Volume 97  ·  Issue 11  ·  2017

Vascular disease is an important disease that endangers human health. Cerebrovascular lesions represented by intracranial aneurysms and arteriovenous malformations have high mortality and disability rates. Since 1970s, with the development of microsurgery, the therapeutic effect of this kind of disease has been continuously improved. However, some cerebrovascular diseases, especially complex cerebrovascular diseases, are still not satisfactory in the traditional microsurgical treatment mode, which may cause serious complications. Therefore, its therapeutic indications and treatment options are still controversial. The emergence of Hybrid operating room provides a new treatment for cerebrovascular diseases. Compound surgery, also known as Hybrid operation, refers to a surgical method that combines interventional therapy with microsurgical therapy in a compound operating room. Compound surgery emphasizes complementary advantages of different techniques rather than simple superposition. In recent years, the construction of composite operating room and composite surgery have been carried out in some international and domestic neurosurgical centers, and good results have been achieved. Compound surgery is still in the primary exploration stage. This article will combine the experience of compound surgery carried out by the neurosurgery department of Beijing Tiantan Hospital and some domestic brother units, and review the application of compound surgery as follows, and look forward to the prospect of compound surgery technique.

neurovascular diseases mainly refer to diseases caused by brain or spinal cord vascular abnormalities, including stroke, intracranial aneurysm, cerebral arteriovenous malformation (AVM), dural arteriovenous fistula (DAVF), spinal cord vascular malformation, blood-rich nervous system tumors and a series of broad diseases. Taking neurovascular diseases as the main research object, vascular neurosurgery and neurointerventional surgery with surgery as the main intervention means were born and developed. However, there are bottlenecks in microsurgery alone or interventional surgery alone, and it is still difficult to obtain safe, minimally invasive and effective diagnosis and treatment of some complex neurovascular diseases. With the technical progress and clinical demand of vascular neurosurgery and interventional surgery, neurovascular composite surgery emerged as the times require. Combined surgery based on high-quality neuroimaging combined with microsurgical technique and endovascular therapy technique solves the main shortcomings of single surgical mode and improves the surgical efficacy of complex neurovascular diseases. The purpose of this consensus is to make constructive recommendations on the rational configuration of neurovascular composite operating rooms and the operating specifications of composite surgery.

To analyze the efficacy and methods of hybrid operation in the treatment of complex intracranial aneurysms.

Fourty-two patients with complex intracranial aneurysms were treated in hybrid operation room of Qilu Hospital of Shandong University between July 2011 and October 2016. Twenty-one cases of aneurysm clipping guided by intraoperative angiography, 10 cases of aneurysm clipping assisted by endovascular therapy, and 11 cases of aneurysm occlusion assisted by bypass surgery.

Thirty-five patients were followed up 6-36 months.Thirty-three (94.3%) cases were completely occlusion, 2 (5.7%) cases were recurrent in follow-up.One of the recurrence case was performed interventional embolization treatment, and the other was continuous follow-up.

Hybrid operating room is beneficial to evaluate the surgical curative effect immediately. It could increase the occlusion rate of complicated aneurysms, and could provide an ideal platform for complicated intracranial aneurysm treatment.

To explore the experience in the treatment of spinal dural arteriovenous fistulas with application of hybrid operating room.

A retrospective analysis was performed among 22 patients with spinal dural arteriovenous fistulas admitted to Department of Neurosurgery of Tianjin Medical University General Hospital who received operation in the hybrid operating room from March 2011 to February 2016. Modified Aminoff-Logue scores (ALS) for myelopathy was used to evaluate the spinal function.All the 22 patients were followed up 6-12 months after the operation.

All the patients were diagnosed by spinal digital subtraction angiography (DSA). The modified ALS pre-operation and post-operation 6 months were (4.7±1.8) and (2.0±1.5), respectively, with significant difference (P<0.01). There were 15 cases with mild dysfunction, 6 cases with moderate dysfunction, severe dysfunction in 1 case before operation.Fifteen cases were cured, 4 cases improved, 1 case had no change after 6 months follow-up.The improvement rate was 95.45%.

