Volume 98 ·  Issue 43 ·  2018

In 2018, the Neurocritical Care Collaboration Group of the Neurology Branch of the Chinese Medical Association and the Neurocritical Care Professional Committee of the Neurologist Branch of the Chinese Medical Doctors Association launched the "Chinese Expert Consensus on Monitoring and Treatment of Respiratory Pump Failure"^[1]。 The reason why respiratory pump failure has attracted much attention in the field of neurocritical disease is that whether it is hemisphere, midbrain, and pons lesions that adjust respiratory rhythm, or oblongus lesions that initiate respiratory movement, whether it is spinal cord, peripheral nerves, neuromuscular junction lesions that conduct and govern respiratory movement, or respiratory endplate (respiratory muscle) lesions that complete respiratory movement, it can lead to respiratory pump failure and be life-threatening. Unfortunately, not all neurologists, emergency physicians, and critical care physicians can keenly perceive and clearly distinguish respiratory pump failure, and give adequate monitoring and treatment.

respiratory pump failure is a critical disease that leads to poor prognosis or even death in patients with critical neurological diseases. Respiratory pump failure can occur regardless of central nervous system injury or peripheral nervous system disease, and rapid identification (diagnosis) and accurate treatment of respiratory pump failure can effectively reduce the mortality rate of patients and provide the opportunity for the recovery of nervous system function. To this end, the Neurocritical Care Collaboration Group of Neurology Branch of Chinese Medical Association and the Neurocritical Care Professional Committee of Neurologist Branch of Chinese Medical Doctors Association launched the Chinese Expert Consensus on Monitoring and Treatment of Respiratory Pump Failure, whose main contents include the definition of respiratory pump failure, monitoring of respiratory pump failure and treatment of respiratory pump failure.

To investigate the long-term prognosis of Second generation drug-eluting stents(G2-DES) in diabetic mellitus(DM) and non-DM patients.

Patients with coronary heart disease(CHD) in Fuwai Hospital from January 2013 to December 2013 who had exclusively G2-DES implantation, were consecutively included the follow-up period was 2 years.

A total of 6 094 patients with CHD were implanted with G2-DES, of which 1 862 patients with DM, and 4 232 patients without DM.The proportion of DM patients receiving G2-DES implantation with the following characteristics: advanced age, female, hypertension, hyperlipidemia, history of previous stroke, history of peripheral artery disease, previous history of PCI, and with triple vessel, high preoperative Syntax score, high number of target lesions, B2 or C type lesions, severe calcification lesions, and chronic occlusive disease were significantly higher than those of non-DM patients(P<0.05). The incidence of major adverse cardiac and cerebral vascular events(MACCE), target vascular revascularization(TVR) and target lesion revascularization(TLR) were higher in DM patients than in non-DM patients during 2 year′s follow-up(P<0.05). The univariate COX regression analysis showed that diabetes was risk factor for MACCE in patients with CHD implanting G2-DES(HR=1.241, 95%CI: 1.053-1.463, P=0.010). However, multivariable COX analysis showed that DM was not an independent risk factor for MACCE in CHD patients with G2-DES(HR=1.125, 95%CI: 0.952-1.330, P=0.167). While age, female, preoperative Syntex score, triple vessel, B2 or C lesion were independent risk factors for poor clinical prognosis in CHD patients with G2-DES.

(1) CHD patients with DM often accompany more clinical risk factors and complicated coronary lesions; (2) the incidence of MACCE, TVR and TLR in DM patients is significantly higher than non-DM patients with G2-DES during the 2 year′s follow-up; (3) after multivariate adjustment, DM is not an independent risk factor for poor clinical prognosis in CHD patients with G2-DES, while traditional risk factors and complex coronary lesions are independent risk factors for poor clinical prognosis.

To compare the reliability and repeatability of simplified skeletal maturity scoring (SSMS) and thumb ossification composite index (TOCI) in the assessment of skeletal maturity in adolescent idiopathic scoliosis(AIS) and their clinical utilization.

