Volume 97  ·  Issue 09  ·  2017

large hemispheric infarction (LHI) is an infarction of ≥2/3 of the middle cerebral artery supply area (with or without anterior/posterior cerebral artery supply area infarction). If the patient has an early neurological deficit with progressive aggravation of disturbance of consciousness and rapid cerebral hernia formation, it is called malignant middle cerebral artery infarction (malignant middle cerebral artery infarction, MMI)^[1]。 The prognosis of MMI patients is poor, and the mortality rate is as high as 78%^[1]； Even if they survived, the rate of severe neurological disability (mRS score 4-5) was as high as 89%^[2]。 In the 21st century, neurologists, especially critical care neurologists, are beginning to challenge this serious cerebrovascular disease.

Patients with spontaneous intracerebral hemorrhage (ICH) develop localized neurological deficit with disturbance of consciousness, unequal pupil size, and abnormal respiratory rhythm in the early stage of the disease. Head CT scan shows supratentorial hematoma volume ≥30 ml, pontic hematoma volume ≥5 ml, thalamic or cerebellar hematoma ≥15 ml, which is called larger volume of intracerebral hemorrhage (LICH)^[1]。 The first thing neurologists and neurocritical care physicians think about when they face patients with LICH is how to keep the patient alive. Studies have shown that the mortality rate of supratentorial LICH patients treated by internal medicine is as high as 74% ~91%^[1]The mortality rate of cerebellar LICH patients was 81%^[2]The mortality rate of patients with pontine LICH reached 100%^[1]。 The direct cause of high mortality is cerebral hernia formation. Therefore, how to remove hematoma, reduce the occupying effect and reduce the formation of cerebral hernia becomes the key to reduce the mortality of LICH.

large hemispheric infarction (LHI) is an infarction of ≥2/3 of the blood supply area of the middle cerebral artery, with or without infarction of the blood supply area of the anterior/posterior cerebral artery. The incidence of LHI was (10~20) per 100,000 persons per year^[1]。 The clinical manifestations of patients with LHI are hemiplegia, hemiparesthesia, hemianopsia, gaze disorders, head-eye separation and aphasia (dominant hemisphere)^[2]。 If the neurological deficit and disturbance of consciousness progressively aggravate in the early onset of LHI patients, and cerebral hernia develops rapidly, it is called malignant middle cerebral artery infarction (MMI)^[3]。 The mortality rate of MMI is 60.9% ~78%, and the cause of death is mostly cerebral hernia^[3,4]。 Even if the patient survives, there will be severe neurological disability (modified Rankin score 4-5 accounts for 43%-89%)^[4,5,6]。 Neurologists must identify LHI as early as possible, and if conditions permit, admit patients to a neuro-intensive care unit (NCU) as early as possible for monitoring and treatment.

intracerebral hemorrhage (ICH) refers to the spontaneous, non-traumatic rupture of blood vessels in the brain parenchyma, resulting in the accumulation of blood in the brain parenchyma. In 2010, a meta-analysis (36 studies in 21 countries around the world) showed that the incidence of ICH was 24.6 per 100,000 persons-years (95%CI19.7~30.7), and the mortality rate within 30 days of ICH was 40.4% (13.1% ~61.0%)^[1,2]Where predominantly large-volume ICH patients^[1]。 Neurologists must identify large-volume ICH as early as possible, and if conditions permit, be admitted to a neuro-intensive care unit (NCU) for monitoring and treatment.

To study intracranial mixed germ cell tumor diagnosis and reasonable treatment strategy.

Clinical data of 17 patients with intracranial mixed germ cell tumor in Tsinghua university Yuquan hospital from October 2012 to October 2016 were retrospective analysed, including the characteristics of the general, the serum tumor markers of AFP, β-HCG, and CEA, imaging findings, pathological results, treatment methods and prognosis.