The application of hybrid operating room in the treatment of spinal dural arteriovenous fistulas achieves good outcome and provides a convenient and effective approach, which embodies the idea of precision medicine.

To investigate the application of hybrid technique for the treatment of cerebral arteriovenous malformations (CAVMs) and to assess the value of hybrid technique.

The cases of CAVMs treated in Qilu hospital and People's Hospital of Xinjiang Uygur Autonomous Region from July 2011 to July 2016 were analyzed retrospectively.Two modes of hybrid surgery, "angiographic diagnosis-craniotomy lesion resection or/and hematoma clearance-intraoperative angiography evaluation" and "angiographic diagnosis-intraoperative embolization-craniotomy lesion resection or/and hematoma clearance-intraoperative angiography evaluation" were applied for all the cases.We placed an aneurysm clip as marker in surgery field during real-time angiography.If CAVMs residues occurred during surgery, we re-resected the residue according to the guidance of the marker (clip) and DSA imaging. Intra-operative angiography evaluated the results of CAVMs resection one more time.Postoperatively, follow-up CT scan was performed for all the patients.

Of all the cases with CAVMs, there were 8 cases of scale Ⅰ, 13 cases of scale Ⅱ, 10 cases of scale Ⅲ and 6 cases of scale Ⅳ according to Spetzler-Martin Scale.There were 28 cases of acute hemorrhagic CAVMs and 9 cases of chronic hemorrhagic CAVMs or no-hemorrhagic CAVMs.Intra-operative angiography showed CAVMs residues in 6 cases of acute hemorrhagic CAVMs and only one in chronic group.About 18.92% residual rate of CAVMs were found for the first time intra-operative assessment angiography.With the guidance of intra-operative angiography and aneurysm clip as Marker, all residues of CAVMs were resected totally.Follow up CT showed the hematomas disappeared in all the cases of acute hemorrhagic cases.The cure rate of CAVMs with hybrid surgery was 100% according to the final intra-operative assessment angiography.

(1)Hybrid surgery for the treatment of CAVMs in one session could evaluate the results of CAVMs resection and instruct the surgical procedure according to real-time angiography.This model could improve the treatment safety and efficacy for patients with CAVMs.(2)Patients with higher Spetzler-Martin Scale (Ⅲ-Ⅳ) who need intra-operative embolization and patients with hemorrhagic CAVMs are more suitable for hybrid surgery.

To explore the efficacy of hybrid management of complex symptomatic intracranial fistulas in neurovascular hybrid operating room.

From March 2014 to January 2015, 2 complex dural arteriovenous fistulas and 1 carotid cavernous fistulas were managed by hybrid surgeries in the PLA Rocket Force General Hospital.With first attempts with endovascular treatment failed, all cases were finally managed by hybrid surgery.Dural arteriovenous fistulas were approached via meningeal artery followed craniotomy.The carotid cavernous fistulas were treated by direct puncture into the left cavernous sinus after craniotomy.

Post-operative angiography demonstrated complete occlusion for 2 cases and nearly complete occlusion for 1 case.All 3 cases had no complications.On discharge 2 patients presented no symptoms and 1 greatly improved.Within the follow-up (1-33 months), 1 patient had recurrence after 21 months and received re-embolization with complete occlusion.

Hybrid surgery is a promising method to manage complex intracranial fistulas.

To explore the clinical features and conduct prognostic analysis about visual recovery and relapse of neuromyelitisoptica (NMO) spectrum disease (NMOSD) with sjogren syndrome (SS).

A retrospective and prospective observational study was conducted.Between July 2013 and June 2016, 172 patients with NMOSD (NMOSD-non SS: 116/172, 67.4%; NMOSD-SS: 56/172, 32.6%) were assessed at Beijing Tongren Hospital, Capital Medical University, Beijing, China.The prognostic factors of NMOSD-SS patients were also analyzed.

