Volume 90  ·   Issue 05  ·  2010

Brain tumor is one of the ten common tumors in human body. Because the tumor grows in the cranium, it is not only difficult to operate, but also harmful, with a high rate of disability and death. In this issue, five papers on brain tumor have been published, which involve the surgical approach and technique of brain tumor, postoperative complications, cognitive and memory function assessment, and the application research of brain tumor stem cells, etc., which generally reflect the current situation and level of surgical treatment and research of neurotumor in China.

Objective To investigate the expressions of putative brain tumor stem cell (BTSC) marker CD133, Nestin and blood vessel endothelial cell marker CD31 in 65 cases of formalin fixed paraffin embedded gliomas. The relationship of BTSC distribution with micro-blood vessels was analyzed using morphometry. Methods (1) The expression levels of Nestin and CD133 proteins were detected using SABC immunohistochemical analysis. Then we calculated the percentage of CD133~+ cells, CD133~+ blood vessels,Nestin~+ cells and Nestin~+ blood vessels among 65 tumors, grade Ⅱ(n=18), grade Ⅲ(n=23) and grade Ⅳ (n=24), according to WHO 2000 classification of nervous system tumors. (2) Double immunofluorescence staining was used to detect the co-expressions of CD133/CD31, CD133/Nestin and Nestin/CD31. Then the correlation of two different marked cells with the corresponding positive vascular endothelial cells were determined. Results CD133~+cells and Nestin~+cells could be observed in all glioma tissues. Furthermore they could also be observed expressing in the endothelial cells. In low-grade group,there were fewer CD133~+ blood vessels or Nestin~+blood vessels in the regions which CD133~+ cells or Nestin~+ cells distributed compared with the high-grade group. The CD133~+/CD31~+ and Nestin~+/CD31~+ cells could be found co-expressed in the endothelial cells by using double immunofluorescence staining.Positive correlation was observed between the CD133~+cells and CD133~+ blood vessels(r=0.945, P < 0.01). It was similar to the correlation between the Nestin~+ blood vessels and Nestin~+ cells (r=0. 727,P<0.01). Conclusion In gliomas, the endothelial cells express brain tumor stem cells markers.Therefore the capillaries in gliomas may come from the differentiation of BTSCs. And the BTSCs are accumulated around the capillaries. Along with the rank of tumor grades, positive correlation is observed between CD133~+ cells or Nestin~+ cells with the corresponding blood vessels.

Objective To analyze the effects of intracranial tumors and tumor resection on patients' memory functions. Methods Four different memory scales were employed to evaluate 58 intracranial tumor patients' memory functions including short-term memory, delayed memory, clue memory and long-term memory. Thirty-five patients received postoperative follow-ups. There were also 18 healthy controls. Results The extra-cerebral tumor patients presented with delayed memory and long-term memory disorders while intra-cerebral tumor patients suffered from short-term, delayed and severe long-term memory disorders.Patients with dominant hemispheric tumors had more serious memory disorders in all types. Scores obtained after surgery showed an aggravated long-term memory disorder. Sellar region tumors and transsphenoidal tumor resection had no effects upon memory functions. Conclusion Intracranial tumors cause memory disorders. Tumors with different locations and characters have different memory impairments. Intra-cerebral tumors result in more severe memory impairment than extra-cerebral tumors. And dominant hemispheric tumors are worse than non-dominant hemispheric tumors. Tumor resection decreases long-term memory functions.

Objective To identify the causes and risk factors of postoperative complications in elderly patients receiving meningioma removal. Methods A total of 320 elderly patients received meningioma removal at our hospital between 1998 to 2007. Among them,90 patients, aged 65 to 82 years old, developed postoperative complications. Results The diagnoses were confirmed by pathological findings. The average diameter of tumors was 5 cm. The average operative duration was 4.8 hours. Local or systemic complications occurring in this group of patients included new-onset neurological deficit (n=37),prolonged coma (n=16), central nervous system infection (n=14), postoperative hematoma (n=10),cerebral infarction (n=7), CSF leakage (n=12), pulmonary infection (n=18), deep vein thrombosis or pulmonary embolism (n=15), gastrointestinal bleeding (n=3) and myocardial infarction (n=2).Twelve patients died within 30 days after operation. Postoperative complications prolonged hospitalization and increased medical costs. Conclusion Large size of tumors, difficulties in resection and preexisting conditions are primary causes of a high rate of operative morbidity in elderly patients receiving meningioma removal.

