Studying tourism development and its impact on carbon emissions

Analyzing the influence of tourism on carbon emission has significant implications for promoting the sustainable development of tourism. Based on the panel data of 31 tourist cities in China from 2005 to 2022, this study utilizes a structural equation model to explore the carbon reduction effect of tourism development and its influencing mechanism. The results show that: (1) The overall carbon emission efficiency of tourism cities first decreased and then increased, rised to a peak of 0.923 in 2022. (2) Tourism development has a significant positive impact on carbon emission efficiency, and there are three influence paths: tourism → environmental regulation → carbon emission efficiency, tourism → environmental regulation → industrial structure → carbon emission efficiency, and tourism → industrial structure → carbon emission efficiency. (3) The influence of tourism development on carbon emission efficiency mainly depends on the direct effect, and the development of tourism also indirectly affect the industrial structure. Environmental regulation also mainly depends on the direct effect on carbon emission efficiency. (4) Foreign direct investment lead to the reduction of carbon emission efficiency in both direct and indirect aspects.

Dialysis disequilibrium syndrome in neurosurgery: literature review and illustrative case example

INTRODUCTION

The dialysis disequilibrium syndrome (DDS) is a complication in those undergoing dialysis for chronic kidney disease (CKD) or acute kidney injury (AKI), characterized by nonspecific symptoms that may progress to coma and death secondary to cerebral edema. This syndrome is associated with rapid change in electrolytes during dialysis with changes in intracranial pressure (ICP) and may have a higher incidence in the elderly neurosurgical patient population.

METHODS

Literature review and illustrative case example.

RESULTS

A 62-year-old female presented with acute mental status change during hemodialysis (HD), with a history of a nonsurgical acute subdural hematoma (SDH) 10 days prior. Imaging showed a conversion of the acute SDH to chronic SDH of 12.2 mm in size with a 14.1 midline shift, for which she underwent a hemicraniectomy with SDH evacuation, with a gradual return to baseline. The literature review identified 5 publications meeting the inclusion criteria. Major theories of DDS include a reverse urea effect, intracerebral acidosis, idiogenic osmoles, and local inflammation. This complication may occur more frequently in the elderly neurosurgical patient population, likely due to age-related comorbidities, preexisting neurological insult, and increased permeability of the blood-brain barrier (BBB), leading to cerebral edema.

CONCLUSION

DDS is a rare and potentially fatal complication of HD that may have a higher incidence in the elderly neurosurgical patient population, yet remains to be fully understood. Further study is recommended to characterize the pathophysiological mechanism and incidence of DDS in neurosurgical patients.

Arteriovenous malformation with unique drainage through the emissary vein of the foramen ovale: illustrative case

BACKGROUND

As part of the laterotrigeminal venous system (LTVS), the emissary vein of the foramen ovale (EVFO) is an underrecognized venous structure communicating between the cavernous sinus and pterygoid plexus. The sphenobasal sinus is an anatomical variation of the sphenoparietal sinus that drains directly into the EVFO. The authors present the case of a ruptured arteriovenous malformation (AVM) with a unique drainage pattern through the sphenobasal sinus and EVFO.

OBSERVATIONS

A 9-year-old female initially presented with loss of consciousness and was subsequently found to have a ruptured AVM in the left basal frontal area. She underwent an immediate decompressive hemicraniectomy, with a computed tomography angiogram demonstrating a unique anatomical variation in which the sphenobasal sinus communicated with the EVFO and LTVS. The final venous drainage returned to the pterygoid plexus and external jugular vein. Postoperatively, the patient made a substantial recovery, with generalized right-sided weakness remaining as the sole deficit.

LESSONS

The authors present the case of a ruptured AVM with unique venous drainage into the sphenobasal sinus and EVFO, for which the current literature remains limited. As exemplified by this illustrative case, technique modification may be warranted in the setting of this unique anatomical variation to avoid venous sinus injury.

Aspirator-Assisted Endoscopic Third Ventriculostomy in an Infant: 2-Dimensional Operative Video

Endoscopic third ventriculostomy (ETV) is an effective treatment for hydrocephalus in carefully selected patients.1 Studies have shown that larger ostomy size may be associated with higher ETV success and reduced ostomy closure in pediatric and adult patients.2-5 Therefore dilation of the ostomy is a key step in this procedure, which is traditionally accomplished with a balloon catheter, leaving behind loose redundant tissue at the ostomy site. In this 2-dimensional endoscopic operation (Video 1), we demonstrate the technique of using an aspiration device to enlarge the ETV ostomy in a controlled and efficient manner while eliminating redundant tissue. The patient is a 6-month-old girl with newly developed triventricular hydrocephalus seen on head ultrasound, manifested as upward gaze palsy, fontanelle fullness, and rapidly increasing head circumference. We chose to treat her with an ETV, given an ETV success score of 70.6,7 She underwent an ETV augmented with the NICO Myriad aspirator (NICO Corporation, Indianapolis, Indiana, USA) and achieved excellent clinical outcome. No intraoperative or postoperative complication occurred. Postoperative magnetic resonance imaging demonstrated an 8.4-mm ostomy on the third ventricular floor, nearly twice the size of a typical ETV ostomy.5 The key considerations in using this device include setting a low aspiration limit to avoid oversuction and using only mediolateral motion to avoid damage to the basilar artery. Future comparative studies are needed to investigate the efficacy, safety, and long-term outcome in aspirator-assisted ETV versus traditional techniques, as well as to evaluate ostomy size as an independent variable for long-term ETV success.

An institutional experience in applying quality improvement measures to pituitary surgery: clinical and resource implications

OBJECTIVE

The aim of this study was to report the authors' experience developing a Lean Six Sigma clinical care pathway (CCP) for endoscopic endonasal transsphenoidal operations.

METHODS

Using Lean Six Sigma quality improvement principles-including the define, measure, analyze, improve, and control framework-the authors developed a CCP for endoscopic endonasal transsphenoidal operations, incorporating preoperative, intraoperative, and inpatient and outpatient postoperative phases of care. Efficacy and quality metrics were defined as postoperative length of stay (LOS), presentation to the emergency department (ED) or readmission within 30 days of discharge, and hospital charges. The study included all adult patients who underwent elective endoscopic endonasal resection for pituitary adenoma, Rathke's cleft cyst, craniopharyngioma, pituicytoma, or arachnoid cyst during the sampling period (April 1, 2018, to December 31, 2022).

RESULTS

Two hundred twenty-eight patients met criteria and were included; 94 were treated before and 134 were treated after implementation of the CCP. Differences between groups in age, gender, race, BMI, American Society of Anesthesiologists classification, geographic distribution, preoperative serum sodium, tumor size, adenoma functional status, and prior surgery were not significant. The mean postoperative LOS significantly decreased from 4.5 to 1.7 days following CCP implementation (p < 0.0001); LOS variability also decreased, with the standard deviation declining from 3.1 to 1.5 days. The proportion of patients discharged on postoperative day (POD) 1 significantly increased from 0% to 61.9% (p < 0.0001). Fewer than one-quarter of the patients (23.4%) were discharged by POD 2 prior to the CCP, while 88.8% of were discharged by POD 2 after CCP implementation (p < 0.0001). Rates of 30-day ED presentations or readmissions were not significantly different (2.1% vs 6.0%, p = 0.20, and 7.5% vs 6.7%, p > 0.99, respectively). Mean per-patient hospital costs declined from $38,326 to $26,289 (p < 0.0001), with an associated change in cost variability from a standard deviation of $16,716 to $12,498.

CONCLUSIONS

CCP implementation significantly improved LOS and costs of endoscopic endonasal resection, without adversely impacting postoperative ED presentations or readmissions.

Threshold effect of technological innovation on carbon emission intensity based on multi-source heterogeneous data

It is of much importance to clarify the impact of technological innovation on carbon emission intensity for the low-carbon transformation of China's economy. This study, based on the panel data of 30 Chinese provinces and municipalities from 2010 to 2020, measures and analyzes the carbon emission intensity and the level of technological innovation, establishing a spatial econometric model to study the spatial spillover effect and a panel threshold model to analyze the nonlinear influence of technological innovation level on carbon emission intensity. The findings are as follows: First, the overall carbon emission intensity in China shows a decreasing trend from 2010 to 2020, with the average dropping from 3.09 in 2010 to 1.98 in 2020; Second, the spatial autocorrelation results reveal that the level of technological innovation and carbon emission intensity in China are obviously aggregated in the global spatial distribution pattern. Third, the regression results of the spatial econometric model show that the direct effect of technological innovation on carbon emission intensity is significantly negative at the level of 1%, that is, the improvement of the technological innovation in a certain area has a significant inhibitory effect on carbon emission intensity. Fourth, based on the level of economic development, there is a significant three-threshold effect of the level of technological innovation on carbon emission intensity in China, and the influence of the level of technological innovation on carbon emission intensity varies in the direction of existence and coefficient values within different threshold intervals. As economic development reaches the third interval, the technological innovation level has the most significant inhibition on carbon emission intensity. These findings enriches the research of the nonlinear relationship between technological innovation and carbon emission intensity, clarifies the spatial spillover effect and threshold effect between among them, and provides inspiration for better promote the low-carbon transformation of economy.

