Volume 93  ·   Issue 23  ·  2013

Since the beginning of the 21st century, modern neurosurgery has undergone revolutionary changes from the concept and equipment. Despite this, there are still great differences in various fields of neurosurgery, especially in neurosurgery critical care medicine, and there are still differences in diagnosis and treatment standards from place to place. In the past 30 years, critical care medicine has made great progress, accumulated rich experience, and saved the lives of many patients with organ failure and even multi-system and multi-organ failure. It is the goal of future development to learn from the experience and ideas of the development of critical care medicine to do a good job in the critical disease of neurosurgery. In order to popularize relevant knowledge and concepts, standardize medical behavior and improve the level of critical care in neurosurgery, the Neurosurgery Branch of Chinese Medical Association gathered a number of experts in the discipline to discuss relevant discussions, and at the same time invited domestic experts in critical care medicine, neurology, emergency medicine and other specialties as consultants and guides to jointly formulate the Expert Consensus on Neurosurgery Critical Care Management (referred to as the Consensus). Neurosurgery critical care is not only an interdisciplinary subject of neurosurgery, critical care medicine, neurology, emergency medicine, critical care and other specialties, but also an important branch of critical care medicine. Specialized, precise, targeted and multidisciplinary collaborative treatment units are the future development direction of neurosurgical critical care medicine. This consensus is mainly applicable to the treatment of critically ill adult neurosurgical patients. In view of the relevant contents involved, this consensus, under the cooperation and guidance of the Center for Evidence-Based Medicine of Peking University, adopted the evidence criteria and recommendation criteria of Oxford Center for Evidence-Based Medicine for grading (seeTable 1)。

To explore the operative strategies for bilateral brain contusion and laceration and evaluate their clinical significance.

Based on the clinical manifestations, computed tomography (CT) and intracranial pressure (ICP), different operative strategies were applied to 25 cases of bilateral brain contusion and laceration.The strategies were classified into 6 types according to the principles of decompression and brain protection.All cases received routine treatments at neurosurgical intensive care unit (ICU) ward.And the occurrences of operative complications and 6-month Glasgow outcome scale (GOS) were statistically analyzed.

Type 1:4 cases of unilateral decompressive craniectomy without resection of contusion focus; Type 2:8 cases of unilateral decompressive craniectomy with resection of bilateral contusion focus; Type 3:5 cases of bilateral decompressive craniectomy with resection of unilateral brain contusion; Type 4:5 cases of bilateral decompressive craniectomy; Type 5:1 case of bilateral brain contusion resection; Type 6:2 cases of bilateral decompressive craniectomy and brain contusion resection.Postoperative complications such as epilepsy, expanding contusion foci, brain infarction, encephalocele, incisional CSF leakage, intracranial infection, subdural hydroma and hydrocephalus were rare.The 6-month GOS revealed 6 cases of good outcome (n=6), moderate disability (n=8), severe disability (n=3) and vegetative status (n=5) and death (n=3).

Different operative strategies may be applied for severe brain contusion and laceration according to their clinical manifestations, CT findings and ICP values.And the efficacies are improved by operative strategies based on the principles of ICP control, prevention of secondary injury and brain function preservation.

To explore the clinical application of intracranial pressure (ICP) monitoring and its prognostic correlation in patients with severe craniocerebral injury.

A total of 216 severe craniocerebral injury patients with scores of Glasgow coma scale 3- 8 underwent craniotomy at Affiliated Qilu Hospital, Shandong University.And 168 cases of ICP monitoring were divided into 3 treatment groups and another 48 cases without ICP monitoring selected as the control group.According to ICP, stepwise treatment was administered to control the level of ICP and maintain the cerebral perfusion pressure to analyze the relationship between ICP monitoring and prognosis.

As compared with the control group, there were significant decreases of disability and mortality rate for patients with ICP monitoring (A, B, C group).Especially group C had a better prognosis than the other groups for statistical significance.In addition, the dose and duration of mannitol of group A, B or C were significantly lower than those of the control group (P<0.05).

The application of ICP monitoring is capable of reducing mortality, improving prognosis and enhancing success rate of treating severe craniocerebral injury.

To elucidate the effectiveness of brain tissue oxygenation (PbtO₂) plus intracranial pressure (ICP) monitoring and targeted therapy in patients of severe traumatic brain injury (TBI).

