Volume 89  ·   Issue 03  ·  2009

In recent years, great progress has been made in both basic research and clinical application of neurosurgery in China [1], but these two aspects of research are carried out in their own independent systems, lack of intersection points, often "two layers of skin", thus leading to the low conversion rate of scientific and technological achievements.

Objective To investigate the therapeutic effect of vascular endothelial growth factor (VEGF) gene expression mediated by recombinant AAV1 (rAAV1) vector in brain ischemia and the mechanism thereof.Methods Sixty-four SD rats were randomly divided into 2 equal groups and received intra-ventricular injection with rAAV1-VEGF or rAAV1-lacZ as controls.21 days later the rats underwent transient middle cerebral artery occlusion (MCAO).Neurological severity score (NSS) was recorded 1,2,3,7,14,and 21 days after MCAO.48 rats were sacrificed 21 days after MCAO and brains were taken out from 48 rats.Immune quantitative analysis was used to identify the quantity of VEGF expression,lmmunohistochemistry was used to identify the site of VEGF expression.Immunofluorescence double labeling of von Willebrand factor (vWF) and 5-bromodcoxy-uridine (BrdU) was performed to detect the proliferation of endothelial ceils.Fluoreseein isothiocyanate ( FITC ) -dextran was infused into the caudal vein of 8 rats from each group and then the rats were killed with their brains taken out to evaluate the cerebral microvessel perfusion and microvessel density.Results The NSSs of the VEGF group 7,14,and 21 days after MCAO were all significantly lower than those of the control group ( all P <0.05 ),and the VEGF165 protein expression quantity was 27 times as that of the control group (P < 0.05 ).Immunohistochemistry demonstrated that VEGF expression was distributed mainly in the caudate putamen,corpus callosum,choroid plexus,and hippocampas in the VEGF group,while no expression was detected in the control group.The microvessel density of the VEGF group was 157 ± 13,significantly higher than that of the control group [ ( 89 ± 9),P < 0.05 ].BrdU +/vWF + endothelial cells were detected in the area adjacent to the MCAO.The density of microvessel infused with FITC-dextran was (152 617 ±13 076) μm2/mm2 in the VEGF group,significantly higher than that of the control group [(91 658 ± 6577)μm2/mm2,P < 0.05].Conclusion rAAV1 mediates the VEGF gene expression in multiple structures in the brain and attenuates the neurological deficit of MCAO.VEGF gene transfer may stimulate angiogenesis and improves blood supply in brain.Neovascularization may be a therapeutic strategy for brain ischemia.

Objective To investigate the effects of individualized endovascular treatment on cerebral venous thrombosis of different types.Methods 168 patients with cerebral venous thrombosis underwent individualized endovascular treatment:direct thrombolysis via internal jugular vein in 26 cases,injection of urokinase via common carotid artery in 98 cases,stent angioplasty in venous sinus in 9,simple anticoagulant therapy in 20 cases,and treating combined intracranial hemorrhage simultaneously in 15 cases.Follow-up was conducted for 6 - 168 moths.Results Follow-up showed that the effective rate was 97.6%,recurrence rate was 6.6%,complication incidence rate was 1.2%,and death rate was 0.6%.Venous sinus recanalization occurred and primary drainage rebounded in most cases.Lateral drainage was strengthened in some cases whose venous sinuses did not recover ideally.The symptoms of most cases were alleviated along with the decrease of intracranial pressure.Conclusion Individualized endovascular treatment based on the characteristics of the disease is effective in treatment of cerebral venous thrombosis.

Objective To investigate the effectiveness of minimal invasive neurosurgery in treatment of intervertehral foraminal lesions.Method Fifty-six patients with intervertebral foraminal lesions were divided into 2 groups: minimal invasive neurosurgery group (MG group,n = 31 ) and traditional neurosurgery group (TG group,n = 25 ).Their pre-operationa] clinical conditions,methods of surgery,duration and effectiveness of operation were analyzed retrospectively.Follow-up was conducted for 3 - 48 months.Results Twenty-three of the 25 patients in the TG group (92%) had their lesions resected completely and 2 of the 31 patients (8%) underwent subtotal resection.In the MG group 28 of the 31 patients (90.32% ) had their lesions resected completely,2 (6.45%) underwent subtotal resection,and 1 patient (3.23%) showed epidural remains and did not receive further treatment.There was no significant difference in the effective rate between these 2 groups.The operation time of the TG group was ( 188 ± 35 ) minutes,significantly longer than that of the MG group [ ( 140 ± 26) minutes,P < 0.01 ].Follow-up showed that all patients resumed their normal life except the patient with epidural remains in the MG group,and no recurrent patient was found.Conclusion The minimal invasive neurosurgery is convenient,effective,and cheaper to treat intervertebral foraminal lesions.However,precise localization and intimate knowledge of the anatomy are important.

