Skull base osseous lesions, including various benign and malignant tumors, and developmental abnormalities like chordomas, osteomas, chondromas, osteosarcomas, fibrous dysplasia (FD), endolymphatic sac tumors, et al, are challenging to treat due to their deep anatomical location near critical nerves and vessels. Surgical treatment demands a balance between complete lesion resection and neural function preservation. In recent years, advances in endoscopy, imaging, intraoperative navigation, proton radiation therapy, and multi-disciplinary team (MDT) have led to continuous optimization of treatment strategies for skull base osseous lesions. This paper briefly reviews the current surgical strategies and breakthroughs for skull base osseous lesions.
Objective: To explore the experience and technical key points of endoscopic transnasal extreme medial approach for resection of chordoma involving the lower clivus. Methods and Results: The clinical data and follow-up data of 8 patients with chordoma involving the lower clivus admitted to The First Affiliated Hospital of Zhengzhou University from June 2022 to June 2024 were retrospectively analyzed. All patients underwent endoscopic transnasal extreme medial approach tumor resection and received triple cranial base reconstruction including fascia lata suture sealing + rigid cranial base reconstruction + mucosa flap application. All 8 patients successfully completed the surgery, with a success rate of 8/8. Postoperative 7 d imaging reexamination showed that 6 patients underwent gross total resection of tumor, and 2 patients underwent subtotal resection. At one month after surgery, the headache symptom was relieved in 3 patients (3/4), and nerve dysfunction relief was observed in 4 patients (4/5). The surgical-related complications included cerebrospinal fluid rhinorrhea (2 cases) and intracranial drug-resistant bacterial infection (one case). One death occurred, and the cause of death was brain herniation secondary to cerebrospinal fluid rhinorrhea and intracranial infection. Two recurrences occurred, and one recurrence was treated with proton radiotherapy + secondary surgical resection, while the other recurrence was treated with secondary surgical resection. Conclusions: The endoscopic transnasal extreme medial approach provides a good technical means for gross total resection of chordoma involving the lower clivus. During the operation, adequate exposure of the tumor can be achieved by referring to important bony landmarks, which can effectively resect chordoma involving the lower clivus.
Objective: To evaluate the clinical application of endoscopic transorbital and transoral approaches for lateral skull base lesion resection. Methods and Results: A retrospective analysis was conducted on 17 patients undergoing endoscopic transorbital or transoral lateral skull base surgery at General Hospital of Eastern Theater Command from June 2021 to September 2024. Eight cases underwent endoscopic transorbital approach surgery, with lesions mainly located in the orbit, lateral orbital apex or spheno-orbital region. Seven cases underwent gross total resection, and one case underwent subtotal resection; postoperative exophthalmos all relieved (4/4), improvement of vision and ocular motility disorders occurred in 4 cases (4/7) and 2 cases (2/4) respectively. There were no postoperative complications such as bleeding, new developed neurological dysfunction, cerebrospinal fluid leakage, intracranial infection, etc., but all patients had significant swelling around the eyelids, which subsided on its own after about 7 d. Nine cases underwent endoscopic transoral approach surgery for lesions in the pterygopalatine fossa, infratemporal fossa, or anterior region of Meckel cave, with gross total resection in 7 cases and subtotal resection in 2 cases; facial numbness improved in 4 cases (4/6) after surgery; no surgery-related complications were observed. One patient with subtotal resection showed tumor progression 3 months after surgery. Conclusions: Endoscopic transorbital and transoral approaches are minimally invasive techniques utilizing ventral natural corridors. They provide effective options for specific skull base regions, expanding the armamentarium of endoscopic skull base surgery.