A total of 46 patients with severe TBI (Glasgow coma scale, GCS scale≤8) admitted at Jiangyin People′s Hospital from June 2009 to June 2012 were divided randomly into 2 groups and evaluated prospectively.Patients undergoing ICP plus PbtO₂ monitoring were compared with controls with ICP monitoring alone.Therapies of both patient groups were attempted to maintain an ICP<20 mm Hg and a cerebral perfusion pressure (CPP) ≥60 mm Hg.Among those with PbtO₂ monitoring, oxygenation was maintained at a level of≥20 mm Hg.The scores of Glasgow outcome scale (GOS) were compared between two groups at Month 6 post-injury.

The mean daily ICP and CPP levels were similar in each group.The mortality rate was 21.7% in patients with ICP monitoring alone and the favorable outcome rate was 47.8%.However, those receiving combined management had a significantly reduced mortality rate of 8.7% and good outcome rate of 65.2% (P<0.05).

The combined use of both ICPand PbtO₂ may be associated with reduced mortality and improved outcome in patients with severe TBI.

To explore the role of small-dose recombinant human coagulation factor Ⅶa (rFⅦa) for coagulopathy in patients with isolated traumatic brain injury.

A total of 86 isolated traumatic brain patients with coagulopathy were treated at our neurosurgery intensive care unit (NICU) from January 2010 to December 2012.Their trauma registry data included mortality, pre-and post-rFⅦa coagulation parameters.Two-tailed paired t-test was used to determine significant changes in coagulation parameters and other major clinical parameters.

Twenty-seven patients made up the low-dose rFⅦa (20μg/kg) group.And the control group had 59 well-matched subjects.At admission, age, blood pressure, Glasgow coma scale score, hemoglobin, platelets and international normalize ratio were similar in both groups.After treatment, the INR of patients on rFⅦa was lower than that of the conventional treatment group (1.1±0.2 vs 1.2±0.2,P<0.01) and it declined more in the rFⅦa group (0.3±0.2 vs 0.1±0.4, P=0.05).No significant difference existed in mortality or length of stay between two groups.There was no occurrence of subsequent thromboembolic events.

The application of small-dose rFⅦa can effectively reduce the value of INR and improve the coagulation status of patients.During the course of treatment, no major adverse events occur.

To explore the treatment outcomes of degenerative lumbar scoliosis (DLS) with selective segmental transforaminal lumbar interbody fusion (TLIF).

The clinical data were analyzed for a total of 42 cases with degenerative scoliosis from November 2008 to March 2011.There were 14 males and 28 females with a mean age of 62.4 years (range, 41-76).The indications for TLIF of motion segment included segmental instability and significant upper endplate obliquities of L3 or L4.Interbody spinal fusion was performed for 3 segments in 3 cases| 2 in 17| 1 in 22.All patients were followed postoperatively with a mean duration of 1.6 years (range, 0.5-3).The imaging examinations included Cobb angle of scoliosis and lumbar lordosis angle.The clinical symptoms were evaluated with Oswestry disability index (ODI) score.

The mean preoperative Cobb angle of 32.7°±12.4° was significantly corrected to 9.2°±5.5°at the final follow-up (t=14.86, P<0.05) with a correction rate of 71.8%.The mean preoperative lumbar lordosis angle of 25.5°±12.6° was also significantly corrected to 39.3°±8.5° (t=12.11, P<0.05) with a correction rate of 46.4%.There was significant difference (P<0.05) in ODI between preoperation (43.8±5.6) and postoperation (18.7±1.8).But no significant difference (P>0.05) existed in ODI between postoperation (18.7±1.8) and the final follow-up (23.6±2.3).And 86% of the patients showed considerable symptomatic improvement of neurogenic intermittent claudication.And clinical symptoms and functional tolerance for daily activities improved postoperatively in 92%.At the follow-up after 6 months postoperatively,all operated segments achieved fusion standard and no pseudoarthrosis formed.

Selective segmental TLIF is helpful in correcting lumbar lordosis, segmental deformity and translation.And it offers better outcomes of posterior spinal fusion for the treatment of DLS.

To explore the efficacy and safety of combined inflating lung and insufflating calf pulmonary surfactant under general anesthesia for treating postoperative intractable atelectasis.