Objective To explore the feasibility of applying the infratentorial supracerebellar keyhole approach for removing tumors of pineal regiom.Methods Infratentorial supracerebellar keyhole approach was performed in 16 cadaveric heads with intracranial vessels perfused by colored later.The microscopic structure was observed.The anatomic structure was measured with Stryker Navigation System and the data were analyzed with the SPSS 10.0 software.And further,infratentorial supracerebellar keyhole approach was performed in 11 clinical cases with tumors located in the posterior third ventricle and pineal region,based on the individualized imaging features.Results Only the central group bridging veins on the cerebellum tentorial surface needed to be sacrificed under infratentorial supracerebellar keyhole approach,and other vessels could be preserved well The distance between the bridging veins of beth left and right medial group could reach (35±6) mm when they were fully dissected,thus offering enough surgical space for applying this keyhole approach.When the culmen of cerebellum was retracted,the pineal body,Galen vein and its tributary,quadrigeminal bodies,even trochlear nerve could be observed.When the underlayer choroid of the third ventricular roof was dissected medially and inferiorly to the posterior choroidal artery,the posterior third ventricle could be reached.If the tentorium of cerebellum was cut open between the straight sinus and the lateral sinus,the surgical field could be enlarged anteriorly and superiorly to the longitudinal fissure region above the tentorium.Eight of the 11 pineal region tumors sized 2 -5 cm in diameter were totally removed,and 3 were subtotally resected.For one case,posterior cranial fossa decompression and ventriculoperitoneal shunt were performed postoperatively.Another one patient suffered from transient mutism and steady fixation after surgery.Other patients had no adverse effect.Conclusions Infratentorial supracerebellar keyhole approach can be applied for removing the pineal region minors without interfering the adjacent deep venous system,and can enter the third ventricle in a nearly non-traumatic way.If necessary the tentorium can be cut open to expose supra-tentorial structures.It can be regarded as a better choice for surgeries in this region.

Objective To investigate the microsurgical strategies of glioma located in lateral fissure area.Methods The clinical data of 123 patients with glioma located in lateral fissure area confirmed by pathology,76 males and 47 females,aged 46.2 (4 -75),were retrospectively analyzed.The optimal surgical approach and comprehensive therapeutic strategies were selected according to the imaging features and pathological properties of tumors.Resections were performed by the pterion approach in all cases to remove the tumors,navigational orientation was used in 17 cases,and supervision by B mode ultrasonography was used in 12 cases.The branches of middle cerebral artery and fissure vein were protected carefully.The patients with tumors above grade Ⅱ,confirmed pathologically after resection,underwent chemotherapy( teniposide + semustine or temozolomide) and radiotherapy that was designated individually according to the pathological grade and distribution of the tumors.Follow-up was conducted by telephone,mail or outpatient department visit on 102 of the 133 patients (82.9% ).Results 82 patients (66.7% ) underwent total resection,18 (14.6%) underwent subtotal resection,16 (13.0%) underwent major resection,and 7 (5.7%) underwent partial resection.Postoperatively cerebral vasospasm in 8 cases,brief aphasia and reaction clumsily in 4 cases,muscle strength decline in 3 cases,and epilepsy in 1 case,these patients were submitted to symptomatic treatment with progressive improvement of the above-mentioned signs and symptoms.One patient died of malignant intracranial hypertension.The follow-up showed that 97 patients survived over 1 year,the 5-year survival rate was 25.6%,and the average survival time was 21.7 months.Conclusion The lateral fissure area glioma can be treated through proficient microsurgical technique after the anatomic training,It is the key in the surgery on the lateral fissure glioma to protect the main branches of middle cerebral artery,trunk of middle cerebral vein,and important brain functional areas.

Objective To evaluate the effects of surgical microscope-based indocyanine green videoangiography (ICGA) in aneurysm surgery and compare the values of ICGA and postoperative digital subtraction angiography (DSA).Methods 101 patients with intracranial aneurysm underwent clipping of 113 aneurysms.A microscope-integrated light source containing infrared excitation light illuminated the operating field.The dye ICG was injected intravenously,and the intravascular fluorescence was recorded by a video camera attached to the microscope with optical filtering to block ambient and laser light for collection of only ICG-induced fluorescence.All patients underwent DSA 6 - 13 days post-operatively.The results of patency of parent,branching,and perforating arteries and documentation of aneurysm obliteration shown by ICGA and DSA were compare& Result 219 times of ICGA was performed in these 101 patients with excellent image quality and resolution,allowing intra-operative real-time assessment of the cerebral circulation.The ICG angiographic results could be divided into arterial,capillary,and venous phases,comparable to those observed with DSA.In all cases,the postoperative angiographic results corresponded to the intranperative ICG video angiographic findings.In 3 cases,the information provided by intraoperative ICGA significantly changed the surgical procedure.Conclusion Simple and repeatable,microscope-based ICGA provides real-time information about vessels and aneurysm sac.This technique may be useful during routine aneurysm surgery as an adjunct to intraoperative microvascnlar Doppler ultrasonography and DSA.