There were 10 cases of male, 7 cases of female. The average age was (11.1±5.2) years old. Nine cases were gross total resection of lesions and 8 cases were subtotal resection of lesions. Eight cases (47.1%) were without recurrence and had more than four courses of chemotherapy after surgery, of which, 7 cases belonged to the gross total resection, and 1 case belonged to the subtotal resection. Nine (52.9%) patients relapsed, including 2 cases of the gross total resection and 7 cases of the subtotal resection. Among them, 4 cases were given second operations and 6 cases obtained satisfactory therapeutic effect by chemotherapy combined radiotherapy. There were 12 of 17 patients with pathological types contain teratoma (including mature, immature or malignant teratoma) ingredients, accounting for 70.6%. The average follow-up time was (17.5±12.1) months, 4 cases (23.5%) patients died.

The diagnosis of intracranial mixed germ cell tumors needs comprehensive consideration of tumor markers in serum or cerebrospinal fluid, chemotherapy and radiotherapy before operation and pathological results. The gross total resection helps to reduce the chances of tumor recurrence. Rational chemotherapy and radiotherapy is helpful to prognosis.

To discuss the clinical feasibility and practical application of retractorless surgical for patients with hypertensive basal ganglia hemorrhage.

A total of 84 patients underwentretractorless surgery in The First People′s Hospital of Huzhou from Jun 2014 to Jun 2016 were retrospectively reviewed.There were 53 male and 31 female of the 84 patients. Their mean age were 58.7 years with range: 29-74 years.Glasgow coma scale score(GCS) at admissionwereas follow: GCS 4-5 points 10 cases(including 3 cases companied dilated pupils), GCS 6-8 points 25 cases, GCS 9-12 points 32 cases, and GCS 13-14 points 17 cases.The average volume of hematoma was 50.2 (30-100) mL.Complications related tosurgery and postoperative activities of daily living (ADL) scorewere analyzed.

0f the 84 cases, there were 76 (90.5%) patientswhose intracranial hematoma were removed more than 90%. Postoperative bleeding was occurred in 6 cases (7.1%), all without secondary surgery. Cerebral infarctionwas occurred in 2 cases (2.4%), subcutaneous effusion associated with infectionwas occurred in 7 cases (8.3%). Postoperative follow-up of 58 cases, 85.3% recovered well.

With the proficiency in microneurosurgery methods, retractorless surgery couldreduce the related postoperative complications, such as postoperative cerebral infarction.

The study aimed to investigate whether sample sizes of F-wave study differed according to different nerves, different F-wave parameters, and amyotrophic lateral sclerosis(ALS) patients or healthy subjects.

The F-waves in the median, ulnar, tibial, and deep peroneal nerves of 55 amyotrophic lateral sclerosis (ALS) patients and 52 healthy subjects were studied to assess the effect of sample size on the accuracy of measurements of the following F-wave parameters: F-wave minimum latency, maximum latency, mean latency, F-wave persistence, F-wave chronodispersion, mean and maximum F-wave amplitude. A hundred stimuli were used in F-wave study. The values obtained from 100 stimuli were considered "true" values and were compared with the corresponding values from smaller samples of 20, 40, 60 and 80 stimuli. F-wave parameters obtained from different sample sizes were compared between the ALS patients and the normal controls.

Significant differences were not detected with samples above 60 stimuli for chronodispersion in all four nerves in normal participants. Significant differences were not detected with samples above 40 stimuli for maximum F-wave amplitude in median, ulnar and tibial nerves in normal participants. When comparing ALS patients and normal controls, significant differences were detected in the maximum (median nerve, Z=-3.560, P<0.01; ulnar nerve,t=5.019, P<0.01; tibial nerve,Z=-2.475, P<0.05; peroneal nerve,Z=-2.088, P<0.05)and mean F-wave latency (median nerve,Z=-3.243, P<0.01; ulnar nerve,t=3.876, P<0.01; tibial nerve,Z=-2.206, P<0.05; peroneal nerve,Z=-2.205, P<0.05)in all four nerves, F-wave chronodispersion (Z=-3.152, P<0.01)in the ulnar nerve, F-wave persistence in the median (Z=6.139, P<0.01)and ulnar nerves(Z=5.350, P<0.01), mean F-wave amplitude in the tibial nerve(t=2.981, P<0.01), maximum F-wave amplitude in the ulnar (Z=-2.134, P<0.05)and tibial nerves (t=2.746, P<0.01)with 20 stimuli; for chronodispersion in tibial nerve (t=2.551, P<0.05)100 stimuli, for chronodispersion in peroneal nerve (Z=-2.086, P<0.05)80 stimuli, for F-wave persistence in tibial nerve (Z=2.119, P<0.05) 60 stimuli, for mean F-wave amplitude in ulnar (Z=-2.552, P<0.05)and peroneal nerve (Z=-2.228, P<0.05)40 stimuli, for maximum F-wave amplitude in peroneal nerve (t=2.693, P<0.01)60 stimuli were necessary to detect differences.