Spatial and temporal evolution of urban carbon emission efficiency in China

Improving carbon emission efficiency is crucial for achieving carbon peak and carbon neutrality. This paper analyzes the carbon emission efficiency of Chinese cities using panel data from 275 prefecture-level cities between 2006 and 2020. The super-efficiency SBM (undesirable slacks-based measurement) model of undesired output, combined with kernel density estimation and exploratory data analysis, is employed. This study finds, firstly, from 2006 to 2020, the average efficiency of carbon emissions in Chinese cities declined from 0.53 to 0.48, indicating a downward trend. Secondly, from a temporal perspective, the level of dispersion in urban carbon emission efficiency has become increasingly distinct over time, coupled with a decrease in polarization. Thirdly, in terms of spatial analysis, urban carbon emission efficiency in China shows a positive correlation in a global context. In terms of local spatial correlation, it primarily exhibits high-high and low-low clusters, with a few instances of low-high and high-low clusters. Finally, based on the research findings, this paper proposes suggestions to improve urban carbon emission efficiency.

Regional common prosperity level and its spatial relationship with carbon emission intensity in China

The characteristics of common prosperity include harmonious relationships between humans and the environment, as well as sustainable economic and social growth. The process of achieving common prosperity will necessarily have an impact on carbon emissions. In this article, panel statistics collected from 30 Chinese provinces and cities between the years 2006 and 2020 are utilized to assess the level of common prosperity and the intensity of carbon emissions in China. Then the SDM model is applied to explore the effects of the common prosperity level on the intensity of carbon emissions. The findings reveal that: (i) The common prosperity level in China has shown an increasing tendency. Between 2006 and 2020, the mean level of common prosperity increased from 0.254 to 0.486. From the regional perspective, eastern China has seen greater levels of common prosperity than central China, while central China has experienced greater levels of common prosperity than western China; regional disparities in the degree of common prosperity are substantial among Chinese provinces from 2006 to 2020; the common prosperity level is relatively high in economically developed provinces and relatively low in economically backward provinces. (ii) China's carbon emission intensity shows a continuous downward tendency. The annual average intensity of China's carbon emissions decreased from 4.458 in 2006 to 2.234 in 2020. From the regional perspective, the three main regions' carbon emission intensity likewise exhibits a decline in tendency between 2006 and 2020; still, western China continues to have the greatest carbon emission intensity, following central China, while eastern China has the smallest; however, certain provinces, notably Inner Mongolia and Shanxi, continue to have high carbon emission intensity. (iii) China's common prosperity level and carbon emission intensity both exhibit positive spatial autocorrelation at a 1% significant level under the adjacency matrix. The spatial agglomeration effect is significant, and adjacent provinces can affect each other. (iv) The SDM (Spatial Durbin Model) model test with fixed effects finds that the increase in the level of common prosperity suppresses the intensity of carbon emissions in the local area and neighboring regions. (v) The mediating effects model indicates that the process of common prosperity suppresses carbon emission intensity through high-quality economic development, narrowing the income disparity, and the development of a sharing economy.

Bilateral cerebellopontine angle lipomas in an infant with encephalocele: illustrative case

BACKGROUND

Bilateral cerebellopontine angle (CPA) lipomas are extremely rare. Herein the authors present a case of bilateral CPA lipomas in an infant along with a literature review of bilateral CPA lipomas.

OBSERVATIONS

A newborn girl was incidentally found to have bilateral CPA lipomas during the workup for an occipital encephalocele. The encephalocele was repaired primarily on day 2 after birth. The patient demonstrated no symptoms associated with the bilateral CPA lipomas. Eight cases of bilateral CPA lipomas were identified in the literature review and are summarized. Conservative management is the consensus strategy, given minimum growth of the tumor and the high risk of surgical intervention.

LESSONS

This is the first reported case of bilateral CPA lipomas in an infant as well as the first with a coexisting intracranial malformation. Intracranial lipomas share an extremely low growth rate and typically do not cause severe symptoms. The management of asymptomatic or mildly symptomatic bilateral CPA lipomas is usually conservative.

A multiline fitting method for measuring ethylene concentration based on WMS-2f/1f

Coal spontaneous combustion risk assessment is a global technical challenge for the sustainable development of deep mining technology, and C2H4 is a key indicator for early warning of coal spontaneous combustion. Tunable diode laser absorption spectroscopy (TDLAS) has the advantages of high selectivity, high sensitivity, high accuracy and real-time on-line measurement, and it can detect multiple gases simultaneously, so it has significant advantages in the accurate detection of coal spontaneous combustion indicator gases. To address the problem of cross-interference between the near-infrared absorption lines of CH4 and C2H4, which are the indicator gases of spontaneous combustion in coal, a multi-line fitting method was proposed in this study to calibrate the concentration of C2H4. The high-precision Environics2000 automatic standard gas dispenser from the United States, which has a built-in CPU computer control and data control and processing system, was used. Its gas concentration accuracy: ± 1.0%, gas flow accuracy: ± 1.0%, gas repeatability accuracy: ± 1.0%, flow linearity accuracy: ± 0.5%, and inlet operating pressure: minimum 10 psig (0.67 bar) ~ 75 psig (5.04 bar). The measured and simulated WMS-2f/1f signals were multilinearly fitted using a multilinear fitting algorithm and wavelength modulation spectroscopy (WMS), and the measurement of C2H4 concentration was achieved based on the extracted spectral line information. The results show that the maximum relative error of C2H4 concentration measurement is 2.40%, which is 54% lower than that of the conventional 2f peak measurement method, thus demonstrating the effectiveness of the multilinear fitting algorithm in the inversion of C2H4 concentration under the interference of absorption lines. In addition, this study has far-reaching implications for the application of TDLAS technology in the accurate detection of coal spontaneous combustion indicator gases.

An endolysin gene from Candidatus Liberibacter asiaticus confers dual resistance to huanglongbing and citrus canker

The most damaging citrus diseases are Huanglongbing (HLB) and citrus canker, which are caused by Candidatus Liberibacter asiaticus (CaLas) and Xanthomonas citri pv. citri (Xcc), respectively. Endolysins from bacteriophages are a possible option for disease resistance in plant breeding. Here, we report improvement of citrus resistance to HLB and citrus canker using the LasLYS1 and LasLYS2 endolysins from CaLas. LasLYS2 demonstrated bactericidal efficacy against several Rhizobiaceae bacteria and Xcc, according to inhibition zone analyses. The two genes, driven by a strong promoter from Cauliflower mosaic virus, 35S, were integrated into Carrizo citrange via Agrobacterium-mediated transformation. More than 2 years of greenhouse testing indicated that LasLYS2 provided substantial and long-lasting resistance to HLB, allowing transgenic plants to retain low CaLas titers and no obvious symptoms while also clearing CaLas from infected plants in the long term. LasLYS2 transgenic plants with improved HLB resistance also showed resistance to Xcc, indicating that LasLYS2 had dual resistance to HLB and citrus canker. A microbiome study of transgenic plants revealed that the endolysins repressed Xanthomonadaceae and Rhizobiaceae populations in roots while increasing Burkholderiaceae and Rhodanobacteraceae populations, which might boost the citrus defense response, according to transcriptome analysis. We also found that Lyz domain 2 is the key bactericidal motif of LasLYS1 and LasLYS2. Four endolysins with potential resistance to HLB and citrus canker were found based on the structures of LasLYS1 and LasLYS2. Overall, the work shed light on the mechanisms of resistance of CaLas-derived endolysins, providing insights for designing endolysins to develop broad-spectrum disease resistance in citrus.

Novel retro-auricular myocutaneous hemicraniectomy flap: Technical note and cadaveric dissection

Objective

The hemicraniectomy is a common technique used in a variety of pathologies including some traumatic brain injury and malignant stroke. A novel technique of performing hemicraniectomies using a retro-auricular incision can avoid transgressing the temporalis muscle and superficial temporal artery while providing adequate hemicranial exposure.