Objective To determine the clinical features of systemic lupus erythematosus (SLE) patients with diffuse alveolar hemorrhage (DAH).Methods The medical records of seventeen SLE patients with DAH were reviewed.Results Hypoxemia ( 100% ),dyspnea ( 88% ),cough ( 88% ) and fever (82%) wore the most common symptoms instead of hemoptysis (71%).The most common extrapulmonary presentation was renal involvement (94%).About 60% patients were complicated with lung infection.The mean drop in hemoglobin was ( 32 ± 11.3 ) g/L Mean SLEDAI was ( 17~10 ).All received high-dose steroids and most also were given cyclophosphamlde.Ratio of mechanical ventilation in non-survivors was higher than that of survivors ( P < 0.05 ).Conclusions DAH is a rare and catastrophic event in SLE.DAH can occur in any course,which suggests active SLE,and frequently complicated with lupus nephritis.Some patients may have no hemoptysis.

Objective To investigate the prognostic factors of surgery-pathological stage Ⅲ endometrial cancer.Method The clinical data of 102 patients with stage Ⅲ endometrial cancer,aged 54.9 (27 -79),71 with endometrioid adenocarcinoma,31 with non-endometrioid adenocarcinoma ,9 undergoing simple surgical treatment,and 42 receiving radiation,16 receiving chemotherapy,and 35 receiving chemoradiation after surgery,were analyzed retrospectively.Follow-up was conducted for 56 (3 - 192) months,Results Cox risk model analysis showed that the risk factors for the prognosis of stage Ⅲ endometrial cancer were pathological types,method of treatment,vascular thrombosis ,and age ( all P <0.05 ).The average survival time of stage Ⅲ a endometrial cancer patients purely positive in peritoneal cytology was 74.4 months,significantly longer than that of the patients with serosa and/or annex involvement (53.8 months,P < 0.05 ).Conclusion The independent prognostic factors of stage Ⅲ endometrial cancer are pathological type,method of treatment,vascular thrombosis,and age.The patients with ,the prognosis of stage Ⅲa endometrial cancer simply positive in peritoneal cytology is better than that with serous and/or annex involvement.

Objective To report the clinical and genetic study of a new Chinese family with autosomal dominant lateral temporal lobe epilepsy (ADLTE).Methods The living affected members underwent a full clinical,neurophysiological,electroencephalogram (EEG),and magnetic resonance imaging (MRI) study.Genetic analysis was performed by LGI1 DNA sequence analysis.Results The clinical feature of the patients was coincidence well with the definition of ADLTE by International league Against Epilepsy in 2001.The living affected members had an adult or children onset of drug-responsive tonic-clonic seizures or complex partial seizures constantly preceded by auditory or visional aura.Routine EEG revealed no focal abnormalities over both temporal regions.MRI detected no structural abnormality.Analysis of LGI1 gene showed no mutation in all affected members.Conclusion This kindred has typical clinical manifestations of ADLTE.The pathogenesis has no association with mutation of the exons of LGIl gene.

Objective To study the olinical and radiographic characteristics of axial fracture with adjacent section instability and the diagnosis and surgical treatment thereof.Methods Seventeen patients of axial fracture with adjacent section instability,11 males and 7 females,aged 34 (23～56) underwent different treatment patterns depending on the fracture type and stability of the adanto-axial joint and C2-3:resection of C 2-3 intervertebral disk and bone grafting,anterior interbody fusion and plate internal fixation,odontoid screw fixation,posterior C2 pedicle screw fixation,odontoid screw fixation combined with bilateral C-2 pedicle screw fixation.Follow-up was conducted for 12 (6～36 ) months.Results Postoperatively all patients were immobilized in a hard collar for 3 months.Bony fusion was obtained in all patients in 3 months.There were no operation-related complications,such as spinal cord injury,eerebrospinal fluid leakage,vertebral artery injury,etc.No re-dislocation was found.Neurological recovery was observed in the 3 patients who presented neurological deficits.Conclusion The type of atlas fracture with adjaeem section instability and the impact thereof on the stability of the atlanto-axial joint and C 2/3 neck joint should be identified early.Surgical treatment results in better outcome.