Objective: To investigate the clinical features, diagnosis and surgical treatment of spontaneous cerebrospinal fluid rhinorrhea (CSFR) in the lateral recess of sphenoid sinus. Methods and Results: A retrospective analysis was conducted on the clinical data of 24 patients with spontaneous CSFR in the lateral recess of sphenoid sinus admitted to Beijing Tongren Hospital, Capital Medical University, between January 2019 and June 2023. Among them, there were 7 males and 17 females, with an average age of 46 years and an average body mass index (BMI) of 27.24 kg/m2. The average preoperative lumbar puncture (LP) cerebrospinal fluid (CSF) pressure was 200 mm H2O in 21 patients, with 11 patients exhibiting CSF pressure ≥ 200 mm H2O. Imaging studies revealed bone defects and meningoencephalocele herniation into the sphenoid sinus in all 24 patients. All patients underwent transnasal endoscopic repair surgery for CSFR. Specifically, 2 patients with preoperative CSF pressure ≥ 300 mm H2O underwent lumboperitoneal shunt (LPS) first, while the remaining 22 patients underwent endoscopic resection of meningoencephalocele in the lateral recess of sphenoid sinus via the pterygoid process approach, accompanied by skull base leak repair surgery. Two weeks postoperatively, the CSF pressure was reviewed in 21 patients, ranging from 140 to 320 mm H2O, with an average of 185 mm H2O. All patients were followed up for an average duration of 25.40 months. Subsequently, 3 patients with recurrent CSFR underwent LPS, and all 24 patients achieved clinical cure. Conclusions: Spontaneous CSFR is related to chronic intracranial hypertension. Transnasal endoscopic leakage repair and CSF shunts are effective methods to treat this disease and prevent recurrence.
Objective: To evaluate the clinical value of the endoscopic expanded endonasal transsphenoidal approach for cerebrospinal fluid rhinorrhea (CSFR) repair in primary hospitals. Methods and Results: A retrospective analysis was conducted on 30 patients between January 2022 and December 2023 at Togtoh County Hospital, Jungar Banner People's Hospital, and Siziwang Banner People's Hospital in Inner Mongolia Autonomous Region. All patients underwent endoscopic expanded endonasal transsphenoidal approach for CSFR repair using standardized endoscopic surgical techniques and repair materials (such as autologous fat, fascia, or synthetic materials). All procedures were successfully completed, with an average operative time of (73.00 ±15.90) min and intraoperative blood loss of (34.00 ±16.94) ml. The postoperative complication rate was 6.67% (2/30), including transient CSFR (one case) and mild nasal infection (one case), both of which resolved with conservative treatment. The average hospital stay was (7.43 ±2.06) d. During an average follow-up period of (9.97 ±3.51) months, recurrence occurred in 3 cases (10%), all of which were successfully cured with secondary repair, resulting in a final cure rate of 100% (30/30). Conclusions: The endoscopic expanded endonasal transsphenoidal approach for CSFR repair demonstrates favorable efficacy and safety in primary hospitals, along with cost-saving benefits, making it worthy of wider adoption.
Objective: To explore the pathogenesis, clinical manifestations, imaging and endocrine function characteristics, treatment methods, pathological characteristics and prognosis of pituitary adenoma apoplexy for ischemic infarction. Methods and Results: All 3 patients with pituitary adenoma apoplexy for ischemic infarction who were hospitalized in Affiliated Hospital of Hebei University from January 2021 to April 2022 were selected. All 3 patients presented with clinical manifestations such as headache, vision loss, cranial nerve palsy, and endocrine abnormalities. Preoperative endocrine examination indicated that one patient had decreased cortisol and prolactin levels. Preoperative MRI showed that all were large adenomas invading the cavernous sinus, hyperintensity on T1WI and T2WI, and uneven ring enhancement of the tumors. All 3 patients underwent endoscopic transsphenoidal resection of pituitary adenoma. Postoperative pathology confirmed pituitary adenoma with necrosis, all of which were coagulative necrosis. All 3 patients were finally diagnosed with pituitary adenoma apoplexy for ischemic infarction. Postoperatively, the clinical symptoms of all 3 patients improved significantly; one patient developed hypothyroidism and was treated with hormone supplementation. Conclusions: The clinical features of pituitary adenoma apoplexy for ischemic infarction are relatively typical. Multidisciplinary cooperation should be carried out, and the best treatment plan should be formulated based on the clinical characteristics of the patients.