Methods

This technique was reproduced in a skull base lab using a cadaveric head. The key steps of this approach were illustrated in step-by-step fashion. A post-approach CT scan of the cadaver was performed to evaluate the decompression exposure.

Results

This approach can provide sufficient middle fossa decompression and area of exposure, while preserving the temporalis along with the superficial temporal artery. A step-by-step technical illustration is demonstrated in the present note.

Conclusions

The modified retro-auricular myocutaneous flap is a novel technique in hemicraniectomy which can provide sufficient middle fossa decompression and exposure while sparing the temporalis muscle and superficial temporal artery during the approach.

Open Surgical Approaches for Meningiomas

Meningiomas are the most common intracranial extra-axial primary tumor. Although most are low grade and slow growing, resection can be technically challenging, particularly when located at the skull base. Appropriate craniotomy and approach selection are of paramount importance to minimize brain retraction, optimize exposure, and achieve complete resection. This article summarizes various craniotomies and their approaches to meningiomas, and illustrates some nuances in performing these techniques with cadaveric dissection and operative videos.

[Effects of different accompanying symptoms of obstructive sleep apnea on the risk of cardiovascular and cerebrovascular and diabetes events]

Objective: To investigate the effects of different accompanying symptoms on the risk of cardiovascular and cerebrovascular and diabetes events in patients with obstructive sleep apnea (OSA). Methods: Patients diagnosed with OSA in the sleep center of Tangdu Hospital from January 4, 2011 to December 28, 2016 were retrospectively collected and divided into four groups according to accompanying symptoms: group A included OSA patients without insomnia and excessive daytime sleepiness (EDS), group B included OSA patients with insomnia, group C included OSA patients with EDS and group D included OSA patients with insomnia and EDS. Patients were followed up by telephone for 6 to 11 years. Outcome measures were composite cardiovascular and cerebrovascular and diabetes events (including new onset or recurrent heart disease, cerebral infarction, cerebral hemorrhage, newly diagnosed hypertension and diabetes). Kaplan-Meier method was used to draw survival curves, log-rank test was performed to compare the prognosis of OSA patients with insomnia and/or EDS symptoms, and multivariate Cox proportional hazards model was constructed to analyze the influencing factors of adverse outcome events in OSA patients. Results: Five hundred and four patients with OSA were included, and 307 patients [274 males and 33 females, aged (49±11) years] completed the follow-up, including 27 patients in group A, 143 patients in group B, 27 patients in group C, and 110 patients in group D. After a median follow-up of 7.7 years, 78 patients developed cardiovascular and cerebrovascular and diabetes events. Outcome events occurred in 1 patient (3.70%) in group A, 30 (20.98%) in group B, 10 (37.04%) in group C, and 37 (33.64%) in group D. Compared with patients in group A, there was a statistically significant difference in the incidence of outcome events in groups B (P=0.034), C (P=0.004), and D (P=0.003). After adjusting for age, sex, body mass index, apnea-hypopnea index, baseline cardiovascular and cerebrovascular risk factors and subsequent continuous positive airway pressure therapy, patients in group C (HR=9.67, 95%CI: 1.23-76.37, P=0.031) and group D (HR=11.35, 95%CI: 1.55-83.43, P=0.017) had an increased risk of cardiovascular and cerebrovascular and diabetes events when compared with group A. Conclusions: In OSA patients with successful long-term follow-up, insomnia and EDS symptoms are risk factors for the development of cardiovascular and cerebrovascular and diabetes events. Insomnia and EDS symptoms should be evaluated in patients with OSA during clinical practice to find the cause and carry out the targeted intervention.

Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training

OBJECTIVE

Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity.

METHODS

Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey.

RESULTS

A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models.

CONCLUSIONS

The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.

The Effect of the Magnesium Sulfate in Ultrasound-Guided Quadratus Lumborum Block on Postoperative Analgesia: A Randomized Controlled Trial

INTRODUCTION

Quadratus lumborum block (QLB) has proven to be an effective analgesic technique in various abdominal surgeries. Magnesium sulfate as an adjuvant in different nerve blocks has been reported. The aim of this study was to assess the efficacy of magnesium sulfate as an adjuvant to ropivacaine in an ultrasound-guided QLB for postoperative analgesia in laparoscopic gynecologic surgery.

METHODS

Ninety patients belonging to American Society of Anesthesiologists (ASA) physical status I or II, aged between 40 and 60 years, scheduled for laparoscopic gynecologic surgery were enrolled. Patients were divided into three groups and received bilateral quadratus lumborum block: ropivacaine group (group N, 0.375% ropivacaine 40 ml + normal saline 4 ml), magnesium sulfate group (group M, 0.375% ropivacaine 40 ml + 10% magnesium sulfate 4 ml), and control group (group C, normal saline 44 ml). Visual analogue scale (VAS) at rest and during activity at 4, 6, 12, 24, and 48 h postoperatively, consumption of morphine, the time of first analgesic request, frequency of rescue analgesia, satisfaction with postoperative analgesia, and any side effects were recorded.

RESULTS

VAS scores in groups M and N were significantly lower than in group C at 4 and 6 h postoperatively (P < 0.001). VAS scores were lower in group M at 12 and 24 h postoperatively compared to groups N and C (P < 0.05). The mean total morphine consumption was significantly lower in group M than in groups N and C (P < 0.001). The mean time to the first patient-controlled analgesia (PCA) bolus was significantly prolonged in group M compared to group C (P < 0.05). The satisfaction with postoperative analgesia of group M was superior to that of groups N and C (P < 0.05). There was no significant difference in side effects among the three groups.

CONCLUSION

Magnesium sulfate as an adjuvant to ropivacaine in ultrasound-guided QLB prolongs the duration of analgesia, decreases analgesic requirements, and improves patient satisfaction without significant side effects.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900027066.

CcRR5 interacts with CcRR14 and CcSnRK2s to regulate the root development in citrus

Response regulator (RR) is an important component of the cytokinin (CK) signal transduction system associated with root development and stress resistance in model plants. However, the function of RR gene and the molecular mechanism on regulating the root development in woody plants such as citrus remain unclear. Here, we demonstrate that CcRR5, a member of the type A RR, regulates the morphogenesis of root through interacting with CcRR14 and CcSnRK2s in citrus. CcRR5 is mainly expressed in root tips and young leaves. The activity of CcRR5 promoter triggered by CcRR14 was proved with transient expression assay. Seven SnRK2 family members with highly conserved domains were identified in citrus. Among them, CcSnRK2.3, CcSnRK2.6, CcSnRK2.7, and CcSnRK2.8 can interact with CcRR5 and CcRR14. Phenotypic analysis of CcRR5 overexpressed transgenic citrus plants indicated that the transcription level of CcRR5 was associated with root length and lateral root numbers. This was also correlated to the expression of root-related genes and thus confirmed that CcRR5 is involved in the root development. Taken together, the results of this study indicate that CcRR5 is a positive regulator of root growth and CcRR14 directly regulates the expression of CcRR5. Both CcRR5 and CcRR14 can interact with CcSnRK2s.

Transfer of extensor carpi radialis brevis branch of radial nerve to anterior interosseous nerve for lower trunk brachial plexopathy after motor vehicle accident

The patient is a 15-year-old male who sustained injury to his right lower brachial plexus (C8-T1) in a motor vehicle accident. Six months after the injury, the patient still had persistent hand weakness and wished to regain function in his first and second digits. Transfer of the extensor carpi radialis brevis (ECRB) branch of the radial nerve to the anterior interosseous nerve (AIN) was performed to restore motor function. The patient did well after the surgery, although it may take 12-24 months for benefits to fully manifest. Pertinent surgical anatomy and techniques are highlighted in this video demonstration. The video can be found here: https://stream.cadmore.media/rr10.3171/2022.10.FOCVID2287.

Nervus intermedius: Microsurgical and anatomic relationships to the cerebellopontine angle neurovascular complex

Background

The nervus intermedius (NI) comprises fibers originating from the trigeminal, superior salivary, and solitary tract nuclei, which join the facial nerve (cranial nerve [CN] VII). Neighboring structures include the vestibulocochlear nerve (CN VIII), the anterior inferior cerebellar artery (AICA), and its branches. Microsurgical procedures at the cerebellopontine angle (CPA) benefit from understanding NI anatomy and relationships, especially for the microsurgical treatment of geniculate neuralgia, where the NI is transected. This study sought to characterize common relationships between the NI rootlets, CN VII, CN VIII, and the meatal loop of AICA at the internal auditory canal (IAC).