Objective To analyze the clinical features, surgical strategy and management outcomes of petroclival meningioma invading into cavernous sinus. Methods Fifteen cases with petroclival meningioma invading into cavernous sinus were retrospectively analyzed. The presigmoidal approach was selected to remove tumors. The surgical strategy for tumor in cavernous sinus was partial resection combined with radiosurgery. Postoperative cranial nerve function and patient survival status were analyzed. Results The main symptoms of subtype of petroclival meningiomas were headache, abducens nerve palsy and trigeminal neuropathy. Gross total tumor removal was achieved in 13 cases and more than 90% resection in 2 cases. There was no operative death. Nine cases suffered from new postoperative cranial nerve deficits. After a follow-up of 6-59 months, complete improvement was achieved in oculomotor nerve deficits, much improvement in Ⅶ nerve deficit, but Ⅴ and Ⅵ nerve function deficits improved slightly. The tumor progression-free survival rate was 86.7%. Conclusion Rational surgical strategy to petroclival meningiomas invading into cavernous sinus should be suggested to reduce the operative morbidity and improve the survival quality of these patients.

Objective To explore the clinical features, surgical approaches and outcomes of craniopharyngiorna in adults.Methods A total of 156 cases of adult craniopharyngioma underwent microsurgery at our hospital were retrospectively reviewed and classified into four types according to the location of tumor relative to sellar diaphragm and the third ventricle. They were divided into four groups: intrasellar type (n=6), suprasellar & extraventricular type (n=59), intraventricular type (n=63) and mixed type (n=28). Unilateral subfrental approach was chosen in 9 cases, anterior interhemispheric approach in 14 cases, pterional approach in 102 cases, transcallosal approach in 28 cases and transsphenoidal approach in 3 cases. Results Tumors were totally removed in 124 cases (79.5%),subtotally removed in 25 cases (16%) and partially removed in 7 cases (4.5%). Two patients died after surgery. Pituitary stalk was identified and protected intraoperatively in 69 cases, and postoperative diabetes insipidus occurred in 109 cases. The follow-up period ranged from 3 months to 5 years. 75. 3% of the cases were capable of normal work and life and tumor recurred in 26 cases. Conclusion Selection of appropriate approach is the key to successful micresurgery for craniopharyngioma according to the site and growth pattern of tumor.

Objective To retrospectively analyze the causes and treatment of distant pain after thoracolumbar compressive fracture. Methods The investigators retrospectively analyzed 14 cases of thoracolumbar compressive fracture with distant pain,observed the pain region and its relationship with thoracolumbar compressive fracture and administered the treatment of pain. Results There were 14 cases of thoracolumbar compressive fracture with lumbarsacral pain whose painful region were located in paravertebral muscles (n=6),near iliac crest (n=5) and in hypochondrium (n=3). Five and 7 cases of pain disappeared after vertebroplasty and local injection respectively and 2 cases were relieved with analgesics.Eighteen patients with throcolumbar vertebrae fractures (T11-L2) were fixed with short segment pedical screw fixation,the instrumentation removed at 1 year post-operation and their Cobb's angle and trauma vertebra height measured from 0. 5-2 years after instrumentation removal. Conclusion The cause of distant pain after thoracolumbar compressive fracture maybe be related with radiating pain resulting from irritated nerves in the vertebral fracture region or distant soft tissue pain. A timely pain treatment can relieve the patients' symptoms.

Objective To investigate the epidemiological features of patients with pelvic fractures. Methods The data of patients with pelvic fractures treated between 2003 and 2007 at our hospital were collected and analyzed through the PACS system and case reports checking system. And analytic items included gender,age,injured sites and type of AO or Young-Burgess classification. Results A total of 1953 pelvic fractures including 917 males and 930 females were selected and 379 patients hospitalized. The high-risk age of all patients was between 31 and 40 years old. And 81 cases were combined with acetabular fractures and 312 cases other parts fracture. The 61-A type fractures are the most common type fractures of AO classification including 766 males and 853 females. The 61-A2 fracture was one of the most common subtype fractures including 562 males and 433 females.In the Young-Burgess classification,the most common fracture was of APC type including 119 males and 70 females. The APC-I fracture was the most common subtype fractures including 68 males and 41 females. Conclusion The current investigation has implied the epidemiological features of pelvic fractures treated between 2003-2007 in our hospital.