Sample sizes of F-wave study differed according to different nerves, different F-wave parameters , and ALS patients or healthy subjects.

To explore the effect of bedside ultrasound in measuring gastric residual volume in neurosurgical critical patients with enteral nutrition support.

From March to August 2016, 70 critically neurological patients with continues enteral nutrition who admitted in Intensive Care Unit (ICU) were randomized into two groups. The observation group applied the bedside ultrasound monitoring gastric residual volume every day to guide the implementation of enteral nutrition. The control group used syringes withdrawing every 8 hours to measure the gastric residual volume.

There was no statistically significant difference in the incidence of complications include regurgitation and aspiration in this two group patients (P=0.356; P=1.000), while the times of interrupting enteral nutrition was lower in the observation group(25.7% vs 5.7%, 74.3% vs 94.3%, P=0.045), the length of target feeding time and the length of ICU stay, the operation time was shortened, with a statistically significant difference[(2.37±0.69) d vs (3.49±0.74) d, P=0.028; (8.52±5.45) d vs (6.40±2.71) d, P=0.022; (58.29±11.22)s vs (67.60±7.05) s, P=0.000].

The application of bedside ultrasound to measure gastric residual volume can be a scientific method to guide enteral nutrition in neurosurgical critical patients, which can reduce the times of interrupting enteral nutrition and shorten the length of target feeding time and ICU length of stay, reduce the workload of nurses.

To evaluate the Treatment effect of geriatric ankle osteoarthritis by arthrodesis with screw fixation through lateral malleolus osteotomy.

Thirty-three patients with severe osteoarthritis according to the classification of Takakura-Tanakawere treated by ankle arthrodesis through lateral malleolus osteotomy with screw fixation from January 2010 to June 2015. Twenty-five patients were combined with more than 1 internal diseases. Twenty-six patients owned ankle injury history. Clinical and radiologic evaluations were performed before surgery and at the most recent follow-up.

The American Orthopaedic Foot and Ankle Society scale was (50.9±12.0) points beforesurgery and (78.8±9.6) points at the most recent follow-up (P<0.01). The visual analogue scalein last follow up was significantly decreased to (1.7±1.1), compared with (6.1±1.7)preoperatively.Seven patients were accompanied with incision complications. 27 patients(81.8 percent) reached complete solid fusion , which was confirmed by CT. 4 patients was partially bony fused, which could also perform weight-bearing walk. The other 2 patients with nonunion were reoperated lastly.

Ankle arthrodesis by screw fixation through lateral malleolus osteotomy is the preferable surgical treatment option in patients with end-stage geriatric ankle arthritis, showing high reliability and effectivity in pain relieving and function improvement. Incision and bony healing complications should draw attention especially in patients combined with internal disease.

To explore the value of dual contrast-enhanced ultrasound in preoperative T staging of rectal carcinoma.

Dual contrast-enhanced ultrasound examinations were performed on 72 patients with rectal carcinoma via transrectal infusion and intravenous injection. The accordance of preoperative dual contrast-enhanced ultrasound results and postoperative pathologic results was evaluated retrospectively.

The overall accordance rate of preoperative T staging was 73.6% (53/72). And accordance rate was 100.0% (3/3), 100.0% (5/5), 68.4% (13/19), 71.4% (25/35)and 70.0% (7/10) for Tis , T1, T2, T3 and T4, respectively. The consistency was good (κ=0.607, χ² =8.363, P<0.01). The accordance rate of middle/lower vs high rectal carcinoma was 68.7% and 85.7%.

Dual contrast-enhanced ultrasound can provide reference for preoperative T staging for patients with rectal carcinoma.

To investigate the feasibility, safety and efficacy of preoperative CT in the classification of adenocarcinoma of the esophagogastric junction.

