Hybrid operation integrates the strengths of open microsurgical neurosurgery with endovascular treatment, enabling sequential or simultaneous multimodal procedures within a hybrid operating suite to deliver "one-stop" precision diagnosis and treatment for complex cerebrovascular diseases. A review of the current status and technical advances of hybrid operation in intracranial aneurysm, cerebral arteriovenous malformation (CAVM), dural arteriovenous fistula (DAVF), symptomatic chronic internal carotid artery occlusion (CICAO), and acute cerebrovascular diseases will help clinicians appreciate its evolution and the challenges it faces. Although hybrid operation still contends with the dual risks of infection and anticoagulation, radiation exposure, and equipment and technical barriers, the standardization of workflows, intelligent imaging, and deeper multidisciplinary integration will further underscore its value in ischemic cerebrovascular diseases, high - grade cerebral arteriovenous malformation, and acute cerebrovascular diseases, positioning it to become the central paradigm in the diagnosis and treatment of complex cerebrovascular diseases.
Objective: To explore the efficacy and safety of multimodal image - guided hybrid operation in the treatment of symptomatic chronic internal carotid artery occlusion (CICAO). Methods and Results: Total 25 patients with symptomatic CICAO who underwent hybrid operation in Tianjin Huanhu Hospital from July 2018 to August 2023 were enrolled. All patients completed preoperative multimodal imaging examinations, including cervical vascular ultrasound, transcranial Doppler ultrasonography (TCD), CTA or DSA, CT perfusion imaging (CTP) or perfusion -weighted imaging (PWI), and high -resolution MRI (HRMRI). Carotid endarterectomy (CEA) combined with endovascular treatment was performed in the hybrid operating room. Vascular recanalization was successfully achieved in all patients after surgery, with a success rate of 100% (25/25). One day after surgery, 25 patients underwent head CT, and one had intraoperative subarachnoid hemorrhage. Within 7 d after surgery, 24 patients underwent CTP or PWI, all of which showed improved perfusion flow compared with preoperation. Within 7 d after surgery, 25 patients underwent head MRI, and 4 had cerebral infarction. Within 7 d after surgery, 24 patients underwent cervical vascular ultrasound or TCD, all of which showed patency of the internal carotid artery (ICA). The mean National Institutes of Health Stroke Scale (NIHSS) scores at discharge, 6 months and one year after surgery were 3.36, 2.72 and 2.72; the mean modified Rankin Scale (mRS) scores were 0.76, 0.60 and 0.60. The perioperative complication rate was 20% (5/25). The average follow-up time was 24.88 months, and the affected ICA restenosis rate was 16% (4/25); no patient had reocclusion of the affected ICA. Conclusions: Multimodal image - guided hybrid operation is technically feasible and safe and effective in clinical application, providing a new treatment option for symptomatic CICAO.
Objective: To evaluate and compare the efficacy and safety of endovascular treatment alone versus hybrid operation in the treatment of symptomatic chronic internal carotid artery occlusion (CICAO). Methods: A total of 103 patients with symptomatic CICAO who underwent hybrid operation (n = 60) or endovascular treatment alone (n = 43) in Qilu Hospital of Shandong University from May 2016 to March 2025 were included. All cases were classified into 4 types, namely type A, type B, type C and type D by preoperative DSA examination combined with Hasan classification. The vascular recanalization success rate, as well as the incidence of complications during the perioperative period, follow-up period and in the vascular recanalization cases were recorded. Results: The vascular recanalization success rate of the hybrid operation group was higher than that of the endovascular treatment alone group (χ2 = 10.885, P = 0.001). Analysis by Hasan classification showed that Hasan type C had more advantages with hybrid operation (Fisher's exact probability: P = 0.024). There was no statistically significant difference in the incidence of perioperative complications between the hybrid operation group and the endovascular treatment alone group (χ2 = 0.008, P = 0.928). The median follow - up time of the hybrid operation group was 33.00 (11.25, 52.75) months, and the median follow-up time of the endovascular treatment alone group was 24 (15, 30) months. During the follow - up period, there were no statistically significant differences in mortality (Fisher's exact probability: P = 1.000), the incidence of new transient ischemic attack/ischemic stroke (Fisher's exact probability: P = 0.251), and the incidence of restenosis/reocclusion of the affected internal carotid artery in vascular success recanalization cases (Fisher's exact probability: P = 0.210). Conclusions: For patients with CICAO, hybrid operation achieves a higher vascular recanalization success rate. This surgical approach is both safe and feasible, and may be particularly beneficial for patients with more complex anatomical features (Hasan type C). There were no significant differences between hybrid operation and endovascular treatment alone in terms of safety and the incidence of postoperative restenosis/reocclusion of affected internal carotid artery.