Objective To summarize the experience of internet-based online database of orthopedic failure surgery.Methods Based on the OrthoChina project,a sub-database for orthopedic failure surgery was established,open to the orthopedic surgeons for viewing,uploading,and sharing the experience.All cases were uploaded by the orthopedic surgeon users registering in the OrthoChina project from 25 August 2006 to 31 December 2007 were summarized.Results 102 failure surgery cases had been uploaded in the database,in which 87 were caused by internal instrumentation,5 by external fixation,7 by conservative treatment,and 3 by hip arthroplasty.Sixty-seven cases involved the poor performance of the orthopedic surgeons,4 involved the patients related,and the causes of the other 31 cases remained unknown.Six failure cases occurred in class 1 hospitals,76 cases in class 2 hospitals,and 20 in class 3 hospitals.Conclusion Internet based online database for orthopedic failure surgery helps collect the failed orthopedic treatment from different surgeons and different hospitals.Sharing such experience helps the orthopedic surgeons avoid such therapeutic errors and improve their work.Qualified training and certification are necessary for the application of new techniques and implants.

Objective To investigate the platelet aggregation in Alzheimer disease (AD) patients and the influence of platelet-derived nitric oxide (NO) on such aggregation.Methods Peripheral blood samples were collected from 40 mild and moderate AD patients,20 males and 20 females,aged ( 72 ± 8 ) ,and 42 healthy controls,13 males and 29 females,aged (69 ± 4).Turbidimetry was used to measure the platelet aggregation,colorimetry was used to detect the concentration of nitric oxide,and the activity levels of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in platelets were examined with nitric oxide synthase assay kit. The correlation among these variables was analyzed.Results The platelet aggregation rate of the AD patients was (58% ± 12% ),significantly higher than that of the healthy controls (53% ± 9%,P < 0.05).The NO concentration of the AD patients was (0.743 ± 0.164) nmol·108 pt -1,significantly lower than that of the healthy controls [ ( 0.874 ± 0.378 ) nmol·108pt -1 ,P < 0.05 ].In the AD patients,the platelet aggregation rate was negatively correlated with the NO concentration (r = - 0.358,P < 0.05 ).The eNOS activity level in platelet of the AD patients was (0.040 ±0.016) nmol·108pt-1·min-1 ,significantly lower than that of the controls [ (0.050±0.023) nmol·10-8pt-1·min-1 ,p <0.05].The iNOS activity level of the AD patients was (0.037±0.016) nmol·108pt-1·min-1 ,not significantly different from that of the controls [ (0.043±0.021 ) nmol · 108pt-1 · min-1 ,P > 0.05 ].In the AD group,the platelet-derived nitric oxide level was positively correlated with the activity level of eNOS ( r = 0.326,P < 0.05 ).There were no significant differences in platelet aggregation,NO concentration,and eNOS,iNOS,and total NOS activity levels between the mild and moderate AD patients.Conclusion The decline of eNOS activity that reduces the NO concentration of platelet may increase the platelet aggregation in the AD patients,since NO can inhibit platelet aggregation.Anti-platelet drug and NO promoting drug may be used to treat AD.

Objective To conclude clinical character and treatment strategy of lower extremity arterial occlusive disease with Crohn's disease.Method A female patient suffering lower extremity arterial occlusion and Crohn's disease was admitted to Peking Union Medical College Hospital in 2007.The other 8 similar cases with clinical details were found through a comprehensive liberature search from 1966 to 2007.Clinical characters of these 9 cases were concluded.Results All the cases were less than 50 years old and mostly female (8/9).Arterial occlusions occurred in either active (5/9) or inactive (4/9) stage of CD.Besides the arteries of lower extremities,other arteries could also be involved such as aorta,iliac artery,renal artery or mesentery artery.7 cases had atberosclerotic arteriographic findings (4 had aortic artery plaques and 6 had iliac artery stenasis).Embolectomy or thromboendarterectomy were mostly performed.4 cases (44.4% ) had recurrent lower limb iscbemia.Conclusions Arterial occlusive disease is a rare extraintesinal manifestation of CD.A thorough inspection of aorta is necessary.Embolectomy is mostly preferred.Anticoagulation treatment is highly recommended after the operation.