Objective: To explore the effect and the possible mechanism of glycyrrhizin acid (GA) on the seizure onset and hippocampal neuron injury in kainic acid (KA) induced epileptic rat models. Methods: The epilepsy model was established by injecting KA into the rat hippocampus. Rats were randomly divided into sham group, epilepsy group (EP group), and GA group (25 mg/kg group and 50 mg/kg group). After injection, the latency period and severity of seizure of rats in each group were observed. The acute phase EEG of rats in different groups were monitored. The neuron injury in hippocampus CA3 region and the expression of high-mobility group box 1 (HMGB1) of rats in different groups were detected by immunohistochemistry staining and Western blotting. Results: Compared to the EP group, the epileptic seizure latency of GA 25 mg/kg group and 50 mg/kg group significantly lengthened [(109.33±42.84) min vs. (51.17±22.31) min, t =-2.950, P = 0.015; (109.50±35.79) min vs. (51.17±22.31) min, t =-3.388, P = 0.007], the times of seizure ≥ Ⅳ grade during 6 h after injection in GA 25 mg/kg group and 50 mg/kg group significantly reduced [(2.83±0.75) times vs. (5.00±1.55) times, t = 3.081, P = 0.012; (2.67±1.75) times vs. (5.00±1.55) times, t = 2.445, P = 0.035]. After the treatment of GA, the number of spike and sharp waves in the acute phase EEG obviously decreased. In the acute stage of epileptic seizure, the neurons number in hippocampus CA3 region of EP group reduced, and was significantly less than that of sham group [(40.33±5.69) neurons vs. (72.33±7.51) neurons, t = 5.886, P = 0.004]; while the number of neurons in hippocampus CA3 region of GA 25 mg/kg group and 50 mg/kg group increased, and was significantly more than that of EP group [(58.33±2.52) neurons vs. (40.33±5.69) neurons, t =-5.014, P = 0.007; (57.00±6.25) neurons vs. (40.33±5.69) neurons, t =-3.418, P = 0.027]. The expression of HMGB1 [integrated optical density (IOD)] in hippocampus CA3 region of EP group heightened, and was significantly higher than that of sham group [(3.79±0.50)×106 IOD vs. (2.16±0.45)×106 IOD, t =-4.216, P = 0.014]; while the expression of HMGB1 in hippocampus CA3 region of GA 25 mg/kg group and 50 mg/kg group decreased, and was significantly lower than that of EP group [(2.50±0.52)×106 IOD vs. (3.79±0.50)×106 IOD, t = 3.090, P = 0.037; (2.66±0.44)×106 IOD vs. (3.79±0.50)×106 IOD, t = 2.955, P = 0.042]. The expression of HMGB1 protein (relative gray value) in hippocampus tissue detected of EP group increased, and was significantly higher than that of sham group (1.19±0.17 vs. 0.54±0.14, t =-5.078, P = 0.007); while the expression of HMGB1 protein in hippocampus tissue of GA 25 mg/kg group and 50 mg/kg group lessened, and was significantly lower than that of EP group (0.65±0.04 vs. 1.19±0.17, t = 5.286, P = 0.028; 0.58±0.13 vs. 1.19±0.17, t = 4.953, P = 0.008). Conclusions: GA can prolong the epileptic seizure latency, reduce the seizure severity and epileptic discharges, and alleviate the hippocampal neuron injury in KA induced epileptic rats. These effects may be associated with its inhibition on the expression of HMGB1.