Objective: To explore the technical key points, clinical efficacy and safety of hybrid operation for symptomatic chronic common carotid artery occlusion (CCAO). Methods and Results: A total of 10 patients with symptomatic chronic CCAO who underwent hybrid operation in The First Affiliated Hospital of Harbin Medical University from December 2022 to October 2024 were included. The median preoperative modified Rankin Scale (mRS) score was 2 (1, 2). All patients successfully completed revascularization with a technical success rate of 10/10, including 6 cases treated with carotid endarterectomy (CEA) combined with retrograde transcarotid recanalization (for patients with short CCA residual stumps) and 4 cases treated with CEA combined with antegrade transfemoral recanalization (for patients with long CCA residual stumps). Postoperative complications included one case of cerebral hyperperfusion syndrome (CHS), with no occurrence of neck hematoma, hemorrhagic stroke, ischemic stroke or transient ischemic attack. During a median follow - up of 10 (9, 12) months, there were no cases of restenosis requiring retreatment, ipsilateral ischemic stroke or transient ischemic attack. The median mRS score at last follow - up was 0 (0, 1). The last follow - up mRS score was lower than the preoperative mRS score (Z = - 0.289, P = 0.004). Conclusions: The hybrid operation is safe and effective for treating symptomatic chronic CCAO. In clinical practice, CEA combined with retrograde transcarotid recanalization may demonstrate relatively significant advantages for symptomatic chronic CCAO with shorter residual stumps, potentially facilitating more optimal revascularization outcomes. However, further case validation remains necessary.
Objective: To explore the potential value of expert - identified CT and MRI imaging features in predicting the MGMT promoter methylation status in glioma. Methods: A retrospective analysis was conducted in 188 patients in The First Medical Center of Chinese PLA General Hospital from January 2019 to December 2020 with pathologically confirmed glioma. Imaging features were extracted, including calcification, clear lesion margins, peritumoral edema, T2WI/T2 - FLAIR mismatch, cortical involvement, subventricular zone involvement, insular involvement, homogeneous signal on T2WI, and enhanced lesions. Pyrosequencing was used to detect the MGMT promoter methylation status. Univariate and multivariate Logistic regression analyses were used to find the imaging feature factors that affect the MGMT promoter methylation status. Then, by plotting the receiver operating characteristic (ROC) curve, verify the predictive efficacy of the imaging features. For the prediction task, further train and test 4 machine learning (ML) models, namely Logistic regression (LR), support vector machine (SVM), random forest (RF), and gradient boosting (GB). Results: Logistic regression analysis showed that homogeneous signal on T2WI (OR = 2.843, 95%CI: 1.055-7.658; P = 0.039) and enhanced lesions (OR = 0.146, 95%CI: 0.069-0.308; P = 0.000) were imaging feature factors affecting the MGMT promoter methylation status. The comprehensive parameters combining both had higher prediction ability compared with homogeneous signal on T 2WI (Z = 3.961, P = 0.000) and enhanced lesions (Z = 2.233, P = 0.026). The prediction accuracies rates of LR, SVM, RF and GB models were 0.84, 0.76, 0.68 and 0.76, respectively. However, there were no statistically significant differences in prediction efficacy when comparing the models pairwise (P > 0.05, for all). Conclusions: Imaging features based on preoperative CT and MRI show promise for non - invasive prediction of MGMT promoter methylation status in glioma.