A review was conducted on 500 AIS patients treated between October 2006 and August 2013 in Nanjing Drum Tower Hospital and one follow-up of each patient was randomly selected for this study.Based on SSMS and TOCI, the radiographs of the left palm were assessed by three observers independently with an interval of 2 weeks.The inter-observer reliability and intra-observer repeatability of two methods were analyzed by using Kappa value.

A total of 3 000 measurements were performed by the 3 surgeons for each method.For SSMS, 50 cases were described as stage 1 258 cases as stage 2 962 cases as stage 3 340 cases as stage 4 315 cases as stage 5 304 cases as stage 6 589 cases as stage 7 and 182 cases as stage 8.The inter-observer and intra-observer agreements was 76.8%-82.0% (Kappa value 0.716-0.778) and 75.8%-82.4% (Kappa value 0.705-0.782), respectively.For TOCI, 27 cases were described as stage 1 183 cases as stage 2 167 cases as stage 3 171 cases as stage 4 745 cases as stage 5 536 cases as stage 6 410 cases as stage 7 and 761 cases as stage 8.The inter-observer and intra-observer agreements was 91.6%-92.4% (Kappa value 0.897-0.907) and 90.4%-92.0%(Kappa value 0.882-0.902), respectively.

The two methods of SSMS and TOCI have substantial inter-observer reliability and intra-observer reproducibility for the assessment of skeletal maturity in AIS.TOCI has relatively higher reliability and repeatability when compared with SSMS.

To assess the bio-mechanical properties of paraspinal muscles in adolescent idiopathic scoliosis (AIS).

The MyotonPro® device and shear wave elasticity imaging(SWEI) technique were applied to detect the paraspinal muscle tone (F), stiffness (S), relaxation time (R), Deborah number (C) and elasticity (D) of paravertebral muscles on the concave side and convex side of scoliosis curvature at several points: apex of the curve (a), upper (b) and lower (c) limits of the curve in 23 cases of AIS treated from October to December 2017 in Beijing Chaoyang Hospital.Cobb angle of the main curve was measured on the standing anteroposterior whole spine radiograph.Pearson correlation analysis was applied to detect the relation between the bio-mechanical properties and Cobb angle of the main curve.

A total of 23 AIS patients [3 males and 20 females, mean age was (15±4) years] were assessed in this study.The mean Cobb angle was (66±33) degrees.The MyotonPro® data showed that the muscle tone on the concave side were all significantly greater than those on the convex side [a: (18.9±2.2) Hz vs (17.4±1.6) Hz, t=4.435, P<0.05; b: (18.2±2.0) Hz vs (16.7±1.7) Hz,t=4.183, P<0.05; c: (18.0±2.3) Hz vs (16.8±1.7) Hz,t=4.520, P<0.05]. The muscle stiffness on the concave side were all significantly greater than those on the convex side at the three points (t=1.974, 2.048, 1.749, all P<0.05). The relaxation time were all longer on the convex side (t=-3.422, -2.713, -2.380, all P<0.05). The Deborah number were greater on the convex side at a and b points (t=-2.939, -2.466, both P<0.05). No significant difference in elasticity was found between the muscles of the two sides.The SWEI results also indicated that the elasticity of the paraspinal muscles of the two sides were similar.The Pearson correlation analysis showed that stiffness on the concave side was moderate positively correlated with Cobb angle of the main curve (r=0.582, P<0.05). Deborah number on the two sides and relaxation time on the concave were moderate negatively correlated with Cobb angle of the main curve (r=-0.632, -0.432, -0.611, all P<0.05).

The bio-mechanical properties of paraspinal muscles in AIS are different significantly between the concave and convex side and affected by the severity of scoliosis.

To analyze the influence of simulation mouse use motion under different wrist forcing postures on median nerve, tendons and ligaments in the carpal tunnel.