Methods

Seventeen cadaveric heads underwent retrosigmoid craniectomy. Following complete unroofing of the IAC, the NI rootlets were individually exposed to identify their origins and insertion points. The AICA and its meatal loop were traced to assess their relationship with the NI rootlets.

Results

Thirty-three NIs were identified. The median number of NI rootlets was 4 per NI (interquartile range, 3-5). The rootlets mainly originated from the proximal premeatal segment of CN VIII (81 of 141, 57%) and inserted onto CN VII at the IAC fundus (89 of 141, 63%). When crossing the acoustic-facial bundle, the AICA most frequently passed between the NI and CN VIII (14 of 33, 42%). Five composite patterns of neurovascular relationships were identified regarding NI.

Conclusion

Although certain anatomical trends can be identified, the NI has a variable relationship with the adjacent neurovascular complex at the IAC. Therefore, anatomical relationships should not be used as the sole method of NI identification during CPA surgery.

Nontraumatic atlantoaxial rotatory subluxation in adults: Report of two cases

Background

Nontraumatic infectious atlantoaxial rotatory subluxation (AARS) is rare and less frequently encountered in adults versus children. We utilized a stepwise approach to treat two adults with nontraumatic infectious AARS and summarized the relevant literature.

Case Description

Two patients, ages 35 and 66, presented with classic clinical and imaging findings for infectious nontraumatic AARS. Here, we summarized the management for these two patients along with the literature.

Conclusion

Nontraumatic infectious AARS in adults requires prompt X-ray diagnosis and timely application of traction to minimize neurological deficits. MR/CT imaging next offers critical information regarding whether operative stabilization is warranted.

Parental presence and intranasal dexmedetomidine for the prevention of anxiety during anesthesia induction in children undergoing tonsillectomy and/or adenoidectomy surgery: A randomized controlled trial

Background: During the perioperative period of pediatric surgery, it is extremely stressful for children and parents to enter the operating room and receive the anesthesia induction. This study was designed to evaluate the perioperative outcomes with parental presence at induction of anesthesia (PPIA), intranasal dexmedetomidine, and combined use of PPIA and intranasal dexmedetomidine. Methods: In this prospective study, 124 children were randomly divided into four groups: control (no parental presence or intranasal dexmedetomidine), PPIA (parental presence), DEX (intranasal dexmedetomidine (1.0 μg/kg)), and PPIA + DEX (parental presence and intranasal dexmedetomidine (1.0 μg/kg)). The anxiety of children was mainly evaluated by the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary evaluation methods were, for example, the Induction Compliance Checklist (ICC), the Pediatric Anesthesia Emergence Delirium Scale (PAED), the COMFORT Behavior Scale (COMFORT-B Scale), the State-Trait Anxiety Inventory (STAI), and the Visual Analog Scale (VAS). Results: Children in the PPIA + DEX group exhibited significantly lower mYPAS-SF and ICC scores compared with all three other groups (p < 0.001), and children in that group exhibited significantly lower mYPAS-SF and ICC scores compared with the PPIA and DEX groups (p < 0.05). The children's PAED scores in the PPIA, DEX, and PPIA + DEX groups were significantly lower than the control group (p < 0.001).The STAI-S scores of the PPIA, DEX, and PPIA + DEX groups were significantly lower than the score of the control group (p < 0.001). The VAS scores of the PPIA, DEX, and PPIA + DEX groups were significantly higher than that of the control group (p < 0.001), while the score of the PPIA + DEX group was significantly higher than those of the PPIA and DEX groups (p < 0.05). Conclusion: The combined use of PPIA and intranasal dexmedetomidine is more effective than PPIA or intranasal dexmedetomidine for alleviating the preoperative anxiety of children, improving children's induction compliance and parental satisfaction.

Torcular pseudomass in a 14-month-old child: illustrative case

BACKGROUND

"Torcular pseudomass," or redundant soft tissue in the torcular region, is not an infrequent incidental finding on advanced imaging of the brain in infants and young children. It was recently codified among pediatric neuroradiologists; however, its report in the pediatric neurosurgical community has not previously been elucidated.

OBSERVATIONS

The authors present a case of a 14-month-old child who presented with fever and a first-time seizure. Computed tomography of the head suggested an epidural abscess; however, magnetic resonance imaging characteristics of the lesion were consistent with torcular pseudomass, a normal variant. At the 3-month follow-up, the child was continuing to do well and had not had another seizure. There have been no indications for surgical intervention or additional radiographic surveillance.

LESSONS

The differential diagnosis for torcular pseudomass includes dural venous sinus thrombosis, dermoid cysts, occipital encephalocele, eosinophilic granuloma, and primary and metastatic tumors, such as neuroblastoma. The management of each of these disorders in the differential diagnosis may be much more invasive than continued observation in the case of torcular pseudomass. Therefore, it is important for pediatric neurosurgeons to become familiar with this developmental anomaly of the dura and occipital skull.

MiR-129-3p regulates ferroptosis in the liver of Selenium-deficient broilers by targeting SLC7A11

Selenium (Se) has been proven to be an essential trace element for organism. Se deficiency in poultry can cause widespread damage, such as exudative diathesis. The liver is not only the main organ of metabolism, but also one of the organs with high Se content in organism. Recent studies have shown that solute carrier family 7 member 11 (SLC7A11) plays a key role in the negative regulation of ferroptosis. In order to explore the mechanism of Se deficiency induces liver ferroptosis in broilers, and the role of microRNAs (miRNAs) in this process, we divided broilers into 2 groups: control group (0.2 mg/kg Se) and Se deficiency group (0.03 mg/kg Se). Hematoxylin-Eosin staining detected liver tissue damage in broilers. Predicted and verified the targeting relationship between miR-129-3p and SLC7A11 through miRDB and dual luciferase report experiments. The genes related to ferroptosis were detected by qRT-PCR and Western Blot. The results showed that the expression level of miR-129-3p mRNA in Se-deficient liver was significantly increased. To understand whether the miR-129-3p/SLC7A11 axis could involve in the process of ferroptosis, our further research showed that overexpression of miR-129-3p could reduce the expression of SLC7A11 and its downstream GCL, GSS, and GPX4, thereby inducing ferroptosis. These data indicates that miR-129-3p affected ferroptosis under Se deficiency conditions through the SLC7A11 pathway. Our research provides a new perspective for the mechanism of Se deficiency on the liver damage.

Selenium Deficiency Induces Inflammatory Response and Decreased Antimicrobial Peptide Expression in Chicken Jejunum Through Oxidative Stress

Selenium deficiency can affect the level of selenoprotein in organs and tissues and cause inflammation. However, the mechanism of selenium deficiency on jejunal injury in chickens remains unclear. In this study, we established a selenium deficiency model in chickens by feeding a low selenium diet and observed ultrastructural and pathological changes in the jejunum. The expression levels of 25 selenoproteins, the levels of oxidative stress, tight junction (TJ) proteins, and antimicrobial peptides (AMP), as well as the expression levels of factors related to inflammatory signaling pathways, were examined in the intestine and analyzed using principal component analysis (PCA). The results of PCA and quantitative real-time PCR (qRT-PCR) showed that selenium deficiency mainly affected the expression of antioxidant selenoproteins in chicken jejunum, especially glutathione peroxidases, thioredoxin reductase, and iodothyronine deiodinase, thus weakening the antioxidant function in the intestine and inducing oxidative stress. We also found disruption of intestinal TJ structures, a significant reduction in TJ protein expression, and downregulation of antimicrobial peptide levels, suggesting that selenium deficiency led to damage of the intestinal barrier. In addition, a significant increase in inflammatory cell infiltration and expression of inflammatory factors was observed in the jejunum, indicating that selenium deficiency induces inflammatory injury. In conclusion, selenium deficiency downregulates antioxidant selenoproteins levels, induces oxidative stress, decreases intestinal AMP levels, and leads to inflammatory injury and disruption of the intestinal barrier in the jejunum. These results shed new light on the molecular mechanisms of intestinal damage caused by selenium deficiency.

The Impact of Environmental Pollution and Economic Growth on Public Health: Evidence From China

A comprehensive understanding of the impact of economic growth and environmental pollution on public health is crucial to the sustainable development of public health. In this paper, an individual fixed effect model is used to analyze the impact of environmental pollution and economic growth on public health, based on the panel data of 30 provinces in China from 2007 to 2018. The research finds that: First, the health status of China's four regions is not only affected by economic growth and environmental pollution, but also affected by the per capita disposable income and urbanization rate. Second, there is a long-term balanced relationship between China's economic growth, environmental pollution and public health. Third, environmental pollution harms children's health and significantly increases the perinatal mortality, while economic growth helps to reduce the perinatal mortality. Fourth, environmental pollution plays a regulatory role between economic growth and public health. Fifth, there are significant regional differences in the impact of environmental pollution and economic growth on public health. Among them, the degree of harm caused by sulfur dioxide emissions on mortality in northeastern China is significantly higher than that of the eastern China, eastern China is higher than that of the western China, and western China is higher than that of the central China. Finally, in order to reduce the adverse consequences of environmental pollution on public health in the process of economic development, this study puts forward relevant policy suggestions.