A total of 517 consecutive patients from May 2012 to June 2016 with esophagogastric junction carcinoma in the department of general surgery of Henan Cancer Hospital was retrospectively analyzed, according to the clinical pathological data of three type four layer method and statistics of various types of surgery in patients with preoperative enhanced CT.

517 patients were successfully received surgery, including 152 cases of type Ⅰ(131 cases of complete abdominal surgery, 21 cases of abdominal incision diaphragm in thoracic surgery), 239 cases of type Ⅱ (177 cases of complete abdominal surgery, 62 cases of abdominal incision diaphragm in thoracic surgery), Ⅲ/Ⅳ type choice of chest abdominal surgery in 126 cases. The operation time was (102±17) min, the amount of hemorrhage was (136±18) ml, the dominant anastomotic fistula happened in 16 cases, 5 cases of pancreatic fistula, 7 cases of intestinal obstruction, anastomotic stenosis in 3 cases, thoracic and abdominal sensation in 12 cases, all the complications were cured by conservative treatment. The average value of esophageal resection margin was(5.1±0.6)cm, 2 cases with positive residual tumor margin and average length of stay was (8.9±1.6)d.

Using preoperative enhanced CT in the adenocarcinoma of the esophagogastric junction to choose surgical approach can ensure the safety margin. What′s more, unnecessary thoracotomy is reduced which is expected to be a new classification method for the operation of esophagogastric junction cancer.

To compare the advantages and disadvantages of radiofrequency ablation of left-sided accessory pathways by via atrial septal approach with retrograde through aortic approach.

A total of 184 patients of left-side accessory pathways were treated in Taizhou People′s Hospital and the Subei People′s Hospital from March 2012 to August 2015.A total of 103 cases were treated by aortic retrograde approach as through arterial group, 81 cases were treated by punctured atrial septal to left atrial for mapping and ablation as through atrial septal group.Comparison of ablation procedure time, total and pathways of different parts(subgroup) at instant success and relapse rates, safety (serious complications), and statistics other complications in operation and postoperative.

Through arterial group and through atrial septal group were no significant difference (P>0.05) in the ablation procedure time((25±18 ) vs (22±15)min ), instant success(98.1% vs 97.5%) and relapse rates(1.0% vs 1.2%), security(1 vs 0 case). There was no statistical difference in septal part subgroups (allP>0.05) in the ablation procedure time((22±18)vs (25±19)min), instant success(91.7% vs 89.9 %) and relapse rates(0 vs 11.1%); posterior wall subgroup had no statistical difference in the ablation procedure time((18±15)vs (16±12)min), instant success(100% vs 100 %) and relapse rates(0 vs 0)(allP>0.05); side wall subgroup had no statistical difference in the ablation procedure time((29±20)vs (21±18) min), instant success (98.3% vs 98.1%)and relapse rates(1.7% vs 0%)(allP>0.05).

Ablation of left-sided accessory pathways by transseptal approach and transaortic approach has no statistical difference in the procedure time, instant success and relapse rates, security.In a particular case, there is a certain complementarity between the two methods.

To identify the expression of apoptosis-associated genes of high- intensity focused ultrasound(HIFU) in xenograft with human pancreatic cancer.

Mice implated with human pancreatic cancer cells (YY-1) were divided into HIFU group or control group. Tumor cell apoptosis was verified by TUNEL. The expression of the apoptosis-associated genes was analyzed by Agilent Human Gene Expression. Selected genes was validated by quantitative real-time PCR(RT-PCR)and Western blot.

The rate of tumor cell apoptosis in HIFU group was higher than that of control group at 7, 14 days after HIFU treatment ((63.6%±15.2%)vs (19.0%±2.4%), P<0.01)and ((41.4%±7.3%)vs(18.0%±2.4%),P<0.01). Gene expression profiling revealed a total of 69 differentially expressed genes in related to apoptosis pathway, among which 44 genes were up-regulated, and 25 genes down-regulated. The RT-PCR results of selected 4 genes were consistent with those of gene expression profiling. The results of Western blot analysis at 7, 14 days after HIFU treatment showed that the expressions level of Bax protein in HIFU group was greater that of in control group ((0.39±0.11)vs (0.20±0.09),P<0.05)and ((0.46±0.12)vs(0.24±0.10),P<0.05), while the expressions level of Bcl-2 protein in HIFU group was lower than that of in control group ((0.68±0.14)vs(1.56±0.21),P<0.05)and((0.51±0.16)vs(1.57±0.22),P<0.05).