From June to November in 2017, a total of 49 healthy volunteers [aged from 18 to 27 years, 24 males (48 cases of hands) and 25 females (50 cases of hands)] were selected in the Institute of Digitized Medicine and First Affiliated Hospital of Wenzhou Medical University.Three hand postures of the volunteers were simultaneously and continuously measured by using LOGIQ E9 ultrasonic diagnostic apparatus and Zebris foot pressure distribution measurement system.Seventeen parameters of nerves, tendons and ligaments in carpal tunnel were observed under natural (0 N), and two forced (25 and 50 N) states.Double factor variance analysis was performed with generalized estimating equation (GEE).

With increasing pressure (0, 25 and 50 N) of hand postures, the distance between median nerve and transverse carpal ligament were all less than 0.2 cm.The differences in both the distance between median nerve and flexor pollicis longus under the hand pressure changes or under the hand posture changes and the top angle of a triangle composed of median nerve, flexor pollicis longus and flexor digitorum superficialis group under the hand pressure changes or under the hand posture changes were all significant under the GEE analysis (all P<0.01). There were no significant changes in all other structural parameters in the carpal tunnel with the increasing of hand pressure (allP>0.05).

The influence of the transverse carpal ligament to the median nerve belongs to the mechanism of pressure-induced irritation damage.The influence of flexor pollicis longus to median nerve belongs to the mechanism of tension-induced irritation damage.The influence of flexor digitorum superficialis to median nerve belongs to the mechanism of mixed shear irritation damage.

To analyze the polymorphisms of human leukocyte differentiation antigens Ⅰ and Ⅱ (HLA-A, B, DRB1) alleles and explore the association between HIV infection and HLA loci, for discovering the distribution of HLA loci in HIV-infected with different disease progression in different parts of Henan Province.

A total of 48 cases of slow progressers and 80 typical progressers in Weishi County, Shangcai County, Xihua County and Xuchang City of Henan Province were studied, and compared with 380 healthy blood donors.For analyzing HLA-A, B, DRB1 alleles and comparing difference among the study subjects, the method of polymerase chain reaction-sequence special oligonucleotide (PCR-SSO) was used.

The association of HLA alleles and HIV infection showed that HLA-B*40∶02, HLA-DRB1*04∶05 was significantly more common in healthy people, while HLA-B*15∶18, B*44∶02, B*67∶01 and HLA-DRB1*14∶01 were present in HIV/AIDS.HLA-A*02∶06, HLA-B*13∶02, B*40∶06 in slow progressers were higher than typical progressers from the grouped study, and HLA-B*46∶01 only appeared in the typical progressers.

HLA-B*15∶18, B*44∶02, B*67∶01, and HLA-DRB1*14∶01 may be associated with HIV susceptibility.HLA-A*02∶06, HLA-B*13∶02, and B*40∶06 may be associated with delayed disease progression in HIV-infected people, while HLA-B*46∶01 may be associated with accelerated disease progression.

To investigate whether HBV genotype influences HBV DNA and RNA responses to tenofovir(TDF) and telbivudine(LDT) in pregnant women with HBeAg-positive in Guizhou.

This was a retrospective analysis of 75 pregnant women hepatitis B with HBsAg and HBeAg double-positive(19-38 years old, median age 26 years old), who were enrolled in the Department of Infectious Diseases and Obstetrics Clinic of the Affiliated Hospital of Guizhou Medical University from May 2016 to July 2017.Blood samples were collected at 12-24, 28-32 and 36-40 weeks of pregnancy for analyses of genotype, including hepatitis B surface antigen(HBsAg), hepatitis B e antigen (HBeAg), HBV DNA, HBV RNA and liver function, alanine transaminase(ALT), aspartate transaminase(AST), total bilirubin(TBiL), total bile acids(TBA), cholinesterase(CHE), alkaline phosphatase (ALP). Continuous variable was adopted by means of mean±standard deviation, and categorical variables were used for statistical analysis.