A two-stage combined anterolateral and endoscopic endonasal approach to the petroclival region: an anatomical study and clinical application

OBJECT

The pretemporal transcavernous anterior petrosal (PTAP) approach and the combined petrosal (CP) approach have been used to resect petroclival meningiomas (PCMs). In this cadaveric anatomical study, a two-stage combined PTAP and endoscopic endonasal far medial (EEFM) approach (the PTAPE approach) was compared morphometrically to the CP approach. A case study provides a clinical example of using the PTAPE approach to treat a patient with a PCM. The key elements of the approach selection process are outlined.

METHODS

Five cadaveric specimens underwent a CP approach and 5 underwent a PTAPE approach. The area of drilled clivus, length of multiple cranial nerves (CNs), and the area of brain stem exposure were measured, reported as means (standard deviations) by group, and compared.

RESULTS

The total area of the clivus drilled in the PTAPE group (695.3 [121.7] mm²) was greater than in the CP group (88.7 [17.06] mm², P < 0.01). Longer segments of CN VI were exposed via the PTAPE than the CP approach (35.6 [9.07] vs. 16.3 [6.02] mm, P < 0.01). CN XII (8.8 [1.06] mm) was exposed only in the PTAPE group. Above the pontomedullary sulcus, the total area of brain stem exposed was greater with the PTAPE than the CP approach (1003.4 [219.5] mm² vs. 437.6 [83.7] mm², P < 0.01). Similarly, the total exposure of the medulla was greater after the PTAPE than the CP exposure (240.2 [57.06] mm² vs. 48.1 [19.9] mm², P < 0.01).

CONCLUSION

A combined open-endoscopic paradigm is proposed for managing large PCMs. This approach incorporates the EEFM approach to address the limitations of the PTAP and the CP approach in a systematic fashion. Understanding the anatomical findings of this study will aid in tailoring surgical approaches to patients with these complex lesions.

Mining key genes related to root morphogenesis through genome-wide identification and expression analysis of RR gene family in citrus

Morphogenesis of root is a vital factor to determine the root system architecture. Cytokinin response regulators (RRs) are the key transcription factors in cytokinin signaling, which play important roles in regulating the root morphogenesis. In this study, 29 RR proteins, including 21 RRs and 8 pseudo RRs, were identified from the genome of citrus, and termed as CcRR1-21 and CcPRR1-8, respectively. Phylogenetic analysis revealed that the 29 CcRRs could be classified into four types according to their representative domains. Analysis of cis-elements of CcRRs indicated that they were possibly involved in the regulation of growth and abiotic stress resistance in citrus. Within the type A and type B CcRRs, CcRR4, CcRR5, CcRR6 and CcRR16 highly expressed in roots and leaves, and dramatically responded to the treatments of hormones and abiotic stresses. CcRR2, CcRR10, CcRR14 and CcRR19 also highly expressed in roots under different treatments. Characteristic analysis revealed that the above 8 CcRRs significantly and differentially expressed in the three zones of root, suggesting their functional differences in regulating root growth and development. Further investigation of the 3 highly and differentially expressed CcRRs, CcRR5, CcRR10 and CcRR14, in 9 citrus rootstocks showed that the expression of CcRR5, CcRR10 and CcRR14 was significantly correlated to the length of primary root, the number of lateral roots, and both primary root and the number of lateral roots, respectively. Results of this study indicated that CcRRs were involved in regulating the growth and development of the root in citrus with different functions among the members.

Cooperation and Competition in the Innovation Ecosystem From the Perspective of Evolutionary Psychology

The innovation ecosystem is distinct from innovation itself; the former is based on technology, talent and markets, as well as many other elements of innovation that form the organisational system. Current research on the innovation ecosystem has primarily focused on theoretical discussions of the concept and analysis of evolution mechanisms and influential factors; however, research on mechanisms that influence cooperation and competition within the system is limited. Corporation and competition are the critical elements in the acquisition value of the innovation ecosystem and the realisation of innovation breakthroughs. Given the dynamic nature and complexity of the innovation ecosystem, this research is based on the "value co-creation" theory of innovation ecosystems and consistency with the "reciprocity" principle of evolutionary psychology. Understanding the mechanisms that underlie corporation and competition in the innovation ecosystem from the perspective of evolutionary psychology may foster more efficient cooperation and competition among enterprises, enabling them to realise the value of co-creation and innovation breakthroughs.

Novel System of Simulation Models for Aneurysm Clipping Training: Description of Models and Assessment of Face, Content, and Construct Validity

BACKGROUND

Aneurysm clipping simulation models are needed to provide tactile feedback of biological vessels in a nonhazardous but surgically relevant environment.

OBJECTIVE

To describe a novel system of simulation models for aneurysm clipping training and assess its validity.

METHODS

Craniotomy models were fabricated to mimic actual tissues and movement restrictions experienced during actual surgery. Turkey wing vessels were used to create aneurysm models with patient-specific geometry. Three simulation models (middle cerebral artery aneurysm clipping via a pterional approach, anterior cerebral artery aneurysm clipping via an interhemispheric approach, and basilar artery aneurysm clipping via an orbitozygomatic pretemporal approach) were subjected to face, content, and construct validity assessments by experienced neurosurgeons (n = 8) and neurosurgery trainees (n = 8).

RESULTS

Most participants scored the model as replicating actual aneurysm clipping well and scored the difficulty of clipping as being comparable to that of real surgery, confirming face validity. Most participants responded that the model could improve clip-applier-handling skills when working with patients, which confirms content validity. Experienced neurosurgeons performed significantly better than trainees on all 3 models based on subjective (P = .003) and objective (P < .01) ratings and on time to complete the task (P = .04), which confirms construct validity. Simulations were used to discuss clip application strategies and compare them to prototype clinical cases.

CONCLUSION

This novel aneurysm clipping model can be used safely outside the wet laboratory; it has high face, content, and construct validity; and it can be an effective training tool for microneurosurgery training during aneurysm surgery courses.

Vidian Canal as a Transcranial Landmark: Anatomy, Technique, and Illustrative Cases

Objective The vidian nerve can be accessed in transcranial approaches in carefully selected patients to ensure its preservation and to serve as a landmark for sphenoid sinus entry. This report is to review a technique, evaluate it in laboratory settings, and present two illustrative cases.

Design The study involves cadaveric dissection and illustrative cases.

Setting The study conducted in a cadaveric dissection laboratory.

Participants The object of the study is one cadaveric head and two illustrative clinical cases.

Main Outcome Measures Two cases using this approach were illustrated, and a cadaver dissection was performed in a step-by-step fashion.

Results: The vidian canal can be accessed by drilling the anterolateral triangle. Two illustrated cases were presented; in one, the vidian nerve was used as part of a corridor to access the sphenoid sinus for tumor delivery, and in the other, the technique was used to find and preserve the vidian nerve during transcranial resection.

Conclusion Careful identification of the vidian canal in transcranial surgery is a beneficial technique in carefully selected cases which allows identification of the nerve both for its preservation in selected cases and to create the vidian–maxillary corridor for tumor resection. Knowing the anatomy and pneumatization variants is important in the surgical approach.

Navigating a Carotico-Clinoid Foramen and an Interclinoidal Bridge in the Endonasal Endoscopic Approach: An Anatomical and Technical Note

Objective  The carotico-clinoid foramen and interclinoid bridge are two anatomical variants of the sellar region. If these anatomical variants go unrecognized and are not managed safely by the surgeon during expanded endoscopic endonasal surgery for a posterior clinoidectomy, a carotid artery injury may occur. We summarize a method to safely navigate in the presence of the carotico-clinoid foramen and interclinoid bridge in an endoscopic endonasal approach. Study Design  The study involves cadaveric dissection and management of the anatomical variants. Setting  The study took place in a cadaveric dissection laboratory. Participants  The object of study is one cadaveric head. Main Outcome Measures  After discovering the two variants in both cavernous sinuses of a cadaveric head, we established a stepwise coping strategy to avoid carotid artery injury while performing an endoscopic endonasal bilateral interdural pituitary transposition, and we report the final view after endoscopic management. Results  Debulking of the middle clinoid process can decrease the obstacle effect, and the pituitary transposition can be performed medial to the ossified carotico-clinoid ligament. Disconnection of the interclinoid bridge is the prerequisite to an effective posterior clinoidectomy, and distinguishing the transition between the sellar diaphragm and the interclinoid bridge is essential. Conclusion  In the presence of both the carotico-clinoid foramen and the interclinoid bridge, a bilateral interdural pituitary transposition can still be performed, although preoperative strategic preparation, full inspection, and stepwise disconnections are of paramount importance in such a scenario to avoid cavernous carotid artery injury.