As compared with NMOSD-non SS patients, NMOSD-SS patients had worse visual impairment (percentage of patients with visual acuity less than 0.1, 83.9% vs 69.8%, P<0.05), higher positive rate of SSA (92.9% vs 0.0%,P<0.05), higher proportion of dryness of mouth and eye (66.1% vs 5.2%,P<0.05) as well as higher percentage of reduced visual evoked potential (VEP) amplitude (60.7% vs 43.1%,P<0.05). NMOSD-SS patients had a significantly higher average year recurrent frequency (0.58 vs 0.53) and significantly shorter mean recurrence time (6.7 months vs 12.4 months,P<0.05). The results showed that recurrent eyes, the worst visual acuities of onset less than 0.1 were independent risk factors of visual impairment (visual activity <0.1), according to at least six months' follow-up of all NMOSD-SS patients (OR=6.410 and 9.434, respectively, P<0.05). Meanwhile, immunosuppressive drugs were protective factors of relapse in NMOSD-SS patients (OR=0.107, P<0.05).

NMOSD-SS patients have worse visual impairment, and they are more vulnerable to relapse than NMOSD-non SS patients, and the vision is lack of recovery for NMOSD-SS with recurrent eyes or the worst vision of onset less than 0.1.Immunosuppressive drugs can reduce the recurrence of NMOSD-SS relapse.

To investigate the prognostic risk factors of acquired immunodeficiency syndrome (AIDS) patients with pneumocystis pneumonia (PCP), and to establish risk models for predicting early outcome.

The clinical data of 418 AIDS patients with PCP admitted to Department of Infectious Diseases, Beijing You'an Hospital, Capital Medical University from January 2008 to May 2016 were retrospectively analyzed.The patients were divided into death group and survival group according to clinical outcome during hospitalization.Data of the two groups were collected including general information and laboratory test results.Multivariate Logistic regression was used to analyze risk factors affecting prognosis of patients, establish prognostic models and evaluate predictive value of the model.

Of the 418 AIDS patients with PCP, 388 cases were male and 30 cases were female, aged from 5 to 82 years, mean age was (40±12) years.There were 82 patients in the death group and 336 patients in the survival group.Disease course, bacterial infection and alveolar-arterial oxygen pressure difference(P(A-a)O₂), serum lactate dehydrogenase(LDH), white blood cell (WBC), neutrophil (N), alanine aminotransferase (AST), urea nitrogen (BUN) and serum potassium (K) were significantly higher in the death group than those in the survival group (all P<0.05), and arterial oxygen pressure (PaO₂), blood oxygen saturation (SpO₂), CD4⁺ T lymphocyte count, lymphocyte (L) , hemoglobin (Hb), platelet (PLT), albumin (ALB), prealbumin (PALB), cholinesterase (CHE), cholesterol (CHO), serum chlorine (Cl) and serum sodium (Na) were significantly lower in the death group than those in the survival group (all P<0.05). Multivariate Logistic regression analysis showed that P(A-a)O₂, ALB, LDH, N and CD4⁺ T lymphocyte count were prognostic factors of AIDS complicated with PCP.Prognostic index=9.736+ 0.112×P(A-a)O₂-0.719×ALB+ 0.006×LDH+ 0.355×N-0.021×CD4.ROC curve of the short-term prognostic model was 0.985 (95%CI 0.977-0.994), with P value 0.000, cut-off value 0.907, sensitivity 92.0% and specificity 98.8%.The mortality rate increased with the increase of equation value.

P(A-a)O₂, ALB, LDH, N and CD4⁺ T lymphocyte count are independent risk factors to predict short-term prognosis in these patients.The short-term prognostic model based on independent risk factors is useful in guiding clinical treatment.

To analyze the diagnostic value of multi-slice spiral computed tomography (MSCT) in preoperative tumor staging, lymphatic metastasis, vascular invasion and perineural invasion.

From January 2013 to December 2015, MSCT images of 87 patients from the Second Hospital of Harbin Medical University who were examined by contrast-enhanced MSCT and diagnosed as pancreatic cancer by surgical pathology within 2 weeks were collected.MSCT images were retrospectively analyzed to evaluate the tumor staging, lymphatic metastasis, vascular invasion and perineural invasion and then compared with surgical pathology.Kappa test and receiver operation characteristic (ROC) curve were used to evaluate the diagnostic value of MSCT in pancreatic cancer.