Objective: To explore the diagnostic value of cerebrospinal fluid (CSF) biomarkers, total tau protein (t-tau), phosphorylated tau protein 181 (p-tau181) and real-time quaking-induced conversion (RT-QuIC) in sporadic Creutzfeldt-Jakob disease (sCJD). Methods: A retrospective study was conducted on 30 patients diagnosed with probable sCJD at Huashan Hospital, Fudan University from April 2020 to November 2022, serving as the sCJD group. Meanwhile, 25 patients diagnosed with rapidly progressive Alzheimer's disease (AD) and 23 patients diagnosed with autoimmune encephalitis (AE), matched for gender and age with the sCJD group, were selected as the AD group and AE group, respectively. CSF t- tau, p-tau181 and t- tau/p-tau181 ratio were collected from the 3 groups. The auxiliary examination data of the sCJD group, including typical manifestations of electroencephalography (EEG) and head MRI, as well as RT- QuIC results, were collected with emphasis. Results: There were statistically significant differences in CSF t-tau (χ2 = 38.247, P = 0.000), p-tau181 (χ2 = 22.855, P = 0.000) and t-tau/p-tau181 ratio (χ2 = 43.780, P = 0.000) among 3 groups. Further pairwise comparisons revealed that the t- tau in the sCJD group was higher than that in the AD group (Z =-4.392, P = 0.000) and AE group (Z =-5.852, P = 0.000); the p-tau181 in the AD group was higher than that in the sCJD group (Z = 2.830, P = 0.014) and AE group (Z = 4.758, P = 0.000); the t-tau/p-tau181 ratio in the sCJD group was higher than that in the AD group (Z =-6.601, P = 0.000) and AE group (Z =-3.339, P = 0.003), and the t-tau/p-tau181 ratio in the AE group was higher than that in the AD group (Z =-2.984, P = 0.009). Among the 30 patients in the sCJD group, 70% (21/30) exhibited abnormal MRI findings in the brain, all displaying the typical cortical "lace sign"; 40% (12/30) showed typical triphasic waves on EEG. In the sCJD group, 7 cases underwent CSF RT-QuIC, and pathogenic prion protein was detected in 5 patients. Conclusions: Elevated CSF t-tau and t-tau/p-tau181 ratio, as well as positive RT-QuIC results, hold certain diagnostic value for sCJD.
Objective: To compare the monitoring effect of abnormal muscle response (AMR) combined Z-L response (ZLR) and simple AMR in keyhole microvascular decompression (MVD) for hemifacial spasm (HFS). Methods: Total 258 patients with primary HFS treated with keyhole MVD between January 2014 and April 2024 from The Second Affiliated Hospital of Soochow University were analyzed retrospectively, including 102 patients underwent simple AMR (ARM group) and 156 patients underwent intraoperative monitoring of AMR combined ZLR (AMR + ZLR group). Calculate the surgical efficiency, and record the occurrence of postoperative complications. Results: In the AMR + ZLR group, 145 cases recovered 7 d after surgery, 11 cases were ineffective, and the surgery effective rate was 92.95% (145/156); 151 cases recovered 6 months after surgery, 5 cases was ineffective, and the surgery effective rate was 96.79% (151/156). In the AMR group, 86 cases recovered at 7 d after surgery, 16 cases were ineffective, and the surgery effective rate was 84.31% (86/102); 92 cases recovered 6 months after surgery, 10 cases were ineffective (2 cases relapsed), and the surgery effective rate was 90.20% (92/102). The MVD effective rates in AMR + ZLR group were better than that in AMR group at 7 d and 6 months after surgery (χ2 = 4.908, P = 0.027; χ2 = 4.904, P = 0.027). On the first day after surgery, 12 cases in the AMR + ZLR group experienced mild facial paralysis, which recovered within 7 d after surgery. In the AMR group, one case had tinnitus and one case had dizziness, both of which recovered within 3 d after surgery, 18 cases experienced mild facial paralysis, which recovered within 7 d after surgery. Conclusions: Intraoperative monitoring of AMR combined ZLR provides more valuable neurosurgical guidance than simple AMR during MVD for HFS. MVD is an effective method for the treatment of HFS, and the MVD rate of keyhole in our center has maintained a high level.
