Volume 90  ·   Issue 15  ·  2010

Hemorrhagic stroke is a kind of sudden cerebrovascular event that seriously threatens the life and health of our people.<Cerebrovascular disease has become the first cause of death among Chinese residents in the third retrospective sampling survey report, among which the damage caused by stroke is not the most important.

：Objective To describethe clinical manifestations of intracranial aneurysm in children and to evaluate theefficacy and safety of difierent therapeutic approaches for children with intracranialaneurysms.Methods Clinical data of 23 pediatric patients with intracranial aneurysmsdiagnosed and treated at our hospital over the past 18 years were retrospectivelyreviewed.Follow-up data were also collected and analyzed.Results Two patients received nofurther treatmenL Surgery was performed in 16 patients.Among them,15 achieved an excellentrecovery and 1 died.5 patients were treated with Guglielmi detachable coil(GDC).Aneurysmwag successfully sealed off in one case and an excellent recovery achieved:remnantaneurysm was detected in two cases.One received trapping while another underwentaneurysmectomy.The patient died postoperatively.Another received neck clipping andresection.And the patient recovered well;two cases experienced aneurysm recanalizationafter interventional therapy.Among them,one received a second embolotherapy but it becamerecanalized again.And it Was finally cured by aneurysmectomy.Conclusion Aneurysm surgeryis proved to be a safe and effective treatment for children with intracranialaneurysm.Endovascular treatment of intracranial aneurysms with GDC is also shown to beeffective and safe for pediatric patient with acute SAH.But a long-term follow-up study iSrequired to determine the clinical outcome.Once a aneurysm remnant or recanalizationoccurs,a microsurgical management is recommended.

Objective To evaluate the feasibility and efficacy of minimally invasive keyhole approach for the treatment of posterior circulation aneurysms.Methods Twelve posterior circulation aneurysms were treated via the keyhole approach.Aneurysms were located in basilar artery(BA)in 6 patients(1 in BA bifurcation,3 in BA-SCA[superior cerebellar artery],1 in BA-PCA[posterior cerebral artery],1 in PCA-BA-SCA),in PCA in 5 patients(1 in PCA1-2 segment,2 PCA2 segment and 2 PCA23 segment)and in PICA[posterior inferior cerebellar artery]in 1 patient.The supraorbital keyhole approach Was performed in 6 BA and 2 PCA1-2 segment aneurysms,the subtemporal approach in 3 PCA2-3 segment aneurysms and the lateral suboccipital keyhole approach in one PICA aneurysm.Results Among those 12 posterior circulation aneurysms,9 aneurysms were completely clipped,2 thrombotic PCA2-3 segment giant aneurysms trapped with thrombectomy,one gourd-shaped aneurysm in PICA incompletely clipped with no recurrent hemorrhage in during a 6-month follow-up.No intraoperative rupture of aneurysms occurred in any operation.All patients were discharged without neurological deficits.Conclusion Anterior or posterior clinoid process may be drilled off under the keyhole approach to increase the manipulating space while clipping the posterior circulation aneurysms.Controlling the proximal parent artery by balloon catheter increases the operative safety.Neuronavigation is helpful in rapidly locating the distal PCA aneurysm.The individualized keyhole approaches can be applied feasibly and effectively for the treatment of posterior circulation aneurysms.

objective To examine the influence of flow diverter on the alterations of cerebral intraaneurysmal hemodynamics.Methods One wide-necked and one narrow-necked sidewall aneurysm in curved vessels were virtually reconstructed.Pulsatile computational fluid simulations were performed on each model for hemodynamic analysis.And the flow diverters were virtually deployed tO cover the aneurismal neck with parent vessels.The hemodynamic changes in parent vessels and aneurysms after a deployment of flow diverter devices with low porosity were studied by the Fluent software.Results After a deployment of flow diverter,the hemodynamics in aneurysm sac changed significantly.The peak velocity and wall stress strength in impingement zone of narrow-necked aneurysms decreased after the placement of a flow diverter.And similar change also occurred in wide-necked aneurysms,but with a less decreased span.Conclusion Numerical simulation confirms that a flow diverter with low porosity significantly may modify the hemodynamics in aneurysms.Which is important for prevention of blieding or rebleeding of intracranial aneurysm.