The overall accuracy of MSCT in T staging of pancreatic cancer was 85.1% (kappa =0.67, P<0.01); the accuracy of T1, T2, T3 and T4 staging were 75.0%, 57.1%, 95.0% and 66.7%; the sensitivity were 75.0%, 80.0%, 87.7% and 75.0%; the specificity were 98.8%, 92.2%, 86.4% and 96.2%; the positive predictive value (PPV) were 75.0%, 57.1%, 95.0% and 66.7%; the negative predictive value (NPV) were 98.8%, 97.3%, 70.4% and 97.4%.The accuracy, sensitivity, specificity, PPV and NPV of MSCT in diagnosing lymphatic metastasis were 62.1%, 62.3%, 61.5%, 79.2% and 41.0%.The accuracy, sensitivity, specificity, PPV and NPV of MSCT in diagnosing vascular invasion were 94.3%, 78.6%, 97.3%, 84.6% and 95.9%.The accuracy, sensitivity, specificity, PPV and NPV of MSCT in diagnosing MSCT perineural invasion were 80.5%, 81.1%, 76.9%, 95.2% and 41.7%.The area under curve (AUC) was 0.79(95%CI 0.68-0.90, P=0.001).

Contrast-enhanced MSCT plays important roles in evaluation of preoperative tumor staging, vascular invasion and perineural invasion of pancreatic cancer while it has little value on diagnosis of lymphatic metastasis.

To explore the value of 3.0 T MRI using multiple sequences (star VIBE+ BLADE) in evaluating the preoperative T staging for potentially resectable esophageal cancer (EC).

Between April 2015 and March 2016, a total of 66 consecutive patients with endoscopically proven resectable EC underwent 3.0T MRI in the Affiliated Cancer Hospital of Zhengzhou University.Two independent readers were assigned a T staging on MRI according to the 7th edition of UICC-AJCC TNM Classification, the results of preoperative T staging were compared and analyzed with post-operative pathologic confirmation.

The MRI T staging of two readers were highly consistent with histopathological findings, and the sensitivity, specificity and accuracy of preoperative T staging MR imaging were also very high.

3.0 T MRI using multiple sequences is with high accuracy for patients of potentially resectable EC in T staging. The staging accuracy of T1, T2 and T3 is better than that of T4a. 3.0T MRI using multiple sequences could be used as a noninvasive imaging method for pre-operative T staging of EC.

To explore the MRI technique and the clinical application in ligament and tendons of fingers.

The study was reviewed and approved by an institutional review board of hospital.A total of 20 normal volunteers and 50 patients from Beijing Jishuitan Hospital between May 2012 and May 2015 with finger injuries were chosen to undergo magnetic resonance examination by using Achieva 3.0 T MR produced by Philips.Scanning from coronal, sagittal and axial view in T₁-weighted and proton fat saturation sequence (PD-FS), choosing suitable parameters, in order to get clear images of finger tendons and ligaments.

Twenty normal volunteers without tendons or ligament injuries showed homogeneous low-signal-intensity on T₁-weighted and proton fat saturation sequence (PD-FS) images.In the 50 patients with finger injuries, there were 33 cases of ligament injuries, 10 cases of extensor tendon injuries and 7 cases of flexor tendon injuries. There were 8 cases of all the 50 cases combined with bone fracture.The injured ligaments and tendons became thicker and discontinued in T₁WI and demonstrated heterogeneously increased signal intensity with edema in the soft tissues surrounding the injured sites in PD-FS.

MRI can demonstrate the anatomy and injuries features of ligament and tendons in fingers accurately.It is significance for the early diagnosis and treatment protocols of the ligament and tendons injuries.

To define a novel disease-lumbosacral nerve bowstring disease, and propose the diagnostic criteria, while capsule surgery was performed and evaluated in the preliminary study.