The HBV genotype was B in 64.0%(48/75)and C in 36.0%(27/75). The TDF and LDT groups showed no differences in demographic and clinical characteristics, including liver function tests, HBsAg, HBeAg, log₁₀HBV DNA and log₁₀HBV RNA.TDF groups, pre-treatment: HBV DNA (4.8±2.0), HBV RNA (6.4±1.1); at 4 weeks of treatment: HBV DNA (4.0±0.8), HBV RNA (6.0±0.9); at the end of treatment: HBV DNA (3.1±0.7), HBV RNA (5.5±0.8). LDT groups, pre-treatment HBV DNA (5.1±2.0), HBV RNA(6.5±0.9); at 4 weeks of treatment: HBV DNA (4.4±1.2), HBV RNA(6.5±0.8); at the end of treatment: HBV DNA(3.5±1.2), HBV RNA (6.1±0.7). Compared with pre-treatment (12-24 weeks), the TDF and LDT group showed significant reductions in log₁₀(HBV DNA) and log₁₀(HBV RNA) at 36-40 weeks ( P<0.05). Under the influence of excluding other variables, the genotype had a certain influence on the HBV RNA load.That was, HBV RNA in patients with the C genome decreased by 0.54 units(log₁₀) at the end of the treatment compared to patients with the B genome, and the P value was less than 0.05.

B and C genotypes are predominant in pregnant women with hepatitis B in Guizhou Province. B-type viruses are more easily controlled when different genotypes are treated with nucleotide analogues.

The main purpose of this paper is to evaluate the level of serum 25-hydroxyvitamin D (25-OH-D) and clinical significance in patients with Takayasu′s Arteritis (TA).

A total of 62 untreated TA patients (TA group) and 60 healthy people (control group) were enrolled. The level of serum 25-OH-D were measured and compared between groups. The correlations of 25-OH-D level with related indicators were analyzed.

Lower concentrations of serum 25-OH-D were detected in TA patients compared with healthy subjects[(11.8±4.7) μg/L versus (23.2±8.3) μg/L]( P<0.001). In active stage group, the 25-(OH)-D level of TA were significantly lower than that in remission stage group[(10.5±4.3) μg/L vs (13.3±4.9) μg/L](P=0.021). In all patients with TA, serum 25-OH-D correlated negatively with interleukin (IL)-6 (r=-0.296, P=0.023). There was no correlation between serum 25-OH-D level and C-reactive protein , erythrocyte sedimentation rate , National Institutes of Health Score, Indian Takayasu Clinical Activity Score 2010, and anti-tumor necrosis factor (TNF)-alpha antibody.

A high prevalence of vitamin D deficiency was observed in patients with TA. The serum 25-OH-D level were negatively correlated with IL-6.

To explore the dynamic features of tumefactive demyelinating lesions (TDLs) in different clinical stages by contrast-enhanced magnetic resonance imaging (MRI).

Thirty-five patients with TDLs proven by pathological studies were prospectively recruited from January 2015 to January 2017.Brain contrast-enhanced MRI of the patients in different clinical stages including acute phase, subacute phase and chronic phase were completed after enrollment.The characteristics of contrast-enhanced MRI in different clinical stages were compared and the evolutional characteristics were summarized.

(1) Acute phase (35/35): the patterns of enhancement were patchy (74.3%, n=26), nodule (34.3%, n=12), closed ring (14.3%, n=5) and open ring (11.4%, n=4). (2) Subacute phase (32/35): the patterns of enhancement were open ring (40.6%, n=13), closed ring (31.3%, n=10), patchy (25.0%, n=8) and irregular edge of enhancement (21.9%, n=7). (3) Chronic phase (15/35): the patterns of enhancement were pale patchy (10/15), open ring (5/15) and closed ring (2/15). (4) The proportions of enhancement patterns including patchy, nodule, edge enhancement and pale patchy were significantly different among different clinical stages: ① The patchy and nodule were the more common enhancement patterns in acute phase. ② The edge enhancement was found mostly in subacute phase. ③ The pale patchy was found mostly in chronic phase.