Objective To evaluate the feasibility and safety of endovascular treatment of ruptured and unruptured intracranial very small aneurysms(≤3 mm in maximal diameter).Methods Forty-eight intracranial very small aneurysms in 44 patients treated with endovascular therapy from June 200l to August 2009 were reviewed retrospectively in clinical,imaging,interventional and follow-up data.Among 44 patients,there were 20 males and 24 females with a mean age of 57.8 years old.The Hunt-Kosnik grade Was as follows:Grade O(n=11);Grades Ⅰ& Ⅱ(n=23);Grades Ⅲ & Ⅳ(n=9);and ungraded(n=1).The sizes of 48 aneurysms were not more than 3 mm in maximal diameter.The locations of aneurysms were as follows:ACoA(n=11),MCA(n=8),PCoA(n=14),ICA(n=12),pericallosal artery(n=1),VA(n=1)and PICA(n=1).Thirty-nine aneurysms were embelized with coil,of which 13 with stent assistance and 6 by balloon remodeling technique.The other 9 aneurysms underwent sole stent placement in parent artery.Results Among 39 coiling aneurysms,100% occlusion wag achieved in 9 aneurysms,90% in 20.80% in 9 and less than 80% in 1 respectively.Only one aneurysm ruptured during coiling.Two patients had transient hemiparesis and one patient had ataxia caused by bilateral cerebellar infarction postoperatively.All patients were clinically followed up for 4-90 months and no recurrent hemorrhage occurred.Thirteen patients received repeat angiography at 4-72 months post-treatment.And no radiological re-growth Wag detected.Conclusion Endovascular treatment of ruptured and unruptured intracranial very small aneurysms seems to be technically feasible,relatively safe and practically effective.

Objective To get the general situation of the cerebral amyloid angiopathy(CAA)incidence in spontaneous intracranial hemorrhage(SICH)patients receiving surgical treatment in Chinesepeople.Methods During the period May 2008 and March 2009,105 patients admitted to 30 hospitals throughout China for acute SICH were studied,including 68 male and 37 female mean aged(55±13).The patients were suffered from SICH proved by computed tomography scan(CT).Emergent craniotomies for hemorrhage evacuation were performed for these patients within 72 h after hemorrhage onset and brain tissue of the cortex was also obtained meanwhile.A further histological study,Congo red stained and Aβ immunochemistry included was followed to verify the existence of CAA.Result Fifteen out of the 105 cases is identified as CAA positive,and the total ratio is 14.29%.As to age groups,about 20.83% (5/24)of the cases of the 40-49 years old group have been diagnosed as CAA,17.14%(6/35)of the 50-59 years old group,4.17%(1/24)of the 60-69 group,and for those older than 70 years,the ratio is 8.00%(2/25).Conclusion We come to the conclusion that 14.29% of the surgically treated SICH events might be closely related to CAA.

Objective To discuss the value of spiral CT in diagnosing infantile intestinal malrotation.Methods The spiral CT findings and clinical data of 23 cases of operatively-confirmed infantile intestinal malrotation were retrospectively analyzed.Results Twenty-three cases of infantile intestinal malrotation were all diagnosed by SCT and confirmed by surgery.The main findings were as follows:whirlpool or concentric circle sign in mesenteric root with midgut volvulus(n=16);duodenum assumed as "Z" or olecranon spur sign(n=18);inverted transposition or vertical arrangement of superior mesenteric artery and vein(n=13);abnormal sign of ileocecal junction and colon in fight lower quadrant(n=23).Conclusion Spiral CT scanning has an important value in the early diagnosis of infantile intestinal malrotation.

Objective The incidence and treatment regimen for deep venous thrombosis(DVT)in hospitalized children in China are rarely reported.This report was to assess the incidence,risk factors and treatment strategy for deep venous thrombosis(DVT)among hospitalized children admitted to the First Affiliated Hospital,Sun Yat-sen University,a single tertiary-care hospital.Methods In twenty years between 1989 and 2009,12 DVTs in hospitalized children(＜17 years old)were identified in this hospital.Clinical data were retrospectively reviewed.Results The incidence of DVT in hospitalized children was low,however,it demonstrated increasing trend from 0.52 per 10 000 admissions between 1989 and 1999 to 3.18 per 10 000 admissions between 2000 and 2009 in this hospital Infection and trauma were the mostly frequent causes of DVT in hospitalized children.The catheter-related DVT was increasingly prevalent cause for DVT in hospitalized children.The other causes included nephritic syndrome,tumor,systemic lupus,and congenital plasma C protein deficiency.Two patients were complicated with pulmonary embolism.Only one neonate died due to kernicterus.Anticoagulation therapy was the first recommended treatment choice in hospitalized children with DVT,especially more low-molecular-weight heparin in recent 10 years.Antithrombotic treatment was used in 9 children older than 30 days through peripheral venous access,its application should be meticulously cautious in dosage.No bleeding occurred in all the patients.Conclusions Cautions should be given to DVT among hospitalized children due to its increasing incidence and special treatment pattern compared with adult patients.