Objective: To investigate the electrocorticographic signal activity characteristics in glioma located in the motor area. Methods: Total 8 patients undergoing awake craniotomy for motor area- involved glioma in West China Hospital, Sichuan University between October 2024 and February 2025 were enrolled. During the awake state, 2 min resting-state electrocorticographic signals were continuously recorded. After preprocessing steps including filtering, signal activity characteristics across θ, α, β, γ1, γ2, γ3, γ4 frequency bands were extracted. Using preoperative MRI data and subdural electrode parameters, individualized brain and electrode models were reconstructed. The spatial relationships between electrodes and tumors during data acquisition were coregistered onto the brain models. Based on the tumor invasion degree into brain tissue beneath the electrodes, the 762 validated electrodes were categorized into 3 groups: normal brain tissue group (n = 460), tumor-invaded cortex group (n = 274) and tumor-non-invaded cortex group (n = 28). Results: In the frequency bands of θ (H = 249.993, P = 0.000), α (H = 251.311, P = 0.000), β (H = 288.834, P = 0.000), γ1 (H = 312.145, P = 0.000), γ2 (H = 263.777, P = 0.000), γ3 (H = 238.691, P = 0.000), γ4 (H = 208.830, P = 0.000), the differences in the electrocorticographic signal activity characteristics among the 3 groups were statistically significant. Further pairwise comparisons revealed that the electrocorticographic signal activity characteristics of the normal brain tissue group were higher than those of the tumor-invaded cortex group in the frequency bands of θ (Z = 5.711, P = 0.000), α (Z = 5.823, P = 0.000), β (Z = 6.907, P = 0.000), γ1 (Z = 7.286, P = 0.000), γ2 (Z = 6.054, P = 0.000), γ3 (Z = 5.247, P = 0.000), γ4 (Z = 4.647, P = 0.000), and higher than those of the tumor-non-invaded cortex group in the frequency bands of θ (Z = 4.051, P = 0.000), α (Z = 3.277, P = 0.001), β (Z = 4.172, P = 0.000), γ1 (Z = 5.013, P = 0.000), γ2 (Z = 4.749, P = 0.000), γ3 (Z = 4.264, P = 0.000). The electrocorticographic signal activity characteristics of the tumor-non-invaded cortex group were higher than those of the tumor-invaded cortex group in the frequency bands of θ (Z =-2.071, P = 0.038), α (Z =-2.871, P = 0.004), β (Z =-2.403, P = 0.016). Conclusions: This study found that normal brain tissue exhibits higher activity characteristics in electrocorticographic signals compared to glioma tissue. These findings suggest the potential for developing glioma localization techniques based on electrocorticographic signals, which could assist neurosurgeons in achieving more precise glioma resection.
Objective: To investigate the functional outcomes for patients undergoing glioma resection in the left middle precentral gyrus and posterior middle frontal gyrus, and evaluate the efficacy of current surgical strategies. Methods: A retrospective analysis was performed on the data of 7 patients who underwent glioma resection in the left middle precentral gyrus and posterior middle frontal gyrus in Huashan Hospital, Fudan University from January 2013 to July 2024. Preoperatively, the surgical plan was determined under the guidance of multimodal MRI navigation and reconstruction technology. Intraoperatively, awake craniotomy combined with direct electrical stimulation was employed to locate and protect functional areas. Preoperatively, the Mini-Mental State Examination (MMSE) was used to assess cognitive function, and the Aphasia Battery of Chinese (ABC) was used to evaluate language function. Postoperatively, the ABC scale was used to assess language function at 1, 3 and 6 months after surgery. Results: Preoperatively, 2 cases presented with mild transcortical motor aphasia, the remaining 5 cases had normal language function. In the early postoperative period, 5 cases presented with transcortical motor aphasia, one case had mixed transcortical aphasia, and one case showed normal language function. In the long-term postoperative period, 4 cases experienced mild writing dysfunction; one case exhibited mild transcortical motor aphasia, and the other 6 cases maintained normal scores for spontaneous speech, repetition, naming, and comprehension. However, 5 cases reported that their spontaneous speech was fluent but a decrease in speech rate and coordination of articulation compared to preoperative levels was noticed, and one case felt that the auditory comprehension response time had increased. The average extent of resection was 98%, with 6 cases (6/7) achieving total resection and one case (1/7) achieving partial resection (84.05%). The median follow-up duration was 69.57 (38.00, 91.00) months, one case had tumor recurrence 74 months after operation and underwent a second surgical resection, while the remaining patients did not experience recurrence. Conclusions: The combination of multimodal MRI navigation and intraoperative awake mapping with neurophysiological monitoring is crucial for optimizing functional outcomes in glioma resection within the left middle precentral gyrus and posterior middle frontal gyrus. This study highlight the critical role of this region in written language and speech motor coordination, providing important clinical evidence for the complex functions of this "non-traditional" core language area.