Objective To assess the effect of modified cervical expansive open-door laminoplasty preserving the posterior extensor musculature inserted into the C2 and C7 spinous process upon maintaining the cervical lordotic alignment and axial syndrome and to determine whether preserving the posterior extensor musculature inserted into C2 and C7 spinous process can reduce the complications. Methods Twenty-eight patients undergoing modified cervical expansive open-door laminoplasty preserving the posterior extensor musculature inserted into the C2 and C7 spinous process and 21 patients undergoing conventional C3-C7 cervical expansive open-door laminoplasty were investigated in pre-operative,post-operative and 3-month follow-up. The investigators assessed the effects of two different cervical laminoplasty types in the recovery rate of JOA score,the changes of Cobb angle and Ishihara's index,axial syndrome,operating duration and intra-operative blood loss,analyzed the results in SPSS and tried to find the difference in two operative types. Results There were the same results in the recovery rate of JOA score and intra-operative blood loss in modified expansive open-door cervical laminoplasty group and the conventional C3-C7 cervical expansive open-door laminoplasty group. The smaller changes of Cobb angle and Ishihara's index in the follow-up of modified laminoplasty group were found. The modified laminoplasty group had fewer patients suffering the axial syndrome in fallow-up.The operating duration was shorter in the modified laminoplasty group.Conclusion Preventing muscle injuries in cervical laminoplasty can reduce the incidence of complications.The modified expansive open-door cervical laminoplasty preserving the posterior extensor musculature inserted into C2 and C7 spinous process can protect cervical posterior extensor musculature. This is helpful to maintain the cervical lordotic alignment and reduce the incidence of post-operative axial syndrome.

Objective To investigate the time perception in affective disorders by using neuropsychological tests and to try to elucidate its neurobiochemical mechanism. Methods Using a time reproduction task,a comparative study was conducted for 28 depressive patients,22 manic patients,and 26 age and education level matched healthy persons as healthy controls. Results Both depressive patients and manic patients are abnormal (P<0.001),depressive patients over-rcproduced the time interval than healthy controls (600 ms/delay 1 s: 1.6±0.6,P <0.001; 600 ms/delay 5 s: 1.7±0.6,P < 0.001; 3 s/delay 1 s:3.9±0.9,P<0.001; 3 s/delay 5 s:3.9±0.7,P<0.001; 5 s/delay 1 s:5.9±1.3,P<0.001;5 s/delay 5 s:6.1±1.3,P<0.001),yet manic patients under-reproduced the time interval (600 ms/delay 1 s:0.7±0.2,P<0.01; 600 ms/delay 5 s:0.6±0.3,P<0.001; 3 s/delay 1 s:1.7±0.5,P<0.001; 3 s/delay 5 s:1.8±0.6,P<0.001; 5 s/delay 1 s:2.9±0.7,P<0.001; 5 s/delay 5 s:3.0±0.8,P< 0.001).The results of time reproduction task in patients were not related to age,education,duration of illness,number of admission (P>0.05),but had some relation to severity of illness. And the results were positively correlated with the score of HAMD in depressive patients (six times:r=0.44,0.46,0.73,0. 61,0.55,0.50,P<0.05),but negatively with the score of BRMS in manic patients (six times:r=-0.57,-0.54,-0.71,-0.69,-0.80,-0.71,P<0.05). Conclusion Emotion will affect one's time perception. And the nearotransmitter in brain may participate in the processes of time perception.

Objective To investigate the differences of cognitive function and brain volume between patients with type 2 diabetes mellitus (DM) and healthy controls.Methods Multi-dimensional neuropsychological tests were employed to evaluated cognitive function in 21 type 2 DM patients and 19 healthy controls,and voxel-based morphometry method was applied to measure volum of whole and regional gray matter in brain of these subjects. Results Compared to healthy controls [(7. 3±1.4),(22.7±1.2),(9.5±2.5) respectively],significantly impaired performance of Auditory Verbal Learning Test (AVLT)-Delay Recall,[(5.7±1.8)]AVLT-Recognition [(20. 8±2. 6)]and Clock Drawing Test (CDT) [(8.0±1.1)]and extensive atrophy of gray matter (after corrected by total intracranial volume)were observed in type 2 DM patients (P<0.05). In addition,whole gray matter/Total Intracranial Volume (TIV) was significantly negatively correlated with BMI(r=-0.352,P=0.013). And negative correlations existed between whole gray matter vs HbA1c(r=-0.309,P=0.026); the performance of AVLT-Delay Recall and AVLT-Recognition vs BMI(r=-0.398,P=0.011;r=-0.4,P=0.011)and HbA1c (r=-0.354,P=0.025;r=-0.323,P=0.042) and CDT vs HbA1c (r=-0.322,P=0.043).Conclusion Mutli-cognitive impairment was associated with the reduced volume of whole and regional gray matter in brain of type 2 DM patients,which indicated that "accelerated brain ageing" might present in type 2 DM patients.