Objective To study the effect of arthroscopy debridement for adolescent ankylosing spondylitis(AS)with early hip-joint disease.Methods A total of 22 cases(26 hips)of adolescent AS were recruited.There were 15 males and 7 females.The distribution was as follows:left side(n=10),right side(n=8)and bilateral(n=4).The average age was 16(14-19)years old.The procedures included adhesion relief of hip joint,removal of hyperplasic synovial membrane,degenerated cartilage debris and repairing exfoliated debris or exposed subchondral bone on hip joint.Results All patients were followed up for an average of 26(6-84)months.Most patients experienced pain relief,restored function and the range of motion.According to Harris hip joint score and VAS pain score evaluation system,the outcomes were excellent(n=6)fair(n=14)and poor(n=2).There was no case of total hip replacement.Conclusion Arthroscopic debridement for adolescent ankylosing spondylitis with early hip joint disease is effective to improve joint motion and relieve pain.

Objective To investigate the independent risk factors for cerebral infarction so as to provide a theoretical basis for the prevention of cerebral infarction after total hip arthroplasty.Methods A retrospective analysis of 571 patients for hip arthroplasty was conducted from January 2003 to September 2008.Twenty-three patients were found with cerebral infarction postoperatively.Single-factor and multi-factor correlation analyses were tested for the patients with cerebral infarction after hip arthroplasty.Results The single-factor analysis for hip arthroplasty revealed that age(P=0.001)and femoral neck fracture(P=0.008)were the main factors for cerebral infarction.Furthermore,age was considered a risk factor for cerebral infarction after hip arthroplasty in multi-factor analysis(P=0.029,OR=1.054,95% CI:1.005-1.105).Conclusion Advanced age(＞70 yr)and femoral neck fracture are the main independent risk factors for cerebral infarction after hip arthroplasty.

Objective To explore the best surgical fusion level for adolescent idiopathic scoliosis (AIS)of PUMC Ⅱ d_2 with finite element model(FEM).Methods FEM(T_5-S)of PUMC Ⅱ d_2 idiopathic scoliosis wag used to simulate upper thoracic curve,lower lumbar curve and double curve fusion manners.The pedicle of concave vertebral arch received 50,100 and 150 N load respectively.Displacement of T_5 and T_(11) on upper sagittal plane(displacement of Z axis positive value on upper sagittal plane,displacement of negative value on lower sagittal plane)and their different values were compared.T_5 displacement represented the outcomes of double curve orthopedics.T_(11) displacement represented the outcomes of lower lumbar curve orthopedics.Their difference(T_5-T_(11))represented the outcomes of upper thoracic curve orthopedics.Different fusion segments and displacement of T_5 and T_(11) under different orthopedic forces were measured.Results In PUMC Ⅱ d_2 lateral curvature,T_5 displacement on Z axis:fusion displacement of double curve wag greater than the upper or lower curve alone(F=8,P＜0.01).Difference of T_5-T_(11) displacement:double curve orthopedics ＞upper thoracic curve orthopedics alone ＞lower lumbar curve orthopedics alone(F=8,P＜0.01).Displacement of T_(11) on Z axis:double curve orthopedics ＞lower lumbar curve orthopedics alone ＞upper thoracic curve orthopedics alone(F=8,P＜0.01).Conclusion Fusing two curves achieves the best effect on the AIS of PUMC Ⅱ d_2 in comparison with upper or lower curve fusion alone.Effects of 3 kinds of load on correction of upper thoracic curve:double curve orthopedics ＞upper thoracic Curve orthopedics alone ＞lower lumbar curve orthopedics alone.Effect of 3 kinds of load on correction of lower lumbar curve orthopedics alone:double curve orthopedics ＞lower lumbar curve orthopedics alone ＞upper thoracic curve orthopedics alone.Three-dimensional finite element analysis is an effective method to analyze the biomechanics of scoliosis deformity correction and provides a virtually noninvasive verification manner.And it may optimize the surgical protocol.