Objective To investigate the effects of ulinastatin (U) on coagulation,platelet function,and postoperative bleeding in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB).Methods Thirty-six selective patients undergoing CABG with CPB were randomly assigned to two groups:Group U (n = 18) in which ulinastatin 4 × 106 U in 100 ml normal saline (NS) was infused intravenously for 30 min since skin incision with 4 × 106 U added to the CPB pump prime,and then 2 × 106 U of ulinastatin was infused intravenously at a rate of 4-6 × 104 U · h-1 until the chest was closed; and control group (Group C,n = 18) in which 100 ml NS was infused without ulinastatin.Peripheral blood samples were collected 1 rain before operation (T0 ),1 min before heparinization ( T1 ),at the end of operation ( T2 ),6 hour after operation ( T3 ),and 24 hour after operation ( T4 ).Platelet membrane glucoprotein Ⅱ b/Ⅲ a (GP Ⅱ b/Ⅲ a) and platelet α granule membrane protein-140 (CD62p) were measured by flow cytometry.Activated partial thromboplasin time ( APTT),activated coagulation time of whole blood (ACT),prothrombin time (PT),fibrinogen,and platelet number were also measured.Postoperative blood loss and aUogeneic transfusion were recorded.Results There were no statistical differences in CD26p,GP Ⅱ b/Ⅲ a,and PT between the 2 groups ( all P > 0.05 ).The APTT levels was significantly shortened in Group U at T1,T3 and T4 compared to T0.The APTT levels of Group U from T1 to T4 were all significantly lower than those of Group C ( all P < 0.05 ).The ACT levels after heparinization and during CPB in Group U were significantly shorter than those of Group C ( all P < 0.01 ),and the amount of added heparin during CPB of Group U was significantly higher than that of Group C ( P < 0.01 ).There were not significant differences in platelet amount,fibrinogen,total amount of blood loss in 24 h after operation was 960 (420,1500) ml in group C,and 850(380,1600) ml in group U (P>0.05).The platelet count,CD26p,GP Ⅱ b/Ⅲa,total amounts of blood loss and blood infusion 24 h after operation,and hemoglobin concentration between these 2 groups ( all P > 0.05 ).Conclusion Ulinastatin shortens the APTT and ACT after heparinization,increases the dose of heparin during CPB,has no effect on the expression of GP Ⅱ b- Ⅲa and CD62p,and does not reduce postoperative blood loss.

Objective To explore the feasibility of combining human patient simulator (HPS) drivers with micro-division teaching during primary resident training by George Miller' medical education step-wised principle of goal and competence.Method The 20 residents from department of anesthesia who are less than 3 years in clinical training were randomized into two Groups.The all residents in Group T received HPS training,and no HPS training in Group N.In simulation system,we designed 8 programmed critical and emergency events.We disassembled and quantified the programmed design and training process with Micro-division teaching principle.The training mode was run by test-feedback-self-analysis-instructor guide-summarize-re- practice-retest The feedback assessment from all residents were collected after finishing HPS training.Results The training score in Group T was much higher than Group N (P <0.05 ).Conclusions The training mode with HPS is an accessory teaching means because it can improve clinical thinking and skill training of primary resident.

Laminin (LN), also known as type IV collagen matrix, is a non-collagen glycoprotein in the extracellular matrix, which exists in the basement membrane of many tissues. The existing data show that LN is the medium of cell-matrix adhesion, and the adhesion of LN to cells is accomplished by laminin receptor [1-2].

Parkinson's disease (PD) is a common chronic progressive neurological variable disease, which has attracted much attention because of its high incidence and disability rate and heavy economic burden in middle-aged and elderly people.

A 45-year-old male was admitted to the hospital on August 19, 2005 because of "transient diplopia for half a year, paralysis of both lower limbs, urinary and stool disorders for 2 months, deafness and visual loss for 1 month". 　　

A 16-year-old male was admitted to hospital in January 2005 due to fever 5 months after bone marrow transplantation. The patient was diagnosed with acute myeloid leukemia M2 by bone marrow imaging in December 2003 due to fatigue and fever, and reached complete remission after chemotherapy. 　　

A 56-year-old female complained of chest tightness and shortness of breath after activity for 30 years, aggravated for 2 years. Physical examination showed that heart rate was 80 beats/min, heart rhythm was uniform, systolic murmur of grade 3/6 and diastolic murmur of moderate loudness could be heard in the mitral valve area, and mild diastolic murmur could be heard in the accessory aortic valve area.

A 17-year-old female was found to have right chest wall deformity after birth, lateral depression of chest wall, anterior bulge, and thick lumbosacral hair. With the increase of age, the chest wall deformity gradually became obvious. In the past 2 years, she suffered from low back discomfort after movement, accompanied by shortness of breath, and decreased conscious mobility endurance. She went to the local hospital for treatment in July 2007, considering congenital deformity of chest wall, but no treatment was given.