From August 2006 to January 2013, 15 patients with obstinate postoperative atelectasis receiving pressure control lung expansion were enrolled.The bronchial cannula was intubated into the affected side to assist the expanding of the lung, and the calf pulmonary surfactant was insufflated selectively.The chest auscultation and computed tomography (CT) scan was performed at 1 d and 5 d after the procedure respectively, to evaluation the effect.The airway pressure, mean arterial pressure (MAP),heart rate (HR), respiratory rate (RR) and oxygen saturation (SpO₂) were recorded before the treatment, during the treatment and after the treatment.Monitoring arterial blood gas before and after treatment.

After the expansion of the lung and insufflation of calf pulmonary surfactants, the iconographic scan showed that collapsed alveolar was reinflated in 12 (80.0%) patients at 1 d after the treatment and in 14 patients (93.3%) at 5 d after the procedure.There were not notable vital sign change and complications during the treatment.At after the treatment, 1,3,5 and 7 d after the treatment,PaO₂was higher (P<0.05),and there were not significantly difference in the PaCO₂and pH (P>0.05).

Combined pressure control lung expansion with selectively insufflating calf pulmonary surfactant under general anesthesia may be an effective therapy for postoperative intractable atelectasis.

To discuss the feasibility of video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy for NSCLC,and to describe this treatment method and the major Indications.

Between September 2010 and December 2012, 10 patients in our hospital underwent VATS bronchial sleeve lobectomy.The patients were one female and nine males.Included 3 cases on the right upper lobe,3 cases on the right lower lobe,1 case on the right middle lobe, 2 cases on the left upper lobe, 1 case on the left lower lobe.2 cases underwent VATS bronchial sleeve lobectomy and sleeve resection of the pulmonary artery.

10 cases were finished by Video-Assisted Thoracoscopic Surgery.They all recovered well.No patient showed bronchopleural fistula, tempyema and atelectasis.There was no perioperative death.

Video-assisted thoracoscopicsurgery (VATS) lobectomy including bronchial sleeve lobectomy is therefore considered to be a feasible surgical modality for the treatment of patients with NSCLC.

To explore the diagnostic value with BI-RADS lexicon and high-frequency color doppler ultrasonic scoring for breast diseases.

A total of 108 breast lesions were studied with BI-RADS lexicon and high-frequency color doppler ultrasonic scoring,and compared with pathologic results.Calculated the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value.

Of these 108 lesions,65 (60.19%) were pathologically confirmed to be benign and 43 (39.82%) to be malignant.There were no statistically significant differences between BI-RADS lexicon and high-frequency color doppler ultrasonic scoring in the diagnosis of breast lesions (P>0.05).

Both of BI- RADS lexicon and high-frequency color doppler ultrasonic scoring have a higher value for dignosing breast disease in clinical application,and BI-RADS lexicon provides the normalized and standardized reporting data for clinical doctor in dignosing breast disease, It is more conducive to guide clinicians with correct judgment and active treatment for breast disease.

To investigate the abnormal expression of microRNAs (miR-216, miR-222, miR-181) in the serum of patients with hepatocellular carcinoma (HCC) and its clinical significance.

Serum miRNAs expression was investigated in 49 patients with HCC and 25 healthy normal controls by using real-time PCR technique,and then correlations between miRNAs expression and the clinicopathological features and prognosis of HCC patients were evaluated.

No differences were observed between the HCC patients and healthy controls with respect to the expressions of serum miR-181 and miR-216 (P>0.05), while miR-222 was found to be significantly overexpressed in HCC serum samples (6.1±6.6 vs 1.2±0.6,P<0.01).According to the median fold change of miR-222 (3-fold) in all HCCserum samples, we divided the 49 patients into two groups:a low expression group (25 patients) and a high expression group (24 patients).High level of miR-222 expression was correlated with cirrhosis (P<0.01), tumor number (P=0.013), portal vein tumor thrombosis (P=0.002) and TNM stage (P=0.020), while not correlated with serum alpha-fetoprotein level, tumor size and HbsAg.Kaplan-Meier survival analysis showed that the median overall survival in the high miR-222 expression group was significantly shorter than that in the low expression group (8.7 months vs 16.5 months, P=0.036).In multivariate Cox analysis, TNM stage and serum miR-222 expression were two independent prognostic factors.