Objective To summarize the experience of the application of stented elephant trunk procedure in the treatment of the patients with complicated Stanford type B aortic Dissection. Methods Between January 2004 and March 2009, 33 patients (27 male and 6 female) underwent stented elephant trunk implantation in the descending aorta for complicated type B dissection. Right axilary artery cannulation was routinely used for cardiopulmonary bypass and selected cerebral perfusion. The stented elephan trunk was implanted through the aortic arch under hypothermic circulatory arrest. Complications were recorded to evaluate the immediate and mid-term results. Results Cardiopulmonary bypass time was 174±29 min, and average selective cerebral perfusion and lower body arrest time was 24±9 min. The in-hospital mortality was 6. 0% (2/33). No paraplegia was observed after surgery. During follow-up CT-scans thrombus formation was observed within the descending aortic false lumen excluded by the stented graft in the acute and chronic aortic dissections. There was one death during follow-up. Conclusions The stented elephant trunk procedure could be an effective treatment for complicated type B dissection; it also could close the false lumen of the descending aorta and in preventing expansion of the descending aorta.

Objective To evaluate the manipulation and effects of continuous femoral nerve block after performing a combined spinal and epidural anesthesia. Methods 60 patients,ASA Ⅰ-Ⅱ,scheduled for elective total knee arthreplasty were randomized to PRE group or POST group (n=30 for the each).CFNB was implemented before CSEA in PRE group,while CFNB was completed after the anesthesia in POST group. After the surgery,1% lidocaine 10 ml was injected in through the catheter as the priming dose following a continuous rate of 5 ml/h of 0.2% ropivacaine. The performance time of CFNB,VAS scores,patient satisfaction and adverse effects were recorded. Results The performance time of CFNB in POST group was significantly lower than it in PRE group ((10.5±2.5) min vs (13.4±3.0) min) (P<0.05).The patient satisfaction was much higher (P<0.05),while the VAS scores was significantly lower in POST group(0.8±0.2) than those in PRE group (3.4±0.5) (P<0.05) during the performance of CFNB.There were no significant differences in VAS scores at postoperative 6,12,24,36 and 48 h,total patient satisfaction and adverse effects. Conclusion The effects of CFNB after CSEA were definitely fine with higher patient satisfaction during the manipulation. It was a better choice of performing CFNB after CSEA.

Objective To study whether using ulinastatin (UTI) during orthotopic liver transplantation (OLT) can decrease acute renal failure after liver transplantation in patients with Severe Hepatitis.Method Thirty-one patients with Severe Hepatitis undergoing orthotopic liver transplantation (OLT) were studied.They were derided into two groups: determination of serumβ_2 microglobulin(β_2 MG),BUN and Cr before operation and 24 h after operation,at the same time,urine samples were taken for determination of urine β_2 MG.Data of HR,ABPM,CVP,CO were recorded during operation.The Incidence of renal failure affiliated liver transplantation(RFALT) and prognosis of these patients were also recorded in the two groups after operation.Results (1)4 cases in group U while 10 cases in group C developed RFALT at 24 h after operation(P<0.05).In these patients who developed RFALT at 24 h after operation,4 cases were all rehabilitation discharge in group U,while in group C,2 cases died,3 cases didn't cure but required discharge,only 5 cases were rehabilitation discharge.(2)Compared with baseline before operation,serum β_2 MG,Urine β_2 MG,BUN and Cr increased significantly at 24 h after operation both in two groups,(P<0.05,P<0.01).(3)Compared with group C,serum β_2 MG,Urine β_2 MG,BUN increased significantly at 24 h after operation in group U (P<0.05,P<0.01).Conclusion Protective effects of ulinastatin during orthotopic liver transplantation on kidney function in patients with Severe Hepatitis can decrease acute renal failure after liver transplantation.

Objective To review the experience with extracorporeal membrane oxygenation (ECMO) in adult postcardiotomy cadiogenic shock and evaluate quality of life (QOL) in survivals.Methods During 4 years 62 of 12,644 patients (0.49%) undergoing cardiac surgery (valve procedures,n=39; coronary artery bypass grafting, n=13; coronary artery bypass grafting plus valve procedures, n=4;heart transplantation, n=4, and total aortic arch replacement, n=2) required temporary postoperative ECMO support. At follow-up (mean 2.3±1.5 years, 100% complete), 32 were still alive and answered the Short-Form 36 Health Survey QOL questionnaire. Results Mean duration of ECMO support was 61±37 hors. Forty patients (64.5%) were successfully weaned from ECMO. Thirty-four patients (54.8%) were discharged from hospital after 44.3±17.6 days. The in-hospital mortality was 45.2%. The main cause of death was multiple organ failure. The postoperative peak lactate levels ≥ 12 mmol/L before ECMO initiation was a risk factor of in-hospital death. Mean QOL scores between the ECMO survivors and other patients after cardiac surgery without ECMO support showed no significant difference , except that the vitality and mental health were significant lower in the ECMO survivors (P<0.05). Both the ECMO survivors and the patients without ECMO support have significant lower QOL scores (except the vitality and mental health) relative to their respective Chinese population norms (P<0.05). Conclusion ECMO offers sufficient cardiopulmonary support in adults.Early indication, reduced complication could improve results with increasing experience. However, ECMO survivors had lower physical and mental health that need to be recovered.