Comparative analysis of the combined petrosal and the pretemporal transcavernous anterior petrosal approach to the petroclival region

OBJECTIVE

The combined petrosal (CP) approach has been traditionally used to resect petroclival meningioma (PCM). The pretemporal transcavernous anterior petrosal (PTAP) approach has emerged as an alternative. A quantitative comparison of both approaches has not been made. This anatomical study compared the surgical corridors afforded by both approaches and identified key elements of the approach selection process.

METHODS

Twelve cadaveric specimens were dissected, and 10 were used for morphometric analysis. Groups A and B (n = 5 in each) underwent the CP and PTAP approaches, respectively. The area of drilled clivus, lengths of cranial nerves (CNs) II-X, length of posterior circulation vessels, surgical area of exposure of the brainstem, and angles of attack anterior and posterior to a common target were measured and compared.

RESULTS

The area of drilled clivus was significantly greater in group A than group B (mean ± SD 88.7 ± 17.1 mm2 vs 48.4 ± 17.9 mm2, p < 0.01). Longer segments of ipsilateral CN IV (52.4 ± 2.33 mm vs 46.5 ± 3.71 mm, p < 0.02), CN IX, and CN X (9.91 ± 3.21 mm vs 0.00 ± 0.00 mm, p < 0.01) were exposed in group A than group B. Shorter portions of CN II (9.31 ± 1.28 mm vs 17.6 ± 6.89 mm, p < 0.02) and V1 (26.9 ± 4.62 mm vs 32.4 ± 1.93 mm, p < 0.03) were exposed in group A than group B. Longer segments of ipsilateral superior cerebellar artery (SCA) were exposed in group A than group B (36.0 ± 4.91 mm vs 25.8 ± 3.55 mm, p < 0.02), but there was less exposure of contralateral SCA (0.00 ± 0.00 mm vs 7.95 ± 3.33 mm, p < 0.01). There was no statistically significant difference between groups with regard to the combined area of the exposed cerebral peduncles and pons (p = 0.75). Although exposure of the medulla was limited, group A had significantly greater exposure of the medulla than group B (p < 0.01). Finally, group A had a smaller anterior angle of attack than group B (24.1° ± 5.62° vs 34.8° ± 7.51°, p < 0.03).

CONCLUSIONS

This is the first study to quantitatively identify the advantages and limitations of the CP and PTAP approaches from an anatomical perspective. Understanding these data will aid in designing maximally effective yet minimally invasive approaches to PCM.

[Biomechanical study of anterior occipital condyle screw plate system]

Objective: To analyze the feasibility of anterior occipitocervical fusion biomechanical characteristic of craniovertebral reconstruction by anterior occipital condyle screw plate system. Methods: Six cervical vertebra specimens including 4 males and 2 females were enrolled, whose mean age of death was (49.3±7.5) years. The normal models were established by soft tissue dissection, and the instability models were established by destroy bone and ligament structure including, anterior arch of the atlas, part of the lateral mass of the atlas, the odontoid process, the odontoid apical ligament, the pterygoid ligament, the transverse ligament of the atlas the joint capsule. The clivus screw fixation models were established by anterior clivus screw fixation, and then those models were performed by anterior occipital condyle screw fixation. All four groups were loaded with a 1.5 N·m continuous pure force in flexion-extension, lateral bending, and axial rotation. Then measured the range of motion of specimen C₀-C₁ and C₀-C₂. And the pull-out force test was conducted to compare the effects of unicortical and bicortical fixation on the pull-out force of screws. Results: In the C₀-C₁ segment, the range of motion in flexion-extension (forward and posterior), lateral bending and axial rotation in the clivus group was 6.46°±0.85°, 5.14°±0.76°, 2.73°±0.36°, 1.12°±0.41°, respectively; and it was 5.92°±0.90°, 4.16°±1.06°, 2.86°±0.50°, 1.05°±0.27°, respectively in the occipital condyle group. As for C₀-C₂ segment, the range of motion in the clivus group was 9.55°±1.99°, 10.46°±2.03°, 6.90°±1.29°, 13.51°±1.37°, respectively; and it was 8.14°±1.38°, 9.53°±1.55°, 4.75°±1.06°, 7.90°±1.68°, respectively, in the occipital condyle group. The ranges of motion in the occipital condyle group were significantly lower than clivus group (all P<0.05). The maximum pull out force by bicortical fixation was significantly better than unicortical fixation ((439±33) N vs (408±28) N, P<0.05). Conclusion: The anterior occipital condyle screw plate system provides better stability especially in anti-bending and anti-rotation than the anterior clival screw fixation.

High-Dose Fluorescein Reveals Unusual Confocal Endomicroscope Imaging of Low-Grade Glioma

Background: Fluorescence-guided brain tumor surgery using fluorescein sodium (FNa) for contrast is effective in high-grade gliomas. However, the effectiveness of this technique for visualizing noncontrast-enhancing and low-grade gliomas is unknown. This report is the first documented case of the concurrent use of wide-field fluorescence-guided surgery and confocal laser endomicroscopy (CLE) with high-dose FNa (40 mg/kg) for intraoperative visualization of tumor tissue cellularity in a nonenhancing glioma.

Case Description: A patient underwent fluorescence-guided surgery for a left frontal lobe mass without contrast enhancement on magnetic resonance imaging. The patient received 40 mg/kg FNa intravenously at the induction of anesthesia. Surgery was performed under visualization with a Yellow 560 filter and white-light wide-field imaging. Intraoperative CLE produced high-quality images of the lesion 1.5 h after FNa injection. Frozen-section analysis demonstrated findings comparable to those of intraoperative CLE visualization and consistent with World Health Organization (WHO) glioma grades II–III. The patient recovered without complications. Analysis of the permanent histologic sections identified the tumor as an anaplastic oligodendroglioma, IDH-mutant, 1p/19q co-deleted, consistent with WHO grade III because of discrete foci of hypercellularity and increased mitotic figures, but large regions of the lesion were low grade.

Conclusions: The use of high-dose FNa in this patient with a nonenhancing borderline low-grade/high-grade glioma produced actionable wide-field fluorescence imaging using the operating microscope and improved CLE visualization of tumor cellularity. Higher doses of FNa for intraoperative CLE imaging and possible simultaneous wide-field fluorescence surgical guidance in nonenhancing gliomas merit further investigation.

Partial Gyrus Rectus Resection as a Technique to Improve the Exposure to the Anterior Communicating Artery Complex through the Junctional Triangle: A Quantitative Study

Objective  The junctional triangle, formed by the distal A1 anterior cerebral artery (ACA) segment, the proximal A2 ACA segment, and the medial surface of gyrus rectus (GR), is a corridor of access to superiorly and posteriorly projecting anterior communicating artery (AComA) aneurysms that is widened by GR retraction or resection. Exposure of the AComA complex through the junctional triangle after GR resection has not been previously quantitatively evaluated. Design  GR resection extent and increase in artery exposure through the junctional triangle were assessed in this study. Setting  This study was conducted in the laboratory with a pterional approach, exposing the AComA complex. Participants  Ten sides of five cadaveric heads were considered. Main Outcome Measures  Exposure extent of ipsilateral and contralateral A1, A2, and AComA and accessibility of branches coming off the AComA complex were measured before and after GR resection. The GR was resected until sufficient bilateral A2 and contralateral A1 exposures were achieved. GR resection span was measured. Results  The mean (standard deviation) resected span of GR was 7 ± 3.9 mm. After GR resection, the exposed span of the ipsilateral A2 increased from 2 ± 0.7 mm to 4 ± 1.1 mm ( p  = 0.001); contralateral A2 exposure increased from 3 ± 1.5 mm to 4 ± 1.1 mm ( p  = 0.03). Contralateral recurrent artery of Heubner (RAH) and orbitofrontal artery were accessible in five and eight specimens, respectively, before GR resection and in all 10 after resection. Conclusion  GR resection improves exposure of bilateral A2 segments through the junctional triangle. Exposure improvement is greater for the ipsilateral A2 than contralateral A2. The junctional triangle concept is enhanced by partial GR resection during surgery for superior and posterior AComA aneurysms.