From June 2016 to December 2016, a total of 30 patients (22 male and 8 female; mean age of 55.1±9.7 years) with lumbosacral nerve bowstring disease were included in Department of Spine Surgery, Changzheng Hospital, the Second Military Medical University.Lumbosacral nerve bowstring disease was defined as axial hypertension of nerve root and spinal cord caused by congenital anomalies, which could be accompanied by other lesions as lumbar disc herniation, spinal cord stenosis or spondylolisthesis, or aggravated by iatrogenic lesions, resulting in neurological symptoms.This phenomenon is similar to a stretched string, the higher tension on each end the louder sound.Meanwhile, the shape of lumbosacral spine looks like a bow, thus, the disease is nominated as lumbosacral nerve bowstring disease.All the patients underwent capsule surgery and filled out Owestry disability index (ODI) and Tempa scale for kinesiophobia (TSK) before and after surgery.

The mean surgery time was (155±36) min, (4.3±0.4) segments were performed surgery.The pre-operative VAS, TSK and ODI scores were (7.6±0.8), (52.0±10.3) and (68.4±12.7), respectively.The post-operative VAS, TSK and ODI scores were (3.3±0.4), ( 24.6±5.2) and (32.1±7.4)(P<0.05, respectively), respectively.

The definition and diagnostic criteria of lumbosacral nerve bowstring disease was proposed.Capsule surgery was an effective strategy with most patients acquired excellent outcomes as symptoms relieved and quality of life improved.

To compare the mid-long term clinical effect of Topping-off surgery and lumbar fusion surgery for two-segmental lumbar degenerative disease.

From March 2009 to March 2012, one hundred and twenty-six consecutive patients (Topping-off surgery and two-segment PLIF surgery) were studied in Orthopedics Department, Beijing Chao-Yang Hospital, Capital Medical University.The VAS and ODI were used to assess clinical symptoms.All patients underwent flexion/extension radiographs examinations before surgery, 1, 2 years and last follow-up postoperatively.Lumbar lordosis, sacral slop, data of Coflex segment and adjacent segment (disc height index, range of motion, foraminal height, foraminal width and Pfirrmann classification of intervertebral disc in MRI) were recorded.The paired double-tailed t test was used to analyze the differences in the results from baseline to each postoperative time point.The paired double-tailed t test was used in both groups to analyze the differences in the results from baseline to each postoperative time point.The Chi-square test was used to evaluate the differences between the incidences of adjacent segment degeneration(ASD) in the groups. Logistic regression analysis was used to analyze risk factors for developing radiographic ASD.

In topping-off group, 60 patients, average operation time was (134.5±10.2) min. The average blood loss was (301.5±64.6) ml.In fusion group, 68 patients, average age (58.3±4.6) years.The average follow-up time was (47.5±5.1) months.The average operation time was (158.6±19.3) min (P=0.000). The average blood loss was (413.6±131.3) ml (P=0.000). Sex, age, body mass index and intervertebral disc grading were matched between the two groups.Better improvement in VAS back pain score was noted in the topping-off group over the fusion group (P=0.030). Both groups achieved good recovery in ODI and improvement in VAS leg pain and back pain scores at last follow-up postoperatively.In the Topping-off group, FH increased from 10.5 mm at baseline to 11.8 mm at 1 year after surgery (P=0.000) and then decreased mildly in the third postoperative year, while in the fusion group, showed no significant change at all postoperative time points.In the fusion group, the disc height and FW at the same segment were no significant change after first year follow-up, while ROM was significantly decreased after surgery (P=0.000). Foraminal height, foraminal width and intervertebral disc height of adjacent segment of Coflex implant level were found decreased at the end of the postoperative follow-up, while compared with preoperative data no significant difference (P>0.05). At last follow-up, eight patients (13.3%) in the Topping-off group and eighteen patients (26.5%) in the fusion group developed ASD (P=0.033).

Topping-off surgery compared with two-segment lumbar fusion surgery can achieve a good result in cases with pre-existing mild or moderate adjacent segment degeneration, restrict the adjacent segment's range of motion and reduce the adjacent segment degeneration. Under strict indications, Topping-off surgery is an acceptable alternative to fusion surgery for the treatment of two-segment lumbar disease.

To evaluate the clinical efficacy between the minimally-Invasive surgical (MIS)-transforaminal lumbar interbody fusion (TLIF) technique associated with percutaneous pedicle screws in micro endoscopy discectomyand MIS-TLIF technique associated with both sides of the lower lumbar spine Wiltse approach in Quadrant channel with treatment of single segment herniation associated with lumbar instability syndrome.