The manifestation of the lesions on contrast-enhanced MRI may have some characteristics of dynamic evolution according to different clinical stages.The dynamic observation may be helpful for the diagnosis and differential diagnosis of TDLs.

Percutaneous radiofrequency thermocoagulation (RFT) of the Gasserian ganglion is an effective treatment for refractory trigeminal craniofacial pain.In the present study, we assessed the feasibility of accessing the Gasserian ganglion through the foramen ovale with neuronavigation guidance in the patients of trigeminal craniofacial pain.

We retrospectively analyzed forty-four patients with type Ⅰ trigeminal neuralgia who had undergone percutaneous RFT treatment in our hospital from June 2014 to December 2016.The patients were divided into fluoroscopy group and navigation group according to the intraoperative guiding manners for foramen ovale cannulation.We compared groups in terms of the duration of the whole RFT procedure and times of intraoperative fluoroscopy.We also analyzed the immediate and late outcome accessing by Barrow Neurological Institute (BNI) pain scale, as well as the complication rates in groups.

There were 32 patients in the fluoroscopy group and 12 in the navigation group.The duration of the surgical procedure in navigation group was less than that in fluoroscopy group (46±12 min versus 67±16 min, P=0.00), and times of intraoperative fluoroscopy was reduced (6.3±2.2 versus 1.3±1.6, P=0.00). The learning curve of navigation-aid RFT was not steep in the present study overall.There was no significant difference between groups regarding pain reduction at the immediate (P=0.07) or late follow-up (P=0.400) time points.However, the rate of pain reduction to BNI-Ⅰ grade was greater in navigation group (P=0.026). No significant difference in the complication rate between both groups, and no serious complications were observed in the both groups.

Neuronavigation may be encouraged in trigeminal Gasserian ganglion RFT with better operating efficiency and less radiation exposure.The immediate and late therapeutic effects for craniofacial pain control were positive, whereas further studies are necessary.

To explore the effect of microwave ablation on thyroid nodules cell activity by the reaction of key enzyme of cell activation.

From November 2017 to February 2018, 104 patients with 120 thyroid nodules underwent ultrasound-guided microwave ablation at Super-minimally Invasive Medicals, Shanghai International Medical Center, aged 14-55 years, 42 males and 62 females.Twice core needle biopsy were performed before and after thermal ablation.The specimen were using hematoxylin and eosin (HE) staining and enzyme histochemical staining with include succinate dehydrogenase (SDH) and nicotinamide adeninedinucleotide phosphate diaphorase (NADPH-d), respectively, and observe under microscope.

Enzyme histochemical staining showed that the positive rate of SDH and NADPH-d in the marginal region and transitional region were 100% before ablation, and were 0% immediately after ablation.The positive rate of SDH and NADPH-d histochemical staining in the same area before and immediately after ablation was statistically significant (P<0.05). Shortly after microwave ablation, the tissue structure and cell morphology showed no obvious alteration in HE stained sections, but in sections with enzyme histochemical staining, the activity of SDH and NADPH-d in ablated tissue disappeared.The accuracy rate of pathologic diagnosis was 100% after ablation.

SDH and NADPH-d enzyme activity may be better in evaluating the short-term efficacy of microwave ablation of thyroid nodules than HE staining.

To investigate the effects of rosuvastatin (RSV)on autophagy and apoptosis of myocardial cells in rats with acute myocardial infarction.

SD rats were divided into control (Sham group), acute myocardial infarction model rats (AMI group), AMI rats treated by RSV with the dose of 5 mg·kg^-1·d^-1 (RSV group), AMI rats treated by RSV and AMPK inhibitor Compound C at the same time (RSV+ CC group)(n=8) based on simple random sampling methods.Rat myocardial cell line H9c2 was divided into control group, Hypoxia group, Hypoxia+ RSV group, Hypoxia+ RSV+ Compound C group, Hypoxia+ AICAR (AMPK activator)group.After 6 weeks, the rats were examined by hemodynamics, and pathological observation of myocardial tissue by HE staining was also carried out.RT-PCR/Western blot were used to detect the expression of Beclin1, p62, BAX and Bcl-2 mRNA or protein of different groups in vivo and in vitro.Western blot was used to detect the expression of mTOR and AMPK protein and phosphorylation in cardiac tissue of each group.