The Glossopharyngo-Cochlear Triangle-Part II: Case Series Highlighting the Clinical Application to High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach

BACKGROUND

Use of the far lateral transcondylar (FL) approach and vagoaccessory triangle is the standard exposure for clipping most posterior inferior cerebellar artery (PICA) aneurysms. However, a distal PICA origin or high-lying vertebrobasilar junction can position the aneurysm beyond the vagoaccessory triangle, making the conventional FL approach inappropriate.

OBJECTIVE

To demonstrate the utility of the extended retrosigmoid (eRS) approach and a lateral trajectory through the glossopharyngo-cochlear triangle as the surgical corridor for these cases.

METHODS

High-riding PICA aneurysms treated by microsurgery were retrospectively reviewed, comparing exposure through the eRS and FL approaches. Clinical, surgical, and outcome measures were evaluated. Distances from the aneurysm neck to the internal auditory canal (IAC), jugular foramen, and foramen magnum were measured.

RESULTS

Six patients with PICA aneurysms underwent clipping using the eRS approach; 5 had high-riding PICA aneurysms based on measurements from preoperative computed tomography angiography (CTA). Mean distances of the aneurysm neck above the foramen magnum, below the IAC, and above the jugular foramen were 27.0 mm, 3.7 mm, and 8.2 mm, respectively. Distances were all significantly lower versus the comparison group of 9 patients with normal or low-riding PICA aneurysms treated using an FL approach (P < .01). All 6 aneurysms treated using eRS were completely occluded without operative complications.

CONCLUSION

The eRS approach is an important alternative to the FL approach for high-riding PICA aneurysms, identified as having necks more than 23 mm above the foramen magnum on CTA. The glossopharyngo-cochlear triangle is another important anatomic triangle that facilitates microsurgical dissection.

Dissection of the Petrosal Presigmoid-Retrolabyrinthine Approach for the Petroclival Region on a Cadaver: 2-Dimensional Operative Video

Skull base epidermoid tumors, meningiomas, and schwannomas can be accessed by different techniques depending on the location and size of the lesion. Small lesions located anterior to the internal acoustic meatus (IAM) can be accessed via the subtemporal approach, and lesions located posterior to the IAM can be approached via retrosigmoid craniotomy. However, expansive lesions that are located anterior to the IAM and extend posteriorly toward the lower clivus can be accessed via the petrosal approach. The petrosal approach (presigmoid-retrolabyrinthine) is centered on the petrous ridge of the temporal bone and is mainly performed for intradural lesions located at the clivus and petroclivus junction area. Patients with intact hearing can benefit from this technique, as the labyrinth is untouched and yet the middle and posterior fossa compartments are connected. Additionally, extension of the lesion from the suprasellar area/cavernous sinus to the foramen magnum can be dissected and removed. There are variations of the petrosal approach, such as translabyrinthine, transotic, and transchoclear, with which hearing cannot be preserved, and the "transcrusal" approach, wherein posterior and superior semicircular canals are sacrificed yet hearing preserved. The endolymphatic duct is usually transected and not reapproximated. Neurotology input is always helpful when dealing with inner ear structures. This complex approach demands exhaustive practice with temporal bone dissection in a cadaver laboratory. Although this approach can be extended anteriorly, combination with an anterior petrosal approach permits more rostral exposure. In this video, we demonstrate the stepwise dissection of the posterior petrosal approach only, showing procedure nuances in a cadaver.1-8Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

The Glossopharyngo-Cochlear Triangle-Part I: Quantitative Anatomic Analysis of High-Riding Posterior Inferior Cerebellar Artery Aneurysms Exposed Through the Extended Retrosigmoid Approach

BACKGROUND

An extended retrosigmoid approach can offer sufficient space for clip reconstruction of some high-riding posterior inferior cerebellar artery (PICA) aneurysms.

OBJECTIVE

To quantitatively investigate the glossopharyngo-cochlear triangle (GCT) and anatomic structures within it.

METHODS

Extended retrosigmoid craniotomies were performed on 10 sides of cadaveric heads, and the GCT was identified in each specimen. The length of the base and the area of the GCT were measured. The depth of the vertebrobasilar system and the abducens nerve to the GCT were measured. The proximal and distal exposable and controllable points on the vertebrobasilar system were identified. Two imaging-based patient selection algorithms are provided using the lengths from those points to the vertebral artery dural entry point and the superoinferior distances from those points to the inferior edge of the foramen magnum. Other factors related to accessibility via the GCT were investigated.

RESULTS

The mean (standard deviation [SD]) area of the GCT was 45.7 (12.55) mm2. The mean (SD) depth of the abducens nerve was 14.3 (1.42) mm. The mean (SD) superoinferior distances from the foramen magnum to those points were 23.1 (7.39), 24.7 (8.25), 30.0 (9.56), and 32.6 (7.79) mm, respectively. The lower segment of the vertebrobasilar system was more superficial in the setting of a high-lying vertebrobasilar junction (VBJ) than a low-lying VBJ.

CONCLUSION

We describe the GCT in an extended retrosigmoid approach for high-riding PICA aneurysms and evaluate the spatial relationship of the neurovascular structures within it. Two potential algorithms are offered for preoperative patient selection.

Transorbital Neuroendoscopic Surgery as a Mainstream Neurosurgical Corridor: A Systematic Review

BACKGROUND

Transorbital neuroendoscopic surgery (TONES) offers a new level of minimally invasive, minimally disfiguring skull base surgery with maximal surgical visualization.

METHODS

This review systematically assesses the body of published anatomic (cadaveric) and clinical evidence for the approach. PubMed, Cochrane Library, Ovid MEDLINE, and Embase were systematically searched for articles in which the TONES surgical technique was used in an anatomic, clinical, or combined study. The outcomes of interest included identification of the diseases, operative outcomes, and complication rates.

RESULTS

Twenty-three articles were selected for this systematic review: 10 were purely anatomic, 10 were clinical, and 3 had both clinical and cadaveric components. The articles reported 69 patients undergoing transorbital or combined transorbital and transnasal intervention. A total of 30 cases of cerebrospinal fluid leak were documented; of these, 28 (93%) had successful resolution, 2 (7%) had recurrence, and 5 (15%) experienced complications. A total of 31 tumors were biopsied (n = 1), resected (n = 22), or debulked (n = 8). Meningiomas were the most common lesion managed via TONES, with 5 of 7 patients with meningioma who reported preoperative neurologic deficits experiencing an improvement in extraocular movement impairment, visual acuity, proptosis, and ptosis. Transient postoperative clinical sequelae, including diplopia and ptosis, were increasingly associated with the superior lid crease incision and the sole transorbital approach.

CONCLUSIONS

TONES is a significant development in transorbital skull base surgery. However, comprehensive, robust, comparative analyses and increasing use and generalizability of this technique in skull base surgery are awaited.

Preoperative embolization versus no embolization for WHO grade I intracranial meningioma: a retrospective matched cohort study

OBJECTIVE

The controversy continues over the clinical utility of preoperative embolization for reducing tumor vascularity of intracranial meningiomas prior to resection. Previous studies comparing embolization and nonembolization patients have not controlled for detailed tumor parameters before assessing outcomes.

METHODS

The authors reviewed the cases of all patients who underwent resection of a WHO grade I intracranial meningioma at their institution from 2008 to 2016. Propensity score matching was used to generate embolization and nonembolization cohorts of 52 patients each, and a retrospective review of clinical and radiological outcomes was performed.

RESULTS

In total, 52 consecutive patients who underwent embolization (mean follow-up 34.8 ± 31.5 months) were compared to 52 patients who did not undergo embolization (mean follow-up 32.8 ± 28.7 months; p = 0.63). Variables controlled for included patient age (p = 0.82), tumor laterality (p > 0.99), tumor location (p > 0.99), tumor diameter (p = 0.07), tumor invasion into a major dural sinus (p > 0.99), and tumor encasement around the internal carotid artery or middle cerebral artery (p > 0.99). The embolization and nonembolization cohorts did not differ in terms of estimated blood loss during surgery (660.4 ± 637.1 ml vs 509.2 ± 422.0 ml; p = 0.17), Simpson grade IV resection (32.7% vs 25.0%; p = 0.39), perioperative procedural complications (26.9% vs 19.2%; p = 0.35), development of permanent new neurological deficits (5.8% vs 7.7%; p = 0.70), or favorable modified Rankin Scale (mRS) score (a score of 0–2) at last follow-up (96.0% vs 92.3%; p = 0.43), respectively. When comparing the final mRS score to the preoperative mRS score, patients in the embolization group were more likely than patients in the nonembolization group to have an improvement in mRS score (50.0% vs 28.8%; p = 0.03).