Serum miR-222, upregulated in HCC, maybe helpful in prognosis of HCC patients.

To summarize the clinical characteristics and surgical treatment of distal posterior inferior cerebellar artery (PICA) aneurysms.

Ten consecutive cases of distal PICA aneurysms at our institute were retrospectively reviewed from June 2005 to June 2010.Among them, there were 6 males and 4 females with a mean age of 39.1 (26- 60) years.The clinical manifestations included intracranial hematoma (n=9) and mass effect (n=1).All patients had computed tomography (CT) and digital subtraction angiography (DSA) scans whilesome of them received computed tomographic angiography (CTA) or magnetic resonance imaging (MRI) examinations.All patients underwent microsurgical suboccipital craniotomy.

DSA was the main diagnostic tool.Eight patients had their aneurysms at left side and 2 at right side.The locations were at second section (n=2),third section (n=2),forth section (n=3) and fifth section (n=3).And 2 cases were associated with arteriovenous malformation at the same side.The diameters of aneurysms were 3-8.3 mm (<5 mm in 5, 5-10 mm in 5).The outcomes included clipping (n=6), trapping (n=3) and resection plus vessel anastomosis (n=1).In all cases, treatment was successful without neurological deficits.One patient had postoperative complication of intracranial infection and 1 patient with hydrocephalus underwent ventricular-peritoneal shunt.All of them achieved excellent recovery.The mean follow-up period was 4.6 years (range:2-5).None of them suffered re-bleeding.And the mean modified Rankin scale scores was 4.9.

Patients with distal PICA aneurysms may obtain excellent outcome after microsurgery.

To review the available data of randomized controlled clinical trials (RCT) to compare endovenous laser therapy (EVLT) with conventional surgery of high ligation and stripping (HL/S) for the treatment of great saphenous varicose veins.

A systematic review of Pubmed, Cochrane Library, Embase, Web of Science, Ovid database, China National Knowledge Infrastructure (CNKI) database and Wanfang database was performed to retrieve RCT studies on the effectiveness of EVLT versus HL/S up to January 1999.The rates of postoperative recurrence at 1 year, 2 years and major complications were analyzed by Review Manager 5.1 software.

Eight retrieved RCT studies and 1743 limps were evaluated.The ratios of recurrence were the same for EVLT and HL/S at 1 and 2 years post-operation.For the ratios of major postoperative complications, there was no statistical difference between EVLT and HL/S in thrombosis, wound infection and phlebitis.But EVLT could reduce the ratio of paresthesia.

Compared with HL/S, EVLT shows no significant difference in the 1/2-year recurrence rate or the rates of thrombosis, wound infection and phlebitis.However, it can decrease the rate of paresthesia.

To compare the clinical efficacies and safety of sevoflurane and propofol versus remifentanil and propofol anesthesia for children with cleft lip and palate repair surgery.

Upon the approval of hospital ethical committee,a total of 60 pediatric patients undergoing cleft lip and palate repair surgery were recruited from two hospitals between April 2011 and December 2012.All patients were randomly divided into 2 groups (n=30 each).Group S:sevoflurane and propofol anesthesia| and group R:propofol and remifentanil anesthesia.Heart rate (HR), mean arterial pressure (MAP) and pulse oxygen saturation (SpO₂) were recorded at the time before the induction (T0), after 2 min of induction (T1),the beginning of surgery (T2) and the end of surgery (T3).Intubating satisfaction, time to extubation,incidence of emergence agitation, postoperative nausea and vomiting, and the complications of the airway were recorded.

Satisfactory intubation rate was 90% in group S, versus 83% in group R.And there was no significantly difference between the two group.There were no significantly difference between the two group with MAP and HR.Compared with T0, There were significantly difference with MAP and HR at T1,T2 in group R (P<0.05).The incidence of emergence agitation was significantly higher in group S (7 cases) than that in group R (2 cases).there were no records of nausea, vomiting and laryngospasm.

Under an adequate depth anesthesia, these two anesthesia techniques are safe for cleft lip and palate repair surgery, emergence agitation was high in sevoflurane anesthesia, propofol and remifentanil anesthesia provides lower heart rate.