Objective: To explore the efficacy and safety of mild hypothermia therapy in patients with acute anterior circulation massive cerebral infarction after endovascular mechanical thrombectomy. Methods: Eighty-two patients with acute anterior circulation massive cerebral infarction admitted to He'nan Provincial People's Hospital from January 2023 to August 2024, who underwent mechanical thrombectomy, were included. Hypothermia group (n = 41) received mild hypothermia therapy with a target core temperature of 33-34 ℃ for 48-72 h immediately after surgery, and the others didn't (mechanical thrombectomy group, n = 41). Serum neuron-specific enolase (NSE) levels were measured 72 h after operation; prognosis was assessed using the modified Rankin Scale (mRS) at 3 months after discharge, and good prognosis and morbidity and mortality rates were recorded; as well as the complication rates were recorded during hospitalization after surgery. Univariate and multivariate Logistic regression analyses were used to screen for factors influencing prognosis after mechanical thrombectomy in patients with acute anterior circulation massive cerebral infarction. Results: The serum NSE level at 72 h after operation in the hypothermia group was lower than the mechanical thrombectomy group [18.86 (13.35, 30.54) μg/L vs. 21.43 (18.30, 32.90) μg/L; Z =-2.147, P = 0.032], and the good prognosis rate at 3 months after discharge was higher than the mechanical thrombectomy group [46.34% (19/41) vs. 21.95% (9/41); χ2 = 5.423, P = 0.020], and the mortality rate (χ2 = 0.734, P = 0.391), incidence of hemorrhagic transformation (χ2 = 0.497, P = 0.481), vascular reocclusion (χ2 = 0.945, P = 0.331), malignant brain edema (χ2 = 1.058, P = 0.304), pulmonary infection (χ2 = 2.614, P = 0.106), electrolyte disturbance (χ2 = 1.222, P = 0.269), arrhythmia (χ2 = 0.456, P = 0.499), deep venous thrombosis (χ2 = 0.311, P = 0.577), and abnormal coagulation function (χ2 = 1.246, P = 0.264) during hospitalization between the 2 groups were not statistically significant. Logistic regression analysis showed that mild hypothermia was a protective factor for good prognosis after mechanical thrombectomy for acute anterior circulation massive cerebral infarction (OR = 4.457, 95%CI: 1.503-13.759; P = 0.007), while age increase (OR = 0.915, 95%CI: 0.856-0.978; P = 0.009), history of hypertension (OR = 0.175, 95%CI: 0.055-0.562; P = 0.003) were risk factors for poor prognosis. Conclusions: Mild hypothermia after mechanical thrombectomy in patients with acute anterior circulation massive cerebral infarction is safe and feasible. Reducing NSE release may be one of its action pathways, and large-scale randomized controlled trials are needed to further verify its efficacy.
Objective: To identify the risk factors of respiratory and cardiac arrest after medullary infarction (MI), and to establish a Nomogram model of respiratory and cardiac arrest after MI. Methods: Total of 3168 patients with MI hospitalized in Tianjin Huanhu Hospital from January 2016 to January 2023 were included, including 66 patients in the respiratory and cardiac arrest group, and 3102 patients in the non-respiratory and cardiac arrest group. Potential risk factors of respiratory and cardiac arrest were collected, and samples were resampled using random undersampling (RUS), random oversampling (ROS), and synthetic minority over-sampling technique (SMOTE). Split the raw data and resampled data into training and testing sets. For the training set, univariate and multivariate stepwise Logistic regression models were used to analyze the risk factors of respiratory and cardiac arrest after MI. Drawn receiver operating characteristic (ROC) curve using the training and testing sets, compared the area under the curve (AUC) of 4 Logistic regression models using Delong test, and established a Nomogram model. Results: Use the testing sets to test the Logistic regression models built on the raw data and 3 resampling methods. The results showed that the AUC of SMOTE resampling was the highest after