CONCLUSIONS

After controlling for patient age, tumor size, tumor laterality, tumor location, tumor invasion into a major dural sinus, and tumor encasement of the internal carotid artery or middle cerebral artery, preoperative meningioma embolization intended to decrease tumor vascularity did not improve the surgical outcomes of patients with WHO grade I intracranial meningiomas, but it did lead to a greater chance of clinical improvement compared to patients not treated with embolization.

Overexpressing a NPR1-like gene from Citrus paradisi enhanced Huanglongbing resistance in C. sinensis

Overexpression of CiNPR4 enhanced resistance of transgenic citrus plants to Huanglongbing by perceiving the salicylic acid and jasmonic acid signals and up-regulating the transcriptional activities of plant-pathogen interaction genes. Developing transgenic citrus plants with enhanced immunity is an efficient strategy to control citrus Huanglongbing (HLB). Here, a nonexpressor of pathogenesis-related gene 1 (NPR1) like gene from HLB-tolerant 'Jackson' grapefruit (Citrus paradisi Macf.), CiNPR4, was introduced into 'Wanjincheng' orange (Citrus sinensis Obseck). CiNPR4 expression was determined in transgenic citrus plants using quantitative real-time PCR analyses. The Candidatus Liberibacter asiaticus (CLas) pathogen of HLB was successfully transmitted to transgenic citrus plants by grafting infected buds. HLB symptoms developed in transgenic and wild-type (WT) plants by 9 months after inoculation. A CLas population analysis showed that 26.9% of transgenic lines exhibited significantly lower CLas titer levels compared with the CLas-infected WT plants at 21 months after inoculation. Lower starch contents and anatomical aberration levels in the phloem were observed in transgenic lines having enhanced resistance compared with CLas-infected WT plants. CiNPR4 overexpression changed the jasmonic acid, but not salicylic acid, level. Additionally, the jasmonic acid and salicylic acid levels increased after CLas infection. Transcriptome analyses revealed that the enhanced resistance of transgenic plants to HLB resulted from the up-regulated transcriptional activities of plant-pathogen interaction-related genes.

Supracerebellar infratentorial inverted subchoroidal approach to lateral ventricle lesions: Anatomical study and illustrative case

Background:

This study provides an anatomical description of a novel supracerebellar infratentorial inverted subchoroidal (SIIS) approach to the lateral ventricle. An illustrative case is presented in which this approach was used to simultaneously resect two tumors residing in the posterior fossa and lateral ventricle.

Methods:

The SIIS approach was performed on five cadaveric heads using microsurgical and endoscopic techniques. Target points were defined in the lateral ventricle, and quantitative analysis was performed to assess limits of exposure within the lateral ventricle. Two coronal reference planes corresponding to the anterior and posterior margins of the lateral ventricle body were defined. Distances from target points to reference planes were measured, and an imaging-based predicting system was provided according to obtained measurements to guide preoperative approach selection.

Results:

Mean (standard deviation) distances between the predefined target points indicating the anterior limits and the anterior plane were 9 (7.0) mm, 11 (5.8) mm, and 7 (5.1) mm; posterior limits had distances of 8 (3.0) mm, 17 (9.2) mm, 15 (9.2) mm, and 9 (7.2) mm to the posterior plane. Limiting factors of the choroidal fissure dissection were the venous angle anteriorly and thalamocaudate vein posteriorly. The position of the venous angle had a high negative correlation with the anterior exposure limit (r = –0.87, P < 0.001; r = –0.92, P < 0.001).

Conclusion:

A step-by-step anatomical description of a new SIIS approach is given, and a quantitative description of the limits of the exposure is provided to evaluate the application of this approach.

Visualization of brain microvasculature and blood flow in vivo: Feasibility study using confocal laser endomicroscopy

OBJECTIVE

Qualitative and quantitative analyses of blood flow in normal and pathologic brain and spinal cord microvasculature were performed using confocal laser endomicroscopy (CLE).

METHODS

Blood flow in cortical, dural, and spinal cord microvasculature was assessed in vivo in swine. We assessed microvasculature under normal conditions and after vessel occlusion, brain injury due to cold or surgical trauma, and cardiac arrest. Tumor-associated microvasculature was assessed in vivo and ex vivo in 20 patients with gliomas.

RESULTS

We observed erythrocyte flow in vessels 5-500 µm in diameter. Thrombosis, flow arrest and redistribution, flow velocity changes, agglutination, and cells rolling were assessed in normal and injured brain tissue. Microvasculature in in vivo CLE images of gliomas was classified as normal in 68% and abnormal in 32% of vessels on the basis of morphological appearance. Dural lymphatic channels were discriminated from blood vessels. Microvasculature CLE imaging was possible for up to 30 minutes after a 1 mg/kg intravenous dose of fluorescein.

CONCLUSIONS

CLE imaging allows assessment of cerebral and tumor microvasculature and blood flow alterations with subcellular resolution intraoperative imaging demonstrating precise details of real-time cell movements. Research and clinical scenarios may benefit from this novel intraoperative in vivo microscopic fluorescence imaging modality.

From Krönlein, through madness, to a useful modern surgery: the journey of the transorbital corridor to enter the neurosurgical armamentarium

Transorbital surgery has gained recent notoriety because of its incorporation into endoscopic skull base surgery. The use of this surgical corridor has been pervasive throughout the 20th century. It has been utilized by multiple disciplines for both clinical and experimental purposes, although its historical origin is medically and ethically controversial. Hermann Knapp first introduced the orbital surgical technique in 1874, and Rudolf Krönlein introduced his procedure in 1889. Rivalry between Walter Dandy in neurosurgery and Raynold Berke in ophthalmology further influenced methods of tackling intracranial and intraorbital pathologies. In 1946, Walter Freeman revolutionized psychosurgery by completing seemingly successful transorbital leucotomies and promoting their minimally invasive and benign surgical characteristics. However, as Freeman's legacy came into disrepute, so did the transorbital brain access corridor, again resulting in its stunted evolution. Microsurgery and endoscopy further influenced the use, or lack thereof, of the transorbital corridor in neurosurgical approaches. Historical analysis of present goals in modern skull base surgery echoes the principles established through an approach described almost 150 years ago: minimal invasion, minimal morbidity, and priority of patient satisfaction. The progression of the transorbital approach not only reflects psychosocial influences on medical therapy, as well as the competition of surgical pioneers for supremacy, but also describes the diversification of skull base techniques, the impact of microsurgical mastery on circumferential neurosurgical corridors, the influence of technology on modernizing skull base surgery, and the advancing trend of multidisciplinary surgical excellence.

Intraoperative Confocal Laser Endomicroscopy Ex Vivo Examination of Tissue Microstructure During Fluorescence-Guided Brain Tumor Surgery

Background

Noninvasive intraoperative optical biopsy that provides real-time imaging of histoarchitectural (cell resolution) features of brain tumors, especially at the margin of invasive tumors, would be of great value. To assess clinical-grade confocal laser endomicroscopy (CLE) and to prepare for its use intraoperatively in vivo, we performed an assessment of CLE ex vivo imaging in brain lesions.

Methods

Tissue samples from patients who underwent intracranial surgeries with fluorescein sodium (FNa)–based wide-field fluorescence guidance were acquired for immediate intraoperative ex vivo optical biopsies with CLE. Hematoxylin-eosin–stained frozen section analysis of the same specimens served as the gold standard for blinded neuropathology comparison. FNa 2 to 5 mg/kg was administered upon induction of anesthesia, and FNa 5 mg/kg was injected for CLE contrast improvement. Histologic features were identified, and the diagnostic accuracy of CLE was assessed.

Results

Of 77 eligible patients, 47 patients with 122 biopsies were enrolled, including 32 patients with gliomas and 15 patients with other intracranial lesions. The positive predictive value of CLE optical biopsies was 97% for all specimens and 98% for gliomas. The specificity of CLE was 90% for all specimens and 94% for gliomas. The second FNa injection in seven patients, a mean of 2.6 h after the first injection, improved image quality and increased the percentage of accurately diagnosed images from 67% to 93%. Diagnostic CLE features of lesional glioma biopsies and normal brain were identified. Seventeen histologic features were identified.

Conclusions

Results demonstrated high specificity and positive predictive value of ex vivo intraoperative CLE optical biopsies and justify an in vivo intraoperative trial. This new portable, noninvasive intraoperative imaging