Objective: To report 2 cases of Charcot-Marie-Tooth disease type 4H (CMT4H) caused by FGD4 gene variation and review the relevant literatures, summarizing the clinical and gene mutation characteristics of CMT4H. Methods and Results: Two families with CMT4H diagnosed by genetic test in Shanghai Sixth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine from May 2020 to July 2022 were included. The probands in 2 families were both sporadic patients with onset in early adolescence, manifesting as progressive postural gait abnormalities, difficulty walking, and foot deformities. Nerve electrophysiological examination showed multiple demyelinating damages to sensory and motor nerves. Sural nerve biopsy in proband of family 1 disclosed a decreased density of myelin fibers and demyelinating neuropathy with thickened and excessively folded myelin sheath. Whole exome sequencing (WES) revealed that both probands had compound heterozygous mutations in the FGD4 gene, all of which were novel, and cosegregated with the family members. Conclusions: CMT4H is a peripheral neuropathy mainly caused by autosomal recessive demyelination, and case report from 2 families further expand the spectrum of FGD4 gene mutations.
Objective: To summarize the clinical manifestations and genetic characteristics of patients with Charcot-Marie-Tooth disease (CMT) caused by ARSs gene variation. Methods and Results: A total of 12 probands with clinical diagnosis of CMT were selected from The First Affiliated Hospital of Fujian Medical University from January 1997 to February 2024 and included in the clinical registration cohort of the hospital. Clinical symptoms: 10 patients had normal proximal limb muscle strength, while the distal limb muscle strength was seriously involved. Most muscular atrophy occurred below ankle joint and wrist joint. Two patients had subjective numbness of limbs, and one patient had reduced symmetry sensation on superficial sensory examination. Tendon reflexes were normal in only one patient. EMG characteristics: for the 11 probands, the median nerve motor nerve conduction velocity (MNCV) ranged from 0 to 65.70 m/s, with an average of 36.67 m/s, and the median nerve compound muscle action potential (CMAP) ranged from 0 to 19.50 mV, with an average of 5.42 mV. ARSs gene variation analysis: there were 4 ARSs gene variants, including GARS1, YARS1, AARS1 and SARS1. Among the 8 GARS1 gene mutation sites (c.1235G > A, c.598G > C, c.362G > A, c.1415A > G, c.637C > T, c.374A > G, c.722G > T, c.1000A > T), c. 598G > C and c. 722G > T had not been reported at home and abroad. EMG showed 5 probands were intermediate CMT (ICMT) and 3 were CMT2. Among the 2 YARS1 gene mutation sites (c. 1333A > G, c. 787T > C), C. 787T > C has not been reported at home and abroad, and the 2 probands were CMT1 and ICMT. One proband with AARS1 gene mutation (c.896C > T), the EMG showed CMT2; and there was one proband with SARS1 gene mutation (c.1187C > T), and the EMG showed ICMT. Conclusions: CMT caused by ARSs gene variation mainly causes hereditary motor neuropathy with or without sensory involvement, and the main clinical phenotypes are CMT2 and ICMT. Different ARSs gene variation-related CMT patients have different clinical manifestations, and gene detection should be performed to confirm the diagnosis. The genetic spectrum of CMT was expanded to provide a basis for disease diagnosis and genetic counseling.