testing (SMOTE∶raw data Z = 3.254, P = 0.000; SMOTE∶RUS Z = 4.385, P = 0.000; SMOTE∶ROS Z = 2.701, P = 0.007). For SMOTE resampling data, age increase (OR = 1.045, 95%CI: 1.021-1.070; P = 0.000), smoking history (OR = 22.216, 95%CI: 10.426-49.920; P = 0.000), the smaller the number of cigarettes smoked (OR = 0.943, 95%CI: 0.915-0.971; P = 0.000), alcohol history (OR = 1.847, 95%CI: 1.068-3.207; P = 0.028), cerebrovascular history (OR = 3.104, 95%CI: 1.842-5.344; P = 0.000), the higher the high-density lipoprotein cholesterol (HDL-C; OR = 5.863, 95%CI: 2.063-16.725, P = 0.000), the higher fibrinogen (FIB; OR = 1.413, 95%CI: 1.381-1.702; P = 0.001), left lateral medullary infarction [LMI; no medial medullary infarction (MMI; OR = 0.173, 95%CI: 0.093-0.312, P = 0.000), no right LMI (OR = 0.337, 95%CI: 0.176-0.634; P = 0.001)], combined with extramedullary infarction (OR = 31.354, 95%CI: 17.496-59.163; P = 0.000), higher Wada Drinking Water Test score (OR = 3.723, 95%CI: 2.913-4.862; P = 0.000), and patients with stress ulcer (OR = 5.266, 95%CI: 2.902-9.813; P = 0.000) were more likely to experience respiratory and cardiac arrest after MI. The Nomogram model showed that the Wada Drinking Water Test score had the greatest predictive effect, while the predictive effect of drinking history was the smallest. Conclusions: Increasing age, high HDL-C, high FIB, smoking history, the smaller the number of cigarettes smoked, alcohol history, cerebrovascular history, left LMI, combined with extramedullary infarction, high Wada Drinking Water Test score and combined with stress ulcer are risk factors for respiratory and cardiac arrest after MI. The Nomogram model can be used to intuitively predict the probability of occurrence of respiratory and cardiac arrest after MI.
Objective: To explore the influencing factors for subcutaneous effusion (SCE) after cranioplasty. Methods: Total of 111 patients with skull defect who underwent cranioplasty from January 2019 to June 2024 in Beijing Rehabilitation Hospital, Capital Medical University were analyzed retrospectively. All the patients were devided into SCE group (n = 29) and non-SCE group (n = 82) according to whether they had SCE after cranioplasty. Univariate and multivariate Logistic regression analyses were applied to explore the influencing factors for SCE after cranioplasty. Results: Among 111 patients, 29 had SCE after cranioplasty, with an incidence of 26.13%. All the 29 patients recovered and there was no bleeding, scalp damage, implant exposure, poor wound healing and intracranial infection after the treatment. Logistic regression analysis showed that age increase (OR = 1.075, 95%CI: 1.027-1.126; P = 0.002), polyether-ether-ketone (PEEK) repair material (OR = 7.673, 95%CI: 2.227-26.435; P = 0.001) and 24 h drainage increase before drain removal (OR = 1.026, 95%CI: 1.008-1.044; P = 0.004) were risk factors for SCE after cranioplasty. Conclusions: Age increase, PEEK repair material and 24 h drainage increase before drain removal were risk factors for SCE after cranioplasty. Timely and effective interventions should be taken according to individual condition.
Surgical treatment of spontaneous intracerebral hemorrhage (sICH) is increasingly oriented toward minimally invasive, precise, and safe, with growing emphasis on disease and prognostic assessment, and perioperative monitoring. As a medical image processing software, 3D Slicer has been gradually applied in the diagnosis and treatment of sICH. It enables precise quantification of hematoma-related pathological changes, assists in preoperative trajectory simulation and intraoperative localization, greatly enriching the approaches for sICH evaluation, monitoring, and treatment. This article reviews the use of 3D Slicer software in sICH monitoring and prognostic evaluation, preoperative pathway planning and surgical simulation, intraoperative localization and puncture guidance, and the design and use of postoperative neuroprotective devices, aiming to provide novel insights to advance clinical practice.