HIFU could induce apoptosis and results in dramatic changes in gene expression, indicating that multiple pathways are involved. Although intrinsic pathway might be predominantly involved in HIFU-elicited apoptosis, further research is needed to clarify the detailed mechanisms.

To study the effect of allogeneic bone marrow mesenchymal stem cells transplantation on the expression of interleukin -22 (IL-22), matrix metalloproteinase -3 (MMP-3) in serum and synovial of rats with collagen induced arthritis.

Type Ⅱ collagen were injected twice to establish the collagen induced arthritis (CIA) rat model. Forty-eight rats were randomly divided into 3 groups: control group, CIA control group, CIA experiment group. Rat bone marrow mesenchymal stem cells were cultured by bone marrow method combined with adherent culture method. After identify, the remaining cells were injected in the CIA experimental group. Enzyme linked immunosorbent assay (ELISA) and immunohistochemistry were used to detect the expression of IL-22 and MMP-3 in serum and anklebone joint′s synovium of rats, respectively. Synovial cells were isolated and cultured, and were treated with different concentrations of IL-22. MMP-3 protein and mRNA were detected before and after stimulation by Western blot and real-time quantitative polymerase chain reaction (RT-qPCR).

After MSC transplantation, arthritis index, X-ray, HE staining of CIA rat showed that joint damage significantly reduced compared with the control group. The ELISA results showed that the expression of MMP-3 and IL-22 in CIA control group was higher than those in the control group (125.79±9.12 vs 102.00±7.63 ng/ml, P<0.05), (292.35±31.23 vs 257.27±13.99 ng/ml,P<0.05) and CIA experiment group (125.79±9.12 vs 97.94±9.50 ng/ml,P<0.05), (292.35±31.23 vs 262.16±22.02 ng/ml,P<0.05) with statistically significant difference (P<0.05). There was no significant difference between the control group and CIA experimental group. Immunohistochemical showed similar results with ELISA. Western blotting and RT-qPCR showed that MMP-3 protein and mRNA expression was increased after IL-22 stimulation in a dose-dependent manner.

IL-22 and MMP-3 play an important role in the pathogenesis of rheumatoid arthritis. IL-22 could regulate the expression of MMP-3, and bone marrow mesenchymal stem cells could reduce the expression of MMP-3 in the treatment of rheumatoid arthritis by reducing the expression of IL-22.

To investigate the effect of preventing perivascular adhesion with topical application of sodium hyaluronate on intimal hyperplasia of the vein grafts in rabbits.

Twenty-four male New Zealand white rabbits, aged 5 months, were randomly divided into 2 groups: Group A and B (n=12 rabbits per group). Artery defect model was established by cutting about 1 cm artery from the middle part of the dissociated left common carotid artery. A section about 3 cm was cut from the right external jugular vein, and the harvested vein was inverted and end-to-end anastomosed to the artery defect. After anastomosis, the adventitia and two anastomosis of the grafted veins in group A was applied 0.2 ml sodium hyaluronate locally to, and corresponding site in Group B was served as a control, but with the sterile normal saline. The grafted veins were obtained 1, 2 and 4 weeks after operation, HE staining and Masson staining were preformed for histological changes of grafted vein wall, proliferating cell nuclear antigen (PCNA) and platelet-derived growth factor (PDGF) immunohistochemistry staining were conducted for proliferation and expression and distribution of PDGF of the grafted vein.