From January 2012 to January 2015, 75 cases that meet the inclusion and exclusion criteria were treated by retrospective study method, which were divided into two groups in Department of Orthopedics, the Affiliated Hospital of Putian University.Experimental group(30 patients) were treated with MIS-TLIF technique associated with percutaneous pedicle screws in microendoscopy discectomy, control group were treated with MIS-TLIF technique associated with both sides of the lower lumbar spine Wiltse approach in Quadrant Chanel.Compare operation time, blood loss, postoperativehospital stay, clinical efficacy, nailing accuracy, fusion rate, postoperative pain scoring of two groups.

The blood loss[(102.1±5.5) min vs(103.7±7.7) min, t=-0.586, P>0.05], postoperative blood loss, hospital stay[(44.6±5.2) ml and(57.2±5.3) ml, (7.3±1.6) d and(9.3±1.9) d;t=-5.813, -2.774, P<0.05], JOA score before and after surgery in same group were statistically significant(P<0.05), respectively.Patients of two groups compared with operation time, clinical efficacy, nailing accuracy[group A: 97.5%, group B: 95.7%; χ²=3.00, P>0.05.Postoperative 3 month , group A: 96.7%(29/30), group B: 94.3%(33/35; χ²=0.79, P>0.05], fusion rate[group A: 96.7%(29/30), group B: 94.3%(33/35), χ²=0.79, P>0.05], preoperative JOA score[(20.4±2.4)score and(7.9±1.0), (19.1±2.7)score and(7.8±1.2)score], postoperative JOA score were no statistically significant respectively,P>0.05. JOA score of both groups were statistically significant respectively Before and after operate.Excellent rate: group A; 84.4%(25/30), group B: 80.0%(28/35), χ²=0.43, P>0.05.

MIS-TLIF technique associated with percutaneous pedicle screws in micro endoscopy discectomy relative to conventional minimally invasive spine surgery had many advantages: minimal damage, operation conveniently, precisely clinical effect, that is a kind of feasible and reliable minimally invasive surgery which is worth promoting.

The aim of this study is to investigate the underlying mechanism of cinnamaldehyde attenuating pressure overload-induced cardiac fibrosis.

The mice were randomly divided into control group, model group and treatment group by random number table and each group had 8 mice.Cardiac hypertrophy was induced by aortic banding. Heart vascular density was detected by immunohistochemical staining of CD31.The expression level of stromal cells marker α-smooth muscle actin (α-SMA) was detected by immunofluorescence staining in different groups.The expression levels of endothelial cell associated markers and stromal cell associated markers were detected by using Western blotting.The possible molecular pathway was also screened by using Western blotting. Human umbilical vein endothelial cell (HUVECs) were stimulated with TGFβ1 and cultured with 10 nmol/L cinnamomum for 24 hour to further confirm the mechanism.

Eight weeks after operation, the vascular density was significantly decreased in model group mice heart.The expressions of stromal cells markers were increased (α-SMA: 2.57±0.38; Vimentin: 0.58±0.02) and endothelial cell markers were reduced (CD31: 0.58±0.29; CD34: 0.62±0.21). While cinnamicaldehyde treatment significantly increased the mouse heart vascular density, increased endothelial cell markers expression (CD31: 1.51±0.11; CD34: 2.37±0.44;P<0.05), and reduced stromal cells marker expression (α-SMA: 1.22±0.14; Vimentin: 0.35±0.03;P<0.05). Further studies showed that the anti-fibrosis effect of cinnamicaldehyde was mainly through the TGFβ /smad signaling pathway.10 nmol/L cinnamomum attenuated TGFβ1 induced endothelial mesenchymal transition in HUVECs.

Cinnamaldehyde may be able to retard the progression of cardiac fibrosis, via blocking endothelial to mesenchymal transition, which, in verse, is through regulating TGFβ /smad signaling pathway.