Objective: To analyze the characteristics of motor function in children with different types of hereditary neuromuscular disease (HNMD). Methods: A total of 61 children with HNMD admitted to Peking University First Hospital from January 2018 to January 2024 were enrolled. Manual Muscle Testing was used to evaluate the muscle strength of the limbs, and the percentage of limb muscle strength was subsequently calculated. The Motor Function Measure (MFM) was used to evaluate the overall motor function, the Brooke grade and the Vignos grade were respectively used to assess the motor function status of the upper and lower limbs. Pearson correlation analysis and partial correlation analysis were used to explore the relationships between the MFM total score and domain scores and body mass index (BMI), the percentage of limb muscle strength, Brooke grade and Vignos grade. Results: A total of 61 cases of children included 18 of congenital muscular dystrophy (CMD group, 29.51%), 17 of spinal muscular atrophy (SMA group, 27.87%), 15 of congenital myopathy (CM group, 24.59%), and 11 of Emery-Dreifuss muscular dystrophy (EDMD group, 18.03%). There were statistically significant differences in the percentage of limb muscle strength (F = 23.749, P = 0.000), MFM total score (F = 17.445, P = 0.000), D1 domain score (F = 18.671, P = 0.000), D2 domain score (F = 10.202, P = 0.017), Brooke grade (F = 9.313, P = 0.025) and Vignos grade (F = 22.967, P = 0.000) among the 4 groups. Correlation analysis showed that the MFM total score was positively correlated with the percentage of limb muscle strength (r = 0.528, P = 0.000), and negatively correlated with Brooke grade (r =-0.607, P = 0.000) and Vignos grade (r =-0.511, P = 0.000); D1 domain score was positively correlated with the percentage of limb muscle strength (r = 0.303, P = 0.020), and negatively correlated with Vignos grade (r =-0.555, P = 0.000); D2 domain score was positively correlated with the percentage of limb muscle strength (r = 0.332, P = 0.010), and negatively correlated with Brooke grade (r =-0.513, P = 0.000); D3 domain score was negatively correlated with Brooke grade (r =-0.469, P = 0.000). Conclusions: The characteristics of motor function in children with different types of HNMD vary greatly. The specific MFM can assist evaluating the disease severity and analyzing the differences of motor function in children with different types of HNMD.
Objective: To investigate the correlation between plasma vascular cell adhesion molecule-1 (VCAM-1) levels and cortical regional blood flow impairment in patients with cerebral small vessel disease (CSVD). Methods: All 67 patients with CSVD diagnosed and treated in Fu Yang People's Hospital in Anhui from October 2021 to June 2023 were selected, and 55 subjects were selected as the control group. Using 3.0T MRI with 3D arterial spin labeling (3D-ASL) perfusion imaging technology to measure the cerebral blood flow (CBF) in different cortical regions, and the levels of plasma VCAM-1 were measured by enzyme-linked immunosorbent assay (ELISA). Pearson correlation analysis and partial correlation analysis were used to investigate the correlation between plasma VCAM-1 levels and CBF values in each cortical region. Results: Correlation analysis showed that plasma VCAM-1 was negatively correlated with CBF value in the left superior temporal gyrus (r =-0.285, P = 0.021), supramarginal gyrus (r =-0.250, P = 0.044), insula lobe (r =-0.270, P = 0.030), medial prefrontal cortex (r =-0.329, P = 0.008), middle temporal gyrus (r =-0.282, P = 0.023), paracentral lobule (r =-0.274, P = 0.027), and in the right middle temporal gyrus (r =-0.298, P = 0.016), postcentral gyrus (r =-0.264, P = 0.033), superior temporal gyrus (r =-0.275, P = 0.027), supramarginal gyrus (r =-0.293, P = 0.018), insula (r =-0.255, P = 0.041) in CSVD group, while the CBF value in the left medial prefrontal cortex in CSVD group was significantly lower than that in control group [(33.46 ± 8.27) ml/(min·100 g) vs. (36.56 ± 8.74) ml/(min·100 g); t =-2.009, P = 0.047]. Conclusions: Plasma VCAM-1 of CSVD patients may serve as a serological marker to evaluate local blood flow damage, suggesting that hypertension causes endothelial damage and inflammatory response.