In this study, the rat model of acute myocardial infarction was successfully prepared.Compared with the AMI group, the myocardium inflammation in the RSV group was alleviated, the LVMI decreased significantly, LVSP increased significantly, LVEDP decreased significantly, HR decreased significantly, the absolute value of dP/dTmax and -dP/dTmax increased significantly.The levels of Beclin1 and Bcl-2 mRNA were significantly up-regulated from 0.43 to 2.01 and 0.30 to 0.72, the expression of p62 and BAX mRNA decreased in half, the phosphorylation level of AMPK was significantly up-regulated, and the level of mTOR phosphorylation significantly reduced(P<0.05). These changes were antagonized by AMPK inhibitors in RSV+ CC group.In vitro experiments showed that, after RSV intervening, the levels of Beclin1 and Bcl-2 mRNA and protein in the myocardial cells of Hypoxia group significantly increased in triple, while the expressions of p62 and BAX mRNA and protein significantly decreased above a half.The above changes were consistent with those of the AMPK activator group and were antagonized by Compound C.

RSV can effectively promote autophagy and decrease apoptosis in rat heart after myocardial infarction through AMPK/mTOR pathway.

Percutaneous coronary intervention (PCI) is an effective treatment for patients with acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) with ticagrelor combined with aspirin after PCI is recommended by major guidelines^[1,2]。 Individualized assessment of DAPT effectively reduces thrombosis and bleeding events, and the CRUSADE bleeding score is a commonly used bleeding risk assessment tool for patients with ACS^[3,4]In-stent thrombosis risk score^[5](ST score) can effectively predict the occurrence of cardiovascular ischemic events. In the treatment of DAPT, there will be clinical intolerance of aspirin, and how to choose a reasonable treatment plan is a clinical doubt. Can ticagrelor be selected as a monotherapy for aspirin intolerant patients treated with DAPT in PCI in ACS patients with high bleeding and low in-stent thrombus during 1 to 12 months? In this study, the efficacy and safety of this protocol were evaluated by clinical observation and data collection.

Extracerebral hydrops in children is a benign self-limiting disease characterized by megacraniosis (enlarged head circumference). The imaging feature is low-density fluid accumulation outside the brain on CT. The vast majority of children with extracerebral hydrops are idiopathic^[1,2]Based on a population study in Norway, the incidence of benign extracerebral hydrops in children was 0.4‰^[2]。 Extracerebral hydrops in adults is relatively rare and rarely reported in the literature. The Department of Neurosurgery, Beijing Tiantan Hospital affiliated to Capital Medical University summarized the diagnosis and treatment experience of 4 adult patients with extracerebral hydrops from July 2016 to September 2018, and analyzed the clinical characteristics, etiology, pathophysiology, diagnosis and treatment principles of adult extracerebral hydrops.

The patient, a 32-year-old male, came to our hospital in October 2017 due to pain in his left foot for 1 1/2 months. The patient reported that he injured his left foot in a car collision with a car one and a half months ago. He was not treated, and the pain in his left foot recurred. Physical examination on admission: local bone bulging on the medial side of the left foot, obvious tenderness, red skin color, slightly higher skin temperature, unlimited flexion and extension of each toe, and no obvious abnormalities in skin sensation and blood supply at the tip of the toe. X-ray examination of left foot was performed after admission (Figure 1) and left foot CT examination (Figure 2), the results showed that the accessory scaphoid of the left foot, the soft tissue of the medial left foot was swollen, and no obvious bone interruption was seen. Laboratory tests: uric acid 591.6 μ mol/L (normal range: 208-428 μ mol/L, the same below), alanine aminotransferase 54.6 U/L (9-50 U/L), glutamate aminotransferase 48.8 U/L (15-40 U/L), glutamyl transpeptidase 276 U/L (10-60 U/L), C-reactive protein 4.3 mg/L (0-3 mg/L), and no obvious abnormalities were found in other test results. Combined with the patient's medical history, clinical manifestations, imaging examination and laboratory examination, the initial diagnosis was gout associated with accessory scaphoid of left foot.