A 27-year-old woman with dopa-responsive dystonia (DRD) for 15 years, 1 birth 0 pregnancy 37^＋3Zhou, was admitted to the hospital for delivery. Usually menstruation is regular, menarche is 12 years old, each menstruation is 5 days, and the menstrual cycle is 30 days. The last menstrual period was 21 July 2015, and the expected date was 28 April 2016. Fifteen years ago, due to poor exercise ability, general tremor, spinal rigidity, limited movement, difficulty walking, and mild morning and severe evening symptoms, I went to Tianjin Medical University General Hospital and was diagnosed with DRD. I was treated with Antan (trihexyphenidyl hydrochloride tablets) (2~3 tablets/d), and the symptoms could be completely relieved. Once underwent "right lower limb ankylolysis" due to restricted movement of right lower limb. Regularly take drugs during pregnancy, reduce the dose to 1 tablet/d, and self-complaint symptoms are worse than those during non-pregnancy. There were no other abnormalities during pregnancy, and Down's syndrome screening was low risk. Physical examination: General condition is OK, heart and lung are not abnormal. The mobility of spine and limbs is acceptable, the muscle strength of upper and lower limbs is normal, grade V, and the muscle tension of lower limbs is high. Dyskinesia of both lower limbs, clubfoot of right foot, knee tendon reflex and Achilles tendon reflex exist, and double Pap sign is not drawn out. Obstetric situation: uterine height 37 cm, abdominal circumference 87 cm, left occipital anterior position (LOA), articulation floating, no contractions, presence of fetal membranes, fetal heart rate 140 beats/min. After admission, after neurological consultation, it is recommended to continue taking trihexyphenidyl hydrochloride tablets 4 mg/d for symptomatic treatment. Due to the uncoordinated exertion of lower limbs in patients with DRD, the onset or aggravation of DRD may be induced during labor, resulting in limb spasm, insufficient labor, prolonged labor, postpartum bleeding, dyspnea during labor, respiratory and cardiac arrest, etc. Therefore, cesarean section under general anesthesia was performed to terminate the pregnancy. During the operation, amniotic fluid was clear, the volume was 400 ml, and a live female was delivered in LOA position, weighing 2 350 g. The Apgar score of the newborn was 9 (A1~9) and A5~10 in 1 min. The newborn was transferred to the neonatal department for treatment. He recovered well 4 days after surgery and was granted discharge.

Twin pregnancies are divided into monozygotic twins and dizygotic twins, and unlike bichorionic twins with two separate fetal placental circulatory systems, the two fetuses of monochorionic twins share a placenta. Monochorionic twins (MCDA) cause a series of complex twin complications due to placental share allocation and the presence of superficial anastomotic vessels, such as twin transfusion syndrome (TTTS), selective intrauterine growth restriction (sFGR), twin anemia-polycythemia sequence sign (TAPS), etc. sFGR is more common in MCDA, and its disease outcome and prognosis are diverse and complex, and there are many controversies in clinical management. This article reviews sFGR to provide reference for clinicians.

Dual antiplatelet therapy is standardized for patients with acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI)^[1]。 In the past 10 years, clopidogrel has been the most commonly used P2Y12 receptor antagonist in clinical practice, and the continuous advent of new antiplatelet drugs has provided a new choice for safer and more effective antiplatelet therapy. Prasugrel has been shown to be useful in clopidogrel-resistant patients treated with percutaneous coronary intervention^[2]。 The large PLATO study demonstrated that ticagrelor improves the prognosis and reduces the incidence of post-treatment platelet hyperreactivity (HTPR) in patients with acute coronary syndrome compared with clopidogrel, and has been recommended by guidelines as a first-line antiplatelet therapy in patients with ACS^[3]。 The choice of antiplatelet drugs in clinical work is influenced by numerous factors. In the process of early treatment, especially in the early emergency treatment of acute patients, it is not possible to obtain sufficient information in time to assess the ischemia and bleeding risk, socioeconomic status, etc. of patients, and to obtain more information to assess patients in subsequent treatment, and at the same time, combining the respective characteristics of antiplatelet drugs, thereby promoting the mutual conversion between antiplatelet drugs. Whether this increases the potential risk of hemorrhage or ischemia in the process of mutual conversion and how to develop the best conversion protocol deserves further research.