To evaluate the effects of early goal-directed diuresis therapy on the outcomes of critical ill patients.

A total of 56 critical patients enrolled received an injection of furosemide 5-40 mg under a precondition of stable hemodynamics.They were divided into two groups:standard group[Central venous pressure (CVP) decreased below 8 mm Hg] (n=30) and control group (if not)(n=26) depending on the goal of CVP.And the differences of survival rate, intensive care unit (ICU) days and ventilation days after diuresis therapy were compared between two groups.

The survival rate of standard group was significantly higher than that of control group (96.7% vs 84.6%,P<0.05) while the ICU days (4.4±3.6 days) and ventilation days (1.2±1.1 days) after diuresis therapy of standard group were significantly shorter than that of control group (12.5±11.7 and 9.8±9.6 days, P<0.05).

Early goal-directed diuresis therapy can improve the prognosis of critical ill patients.

To evaluate the efficacies of treating osteonecrosis of the femoral head (ONFH) with percutaneous retaining catheterization.

A total of 85 patients (106 hips) of ONFH underwent percutaneous retaining catheterization with self-made instrument.There were stageⅠ (n=32, 40 hips), stageⅡ (n=41, 50 hips), stageⅢ (n=7, 9 hips) and stageⅣ (n=5, 7 hips) by Ficat and Arlet classification.The selection criteria include bone marrow edema (BME) of the femoral head and neck and joint fluid on magnetic resonance imaging (MRI).The percent method (%) of Orthopedics Branch of Association of Chinese Medical Association was used for evaluating the efficacies of ONF H with retained femoral head.A follow-up period of 2- 10 years was conducted with plain radiograph.The standard was as follows:>90, excellent; 75-89, good; 60-74, passable;<60, bad.The combination of excellent and good denoted obvious effect rate; passable for valid rate; bad for invalid rate.The historical core decompression was used as control group.And χ² test was used for statistical analysis (P<0.05).

The obvious effect rate was 88% (35/40), 74% (37/50), 22% (2/9), 14% (1/7), the valid rate 7% (3/ 40), 12% (6/50), 22% (2/9), 14% (1/7) and the invalid rate 5% (2/40), 14% (7/50), 56% (5/9), 72% (5/7) respectively in Ficat Ⅰ, Ⅱ, Ⅲ and Ⅳ stage.No statistically significant differences existed between Ficat Ⅰ and Ⅱ stage (P>0.05).But there were statistically significant differences in other groups (P<0.01).

Percutaneous retaining catheterization is efficaciously treating ONFH in Ficat Ⅰ and Ⅱ stage and it may also be used for ONFH in Ficat Ⅲ and Ⅳ stage.

To examine vascular endothelial growth factor (VEGF) protein secretion and expression and explore the osteogenic activity of adipose tissue-derived stem cells (ADSCs) after transfection of human VEGF.

The ADSCs were isolated from human adipose tissue after the digestion of collagenase.After identification by flow cytometry, the cells were cultured and passaged in nutritive medium.Gene sequence encoding human VEGF mature peptide was obtained by Trizol reagent method from human vascular tissue.Target gene VEGF was connected with bicistronic expression vector containing green fluorescent protein to form pSELECT-GFPzeo-VEGF for transfecting 2nd,3rd,4th,5th generation ADSCs mediated by liposome.The transfection results were verified under fluorescence microscope.VEGF protein secretion by transfected cells was detected by enzyme-linked immunosorbent assay (ELISA).Secondgeneration transfected ADSCs were cultured under osteogenic conditions.The supernatant levels of alkaline phosphatase (ALP) and osteocalcin (OC) were detected.

Liposome-mediated VEGF target gene fragment could transfect ADSCs successfully.ELISA quantitative detection showed that VEGF mRNA expression levels in supernatant of the transfected group was significantly higher than the control group.And there were significant differences.After osteogenic culturing, the detections of ELISA, real-time PCR and Western blot showed that the secretion of ALP and OC of VEGF transfected group was significantly higher than that of empty vector transfected and blank cell groups.And there were significant differences (P<0.01).

After transfected by liposome-mediated VEGF target gene fragment, human ADSCs can express biologically active VEGF mRNA in vitro continuously and effectively.Directional differentiation capacity of transfected ADSCs is significantly enhanced.