Objective To investigate the tropism capacity of the rat bone mesenehymal stem cells (BMSC) for hepatic tumors mieroenvironment and the effect on the form of tumor stromal. Methods Rat BMSC were isolated,cultured and expanded,then incubated with superparamagnetic iron oxide (SPIO) nanoparticles. Prussian blue stain was performed for showing intracellular irons.Walker-256 cells were injected into the rat livers directly to establish hepatic tumor models. The experiment was divided into two experimental groups(the group venous injected with BMSC after tumors boo,ruing mass: tail venous injected with BMSC after MR showed the presence of tumors at 6-8 days after operation and the group venous injected with BMSC before tumors becoming mass: tail venous injected with BMSC when MR showed no presence of tumors at 3 days after operation) and one control group. To the experimental groups animals,MRI was made before venous injection of BMSC and at 5,10,15 days after BMSC transplantation. The rats were killed at corresponding period. The pathologic examinations were analyzed,including HE,Prussian blue stain. The expression of vascular endothelial growth factor (VEGF),CD31,yon Willebrand factor (vWF) in the specimens harvested at 10 days after BMSC transplantation were detected immunohistochemically. Results Prussian blue staining of SPIO labled BMSC demonstrated cells could be effectively labeled and the labeling efficiency was almost 90%. After BMSC transplantation,two experimental groups were showed tuberculous signal intensity loss at the margin of tumors on T_2weighted MR images at 5,10 days after transplantation and the signal intensity loss was not visualized at 15 days after transplantation. The control group was not observed signal intensity decrease. Prussian blue staining of histological analysis showed blue-stained iron particles distributed at the margin of tumor at 5,10,15 days after transplantation.Immunohistochemical examination showed that the expression of VEGF,CD31,vWF in two experimental groups at 10 days after transplantation were higher than that in the control group(F=34.03,P<0.01; F=84.24,P<0.01;F=7.08,P<0.05). Conclusion Rat BMSC have the ability to migrate towards hepatic tumors in vivo and promote to form vascular endothelium.

A 29-year-old male was admitted to the hospital on October 20, 2008 due to "repeated fever for 5 months, left mouth angle skew and limb weakness for more than 2 months". The patient began to have repeated fever in May 2008, mostly around 38.0℃; Self-administration of "acetaminophen" can reduce fever. No obvious abnormalities were found in local chest X-ray and blood routine. In early July 2008, the patient had numbness on the left half of the body and face above the abdomen, abnormal sensation on the right limb, and the angle of the mouth was skewed to the right. The head CT showed "patchy low-density shadow in the right basal ganglia area".

The patient was a 65-year-old female. After an argument with her family at 10:00 a.m. on August 10, 2008, she took 68 tablets of amlodipine besylate (5 mg/tablet), totaling 340 mg, and became irritable for 1 h. After 1 h, her family discovered and sent to the emergency room. She had a history of hypertension for 10 years. She took 5 mg/d orally, and her blood pressure was controlled at 130/80 mm Hg (1 mm Hg =0.133 kPa).

The 8-year-old woman was admitted to hospital with 4 days of fever. The abdomen was flat and soft, without tenderness, and the liver and spleen were not subcostal. CT showed a round mass in the tail of pancreas with a diameter of about 2.6 cm, the CT value was about 40HU, the border was clear, and the lesion showed gradual enhancement after enhancement (Figures 1A, 1B). MRI showed a round mass in the tail of pancreas with a size of about 2.6 cm ×2.4cm, with low signal at T_1 WI, high signal at T_2 WI and STIR sequence, and moderate enhancement on enhancement scan (Figures 1C, 1D). During the operation, the mass in the tail of pancreas was closely adhered to the pancreas, easily bleeding, and the size was about 3.0 cm ×2.5cm. The mass and the tail of pancreas were removed, and the operation went smoothly.