：Objective To evaluatethe outcome of cancellous bone grafting plus iliac cancellous bone in the treatment ofnon-traumatic avascular talar necrosis.Methods Twenty patients,14 males and sixfemales,eight at stage Ⅱ,ten at stage Ⅲ and three at stage Ⅳ according to the modified Ficat & Arlet necrosisclassification system,were treated with vascularized bone flap from January 2000 to June2005.Results All patients were followed up for a mean of 37 months(range:14 to 68months).The clinical function outcome evaluated by Kenwright criteria were excellent in 8cases,good in 10 cases,fair in 1 case and poor in 1 case.Clinical symptom Was completelyor partially relieved.The necrotic area was fiIled with newly formed bone and theexcellent-to-good rate was 90%.Conclusion Transposition of vascularized cuneiform boneflap plus iliac cancellous bone grafting may be an ideal therapeutic method fornon-traumatic avascular talar necrosis.And the clinical outcome is satisfactory.

Objective To investigate the expressions of NF-κB and TNF-α in lumbar spinal cord in a rat model of chronic constrictive injury(CCI).Methods Seventy-six male SD rats were randomly divided into 2 groups(n=38 each):CCI group receiving chronic constriction injury and sham group receiving sham operation as control.The mechanical and thermal nociceptive thresholds were assessed with paw withdrawal latency(PWL)to von Frey filaments and radiant heat at difierent time points.Five animals were sacrificed at each time point for real-time polymerase chain reaction(real-time PCR)and another three animals sacrificed at 7 d post-operation for double-immunofluorescence histochemical staining.Lumbar segments of spinal cord were removed.The expressions of NF-κB and TNF-α in spinal cord were examined by real-time PCR and double-immunofluorescence histochemical technique.Results The post-operative thresholds to mechanical and thermal stimuli decreased obviously.As compared with contralateral side and sham group,the expressions of NF-κB and TNF-α mRNA increased significantly in ipsilateral spinal dorsal horn.Their expressions began to increase at 4 d post-operation and peaked at 7 d.Then TNF-α began to decrease while NF-κB maintained at a high level throughout the experiment.Double-immunofluorescence histochemical staining revealed extensive co-localization of NF-κB with TNF-α on ipsilateral side of dorsal horn.Conclusion The activation of NF-κB and its downstram inflammatory mediators may be involved in the regulation of neuropathic pain.

Objective To clone the sequence of mutation type GJA8 gene(mGJA8)and wild type GJA8 gene(wGJA8)of a congenital inherited nuclear cataract family and study their expression in eukaryotic cell lines in vitro.Methods The mGJA8 and wGJA8 were amplified from this family's DNA and healthy people's DNA by PCR respectively.The mGJA8 and wGJA8 were recombined with plasmid pEGFP-N1 respectively.The accuracy of pEGFP-N1-GJA8 was confirmed by restriction enzyme digestion and DNA sequencing.Finally pEGFP-N1- mGJA8 and pEGFP-N1- wGJA8 and GFP protein were transfected into COS7 cells by lipofectin.The expression of pEGFP-N1-GJA8 and GFP fusion protein were to observe under fluorescence microscope,and to detecte by Western-blotting and Immunohistochemical staining.Results The mCJA8 and wGJA8 were cloned successfully.With restricting enzyme digestion analysis and DNA sequencing,recombinant plasmid pEGFP-N1-mGJA8 and pEGFP-N1-wGJA8 were constructed correctly and their GFP fusions were expressed in transfected COS7 cells.The expression of pEGFP-N1-mGJA8 and pEGFP-N1-wGJA8 fusion protein were observed under fluorescence microscope,and detected by Westernblotting and lmmunohistochemical staining successfully.Conclusions The mGJA8 gene and wGJA8 gene are cloned successfully,and pEGFP-N1-mGJA8 and pEGFP-N1-mGJA8 fusion protein Can be expressed in COS7cells,which establish the foundation for further studying the mechanism of this congenital inherited nuclear cataract family.

