vein (GSV) was used for interposition in 4 cases, and recipient arteries were used for reimplantation in 5 cases. Of 4 cases of interposition, the cavernous sinus seoment of internal carotid artery (ICA)-GSV-ICA bypass was adopted in one case, middle cerebral artery (MCA) M2-RA-M2 bypass in one case, anterior cerebral artery (ACA) A3-GSV-A3 bypass in one case, posterior cerebral artery (PCA) P2-RA-P2 bypass in one case. Of 5 cases of reimplantation, MCA M2 inferior trunk was reimplanted to M2 superior trunk in one case, ACA A3 was reimplanted to contralateral A3 in 2 cases, the posterior inferior cerebellar artery (PICA) was reimplanted to the anterior inferior cerebellar artery (AICA) in 2 cases. CTA in 3 d postoperatively showed all cases grafts were patent and aneurysms disappeared. After 3 months of discharge, 2 were lost to follow-up. The other 7 cases kept the patency of grafts and no new aneurysms, and were constantly followed up, with an average follow-up time of 30.71 months, and mRS score was 1 or lower. Conclusions: Intracranial-intracranial bypass can be applied for complex intracranial aneurysms that are difficult for conventional surgical treatment to solve. Compared with extracranial-intracranial bypass, its grafts are shorter and its hemodynamics features are more in line with physiological conditions.
Alzheimer's disease (AD) is the most common type of dementia in the elderly. The ApoE ε4 gene is the main genetic risk factors for sporadic AD, and is associated with the changes in the amyloid β-protein (Aβ) and tau protein, the core pathological features of AD. ApoE ε4 has great potential as a genetic biomarker for AD. Clinical studies have shown the important role of peripheral blood ApoE ε4 in AD risk assessment and disease detection. But in the current clinical practice, there are many weak points of insufficient understanding and insufficient attention about the clinical use of ApoE ε4. The importance of ApoE ε4 is highlighted especially with the development of high-quality clinical drug trials or the arrival of clinical drug therapy targeting Aβ for AD. So far, there is still a lack of Chinese expert consensus on the standardized application of ApoE ε4 in AD. Given that, this article systematically summarizes the current domestic and international research on the application of ApoE ε4 in AD. The consensus is written and aimed to fully reflect the clinical application value of ApoE ε4 in AD, and improve the diagnosis and treatment level of AD, and guide further clinical research.
Objective: To screen the risk factors related to primary trigeminal neuralgia (PTN) based on radiomics. Methods: A total of 48 patients with PTN admitted to Guangdong Second Provincial General Hospital from January 2017 to December 2020 were selected. The mean arterial pressure (MAP) of the patients was measured, and the neurovascular compression model was constructed by head MRI examination. Univariate and multivariate Logistic regression analyses were used to screen for risk factors associated with PTN, and the predictive efficacy was evaluated by receiver operating characteristic (ROC) curve according to the risk factors. Results: Among 48 patients, 42 patients (87.50%) had unilateral lesions and 6 patients (12.50%) had bilateral lesions. The MAP was 56.89-120.44 mm Hg, with an average of (94.32 ± 11.34) mm Hg. The neurovascular compression model of 54 cases was divided into the affected side (n = 40) and the healthy side (n = 14) according to whether the disease occurred. The neurovascular compression area (Z =-2.823, P = 0.005) and neurovascular pressure (Z =-0.365, P = 0.006) on the affected side were greater than those on the healthy side. Logistic regression analyses showed that high neurovascular pressure (OR = 1.001, 95%CI: 1.0003-1.0022; P = 0.011) was showed the area under the curve (AUC) of neurovascular compression area for predicting PTN was 0.747 (95%CI: 0.605-0.890, P = 0.006), the sensitivity was 42.50%, the specificity value was 25.34 mm2. The AUC of neurovascular pressure was 0.755 (95%CI: 0.616-0.895, P = 0.005), the sensitivity was 67.50%, the specificity was 78.60%, and the cut-off value was 1672.99 mm Hg·mm2. Conclusions: The neurovascular compression area and neurovascular pressure are important in the diagnosis of PTN.
Objective: Summarize the clinical and genetic characteristics of atypical Rett syndrome and developmental epileptic encephalopathy caused by IQSEC2 gene variation. Methods and Results: From May 2020 to April 2022, Anhui Provincial Children's Hospital diagnosed and treated 4 children with atypical Rett syndrome and developmental epileptic encephalopathy caused by IQSEC2 gene variation, including 2 males and 2 females were a pair of identical twins. They all had comprehensive developmental delay before onset. At the age of 2 years, all cases gradually exhibited clinical manifestations of atypical Rett syndrome, such as frequent clapping, biting, sleep disorders (increased sleep or difficulty falling asleep), and grinding teeth, followed by developmental regression and seizures. The initial age of epilepsy was from 2 years and 2 months to 2 years and 10 months. All cases started with generalized tonic-clonic seizure, with epileptic spasm occurring between 2 and 11 months of course. Case 2, Case 3 and Case 4 were also accompanied by focal seizures. Four cases with VEEG background of 4-6 Hz θ wave, the VEEG during the interictal phase was a broad multifocal sharp slow complex wave. In Case 2, Case 3 and Case 4, MRI was abnormal, mainly with increased depth of cerebral hemispheric sulcus and gyrus. The whole exome sequencing suggested pathogenicity and possible pathogenic variations in the IQSEC2 gene, Case 1 and Case 2 were frameshift mutations of c. 608dup (p. Gln204Profs*35), while Case 3 and Case 4 were nonsense mutations of c. 2231C > A (p. Ser744Ter) and c. 2521C > T (p. Gln841Ter), respectively. The four mutation sites have not been reported domestically or internationally. All cases received treatment with multiple antiepileptic seizure medicine. The last follow-up age was from 4 years and 3 months to 6 years and 3 months. All cases were unable to walk alone and had no active language. There were no seizures in Case 1 for 3 years, occasional seizures in Case 2 and Case 4, and frequent seizures in Case 3. Conclusions: IQSEC2 gene variation can manifest as atypical Rett syndrome, which can be accompanied by refractory epileptic spasms. Both males and females have severe phenotypes, and the severity of clinical phenotypes at the same mutation site varies. Our report enriches the variation spectrum and clinical phenotype spectrum of the IQSEC2 gene, expands the genetic spectrum of Rett syndrome and developmental epileptic encephalopathy, and provides value for the clinical diagnosis, treatment and subsequent research of this disease.