A 54-year-old male was admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine on September 18, 2017 due to "facial numbness and tightness for 5 years and aggravation for 1 year". Five years ago, the patient experienced facial numbness and tightness without obvious inducement, involving both sides of the face and lips, rice grains stuck on both sides of the cheeks during meals, sometimes choking and coughing after drinking water, no dry mouth and eyes, no parotid gland swelling, no numbness, weakness and pain in the limbs, etc., and no systematic diagnosis and treatment was performed. In the past year, the patient felt that the symptoms had aggravated, and went to our outpatient clinic for electromyography to consider the possibility of trigeminal neuropathy, but there was no improvement after treatment such as nutritional nerve. Past physical fitness. Family history and genetic history were denied. Physical examination of the nervous system at admission: vague speech, pertinent answers, bilateral pupils of equal size and round, sensitive to light reflection, eyeball movement in all directions, bilateral corneal reflex weakening, bilateral facial and perioral acupuncture sensation decreasing, normal chewing movement, bilateral inability to bulge gills, bilateral facial muscle atrophy (Figure 1), bilateral frontal lines were symmetrical, bilateral nasolabial folds were not shallow, the mouth corners were not skewed, the taste was normal, the pharyngeal reflex disappeared, the head-up force was weak, the proximal and distal muscle strength of the limbs was grade 5, no muscle fibrillation was observed, no muscle atrophy of the limbs was observed, the muscle tone was normal, the depth and shallow sensation of the limbs was not abnormal, the tendon reflex of both upper limbs (+ +), the tendon reflex of both lower limbs (+ + +), the bilateral Hoffmann's sign was positive, the bilateral palmaromandibular reflex was positive, and the bilateral Babinski sign was negative. Auxiliary examinations: blood, urine, stool routine, blood biochemistry, complete set of antinuclear antibodies (including anti-SSA antibodies and anti-SSB antibodies), rheumatoid factor, thyroid function, immunoglobulin, IgG4, HIV, syphilis, hepatitis series, tumor series, etc. No abnormalities were found. Cerebrospinal fluid: Protein content 0.614 g/L (reference value 0.08~0.43 g/L), sugar, cell count and IgG synthesis index were normal. Whole exon gene test was negative. Cranial MRI plain scan + black water imaging showed no obvious abnormalities; MRI of trigeminal nerve showed that the right superior cerebellar artery was adjacent to the trigeminal nerve; Cervical MRI showed cervical 3/4, cervical 4/5 and cervical 5/6 disc herniation (Figure 2)。 Nerve conduction detection showed that the sensory nerve conduction velocity of the right and left superficial ulnar branches was slowed down, the amplitude of the evoked potential of the right and left superficial median branches and superficial peroneal nerves was reduced, and the amplitude of the motor conduction evoked potential of the left facial nerve (frontal muscle) was lower than that of the right side; Blink reflection measurement: incubation period of both R1 and R2 waves is prolonged (Figure 3)； Electromyography showed extensive neurogenic lesions in the three segments of medulla oblongata, cervix and thorax. Clinical diagnosis: FOSMN syndrome. Intravenous methylprednisolone 80 mg/d ×14 d + intravenous immunoglobulin 20 g/d ×5 d was administered, followed by oral prednisone 60 mg/d, and the dose was gradually reduced (10 mg per week) until discontinuation. On October 10, 2017, the patient's facial numbness and tightness improved, and facial muscle atrophy was reduced compared with before. At the last telephone follow-up on Oct. 3, 2018, the patient's symptoms were similar to those at discharge, and no disease progression was observed.