Objective To investigate the infective efficiency of Ad5/EGFP versus AdF35/EGFP to rat bone marrow mesenchymal stem cells(rBMSC)and understand its mechanism.Methods rBMSC were isolated from rat bone marrow by density gradient method.The expressions of CD90,Cd29,CD44,CD34,CD11b and CD45 on the surface of rBMSC were measured by flow cytometry.The EGFP-carrying Ad5 and AdF35 were infected into rBMSC respectively.The effect of Ad5/EGFP and AdF35/EGFP with different MOIs to rBMSC was tested by MTT.Infected rBMSC were observed by fluorescence microscopy.The infective efficiency and mean fluorescence intensity were determined by flow cytometry after a cellular infection for 1-9 days.The expressions of CAR and CD46 on rBMSC were measured by real-time PCR.Results The expressions of CD90,Cd29 and CD44 on rBMSC were positive while those of CD34,CD11b and CD45 were negative.When MOI ≤1600 and ≤1000,Ad5/EGFP and AdF35/EGFP could not inhibit the growth of rBMSC respectively(t=3.12,P=0.052;t=2.20,P=0.15).RBMSC with EGFP expression could be observed under fluorescence microscope after a 1-day infection by Ad5/EGFP.The number of observed cells peaked after an infection for 2-3 days and then decreased gradually.And a few cells could be still observed for 9 days.Fewer cells could be observed after an infection by AdF35/EGFP for 1-9 days.The infective efficiency of Ad5/EGFP was significantly higher than that of AdF35/EGFP(t=2.45,P=0.008).There was a high expression of CAR on rBMSC.The expression of CD46 was quite low.There was significant difference between them(t=2.57,P＜0.01).Conclusion The infective efficiency of Ad5/EGFP is significantly higher than that of AdF35/EGFP.It may explain the expression patterns of CAR and CD46 on rBMSC.AdF35 iS not a suitable gene-carrying vector to infect rBMSC.Yet Ad5 can be an efficient vector carrying target gene to infect rBMSC for curing diseases.

Medical records: A 59-year-old female was admitted to hospital on February 1, 2009, mainly due to progressive walking instability accompanied by intelligence decline for 3 months and aggravation for 1 month. Accompanied by the decline of intelligence, playing mahjong is getting worse and worse until it can't play at all, and there has been an illusion, taking toilet paper as a cup to receive water; He was accompanied by vague speech, dysphagia, and once complained of blurred vision. The symptoms progressively aggravated. One month ago, he could not walk, could not hold objects with his left hand, had difficulty lifting his left upper limb, and sometimes had incontinence.

Stroke is one of the main diseases that threatens human health worldwide and leads to death and disability ~ ([1]). With the improvement of national living standards, the change of lifestyle and the prolongation of average life expectancy, the incidence and mortality of stroke are increasing. At present, there is no other effective treatment except plasminogen activator.

Perioperative hemorrhage in neurosurgery mainly refers to hemorrhage or rebleeding at the surgical site caused by various reasons. In severe cases, it can lead to increased intracranial pressure and cerebral edema, and in critical cases, it can cause central respiratory and circulatory failure, cerebral hernia, and even life-threatening. Therefore, effective prevention and treatment of perioperative hemorrhage and rebleeding is very important for improving the curative effect and reducing surgical complications. In order to improve the prevention and treatment level of perioperative hemorrhage in neurosurgery, the Neurosurgery Branch of Chinese Medical Association invited many experts from the departments of neurosurgery, hematology and anesthesiology in China to make several discussions.<Expert Consensus on Prevention and Treatment of Perioperative Hemorrhage in Neurosurgery>, which aims to improve neurosurgeons' understanding of perioperative hemorrhage and make its prevention and treatment more systematic, comprehensive, effective and standardized.

Because of the high incidence rate and great harm of glioma ~ ([1]), there are different views on the diagnosis and treatment of glioma in various hospitals in China, and the diagnosis and treatment behavior is very irregular, which seriously affects the overall diagnosis and treatment effect of glioma in China, especially malignant glioma<Chinese Consensus on Diagnosis and Treatment of Malignant Gliomas of the Central Nervous System>~ ([2]) (hereinafter referred to as<Consensus>), hoping to take this opportunity to promote and popularize it to the whole country.