The macroscopic and histological observation showed that the perivascular adhesions in Group A were looser when compared with those in Group B. The thickness of the intima, the degree of intima hyperplasia of 2 groups at different time points were as follows: at 1 week after operation, group A[(25.5±3.9) μm, (1.2±0.1) ]and group B[(26.2±4.2)μm, (1.2±0.1)]; at 2 weeks after operation, group A[(44.3±2.5)μm, (1.2±0.1)]and group B[(51.0±3.8)μm, (1.4±0.0)]; at 4 weeks after operation, group A[(69.9±6.8)μm, (1.5±0.1)] and group B[(84.4±6.4)μm, (1.7±0.1)]. Group A was inferior to group B in terms of the above three parameters 2 and 4weeks after operation ( P<0.05). Cell proliferation index of intima and that of media were as follows: at 1 week after operation, group A (7.4±2.2), (21.5±3.2) and group B (11.5±2.0), (28.6±4.5); at 2 weeks, group A (20.0±3.2), (35.8±3.4) and group B (26.8±4.1), ( 42.6±4.2); at 4 weeks, group A (11.4±2.0), (22.1±2.7) and group B (15.5±2.4, 28.6±3.9). Group A was inferior to group B in terms of cell proliferation index of intima and media 1, 2 and 4 weeks after operation (P<0.05). The percentage of PDGF-positive cells of intima, media and adventitia was as follows: at 1 week after operation, group A (7.7±1.6), (19.6±3.7), (2.5±1.5) and group B (7.6±2.4), (20.6±4.4), (10.3±2.3); at 2 weeks after operation, group A (11.4±2.6), (19.8±3.1), (12.9±3.3) and group B (19.5±3.5), ( 30.6±5.2), (30.5±5.8); at 4 weeks after operation, group A (6.2±1.9), ( 11.1±2.8), (10.2±2.4) and group B (10.5±2.0), (18.6±3.2), (26.5±3.8). Group A was inferior to group B in terms of the percentage of PDGF-positive cells of intima, media and adventitia 2 and 4 weeks after operation (P<0.05) and Group A was inferior to group B that of adventitia 1 week after operation (P<0.05).

Preventing perivascular adhesion with topical application of sodium hyaluronate can inhibit intimal hyperplasia.

Anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis is currently the highest incidence of autoimmune encephalitis. Since 2007 Dalmau et al.^[1]Anti-NMDAR encephalitis has attracted increasing attention since its first report. Despite the risk of death, nearly 80% of patients can significantly improve neurological function through tumor resection and early immunotherapy. This study aimed to analyze the clinical characteristics of 20 patients in order to increase the knowledge of the disease and provide assistance for early diagnosis. In addition, by combining domestic and foreign literatures, it can provide help for the early standardized application of immunosuppressants.

Cushing's disease, or pituitary adrenocorticotropic hormone (ACTH) adenoma, is one of the important causes of endogenous Cushing's syndrome, accounting for about 60% of endogenous Cushing's syndrome^[1,2,3]。 Cyclical Cushing's disease (CCD) is a rare form of Cushing's disease. Unlike classical Cushing's disease, where cortisol levels rise relatively steadily, CCD is characterized by periodic fluctuations in cortisol levels. 1956 Birke et al.^[4]The first case of periodic Cushing's syndrome is reported; 1973, Brown et al.^[5]The first case of CCD, periodic Cushing's syndrome caused by an ACTH adenoma, is reported. Diagnosis of CCD requires long-term and continuous endocrine monitoring. If the diagnosis is wrongly established according to the cortisol level at individual moments, it is easy to lead to missed diagnosis and misdiagnosis. In addition, there are many differences between CCD and classic Cushing's disease in treatment and prognosis. This article reviews the relevant literature and reviews the characteristics of CCD in epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment and prognosis, so as to improve the understanding of CCD in clinical work.

Unified clinical classification can not only provide an academic basis for clinical communication, but also provide guidance on treatment options and clinical prognosis. At present, there are relatively unified clinical classification for idiopathic, congenital and neuromuscular scoliosis, but there is no unified clinical classification standard for adult degenerative scoliosis. adult degenerative scoliosis (ADS), also known as de novo scoliosis, is defined as a spinal deformity with a Cobb angle>10° in a population with mature skeletal development^[1]。 Adult degenerative scoliosis is different from other types and scoliosis, mainly due to asymmetric degeneration of spinal segments. Adult degenerative scoliosis occurs mainly in the elderly population. As the average human life expectancy increases, the incidence of degenerative scoliosis increases year by year^[2]。 Through reviewing the research progress of clinical classification of adult scoliosis and evaluating the contents, advantages and disadvantages of four adult degenerative scoliosis classification systems, it can play a guiding role in clinical treatment.