Objective: To preliminarily explore the efficacy and safety of the Woven EndoBridge (WEB) device in the treatment of intracranial bifurcation wide-neck aneurysms. Methods: A retrospective analysis was conducted on the clinical data of 12 patients with intracranial bifurcation wide-neck aneurysms treated with the WEB device in Ruijin Hospital, Shanghai Jiaotong University School of Medicine between January and June 2024. The aneurysms were located at the bifurcation of middle cerebral artery (MCA) in 7 cases, the apex of basilar artery (BA) in 4 cases, and the anterior communicating artery complex (ACoAC) in one case. Neurological functional prognosis was assessed at discharge using the modified Rankin Scale (mRS), and complications occurring immediately after operation, within 24-48 h postoperatively, during hospitalization, and at 30 d postoperatively were recorded. Results: A total of 12 aneurysms in 12 patients were included. Preoperatively, 11 cases were unruptured aneurysms (mRS scores of 0), and one case was a ruptured aneurysm (mRS score of 1). All 12 patients underwent treatment with a single WEB device, which was successfully delivered and deployed in one attempt, achieving a technical success rate of 12/12. At discharge, 11 cases had an mRS score of 0, and one case had a score of 1. Immediately postoperative CT revealed no evidence of new cerebral ischemia or hemorrhage. No new intracranial hemorrhage, subarachnoid hemorrhage (SAH), or new cerebral infarction related to the aneurysm was observed within 24- 48 h postoperatively, and no complications such as puncture site bleeding occurred during hospitalization. At 30 d postoperatively, there were no neurological ischemic or hemorrhagic adverse events and complications such as puncture site bleeding. Conclusions: Preliminary findings suggest that the WEB device is safe and effective for treating intracranial bifurcation wide-neck aneurysms.
Objective: To analyze the influencing factors of acute kidney injury (AKI) after surgery in spontaneous intracranial hemorrhage (sICH). Methods: A total of 151 patients with sICH who underwent surgery in Tianjin Huanhu Hospital from March 2023 to June 2024 were selected. According to whether AKI occurred after surgery, they were divided into AKI group (n = 100) and non-AKI group (n = 51). Logistic regression analyses were used to screen the influencing factors of AKI after surgery in patients with sICH. The receiver operating characteristic (ROC) curve was drawn to evaluate the predictive efficacy of intracranial pressure (ICP) and serum neuron-specific enolase (NSE) 3 d after surgery and their combination for AKI. Results: Logistic regression analysis showed that increased cardiac troponin (OR = 1.011, 95%CI: 1.005-1.017; P = 0.001), and increased ICP 3 d after surgery (OR = 1.289, 95%CI: 1.126-1.477; P = 0.000) were the risk factors for AKI after surgery in sICH patients. ROC curve showed that the area under the curve (AUC) of ICP and serum NSE 3 d after surgery and their combination in the prediction of AKI after surgery were 0.729 (95%CI: 0.649-0.810, P = 0.000), 0.720 (95%CI: 0.631-0.809, P = 0.000) and 0.751 (95%CI: 0.672-0.830, P = 0.000), the sensitivity were 45%, 73% and 51%, and the specificity were 88.24%, 66.67% and 90.20%. There was no significant difference in the AUC among the 3 indicators (P > 0.05, for all). Conclusions: The increased cardiac troponin and ICP 3 d after surgery were risk factors for AKI after surgery in sICH. Moreover, the elevated ICP and serum NSE 3 d after surgery can predict the occurrence of AKI, but the combined monitoring does not improve the prediction efficiency.
Cerebral ischemia secondary to intracerebral hemorrhage (ICH) in the acute phase can aggravate mortality and disability in ICH patients. The underlying pathophysiology of secondary ischemic is still unclear, and may be closely related to blood pressure fluctuations, hematoma compression, and cerebral small vessel lesions. The prevention methods for this problem include the designation of antihypertensive targets according to cerebral autoregulation (CA) and release of hematoma compression, etc., and the key is to explore the personalized treatment plan for ICH, which can effectively prevent or alleviate the possibility of nerve damage, and aviod secondary cerebral ischemic. This article mainly expounds the pathophysiological mechanism, early diagnosis and prevention of secondary cerebral ischemia after ICH, aiming to provide clinical guidance for individualized secondary prevention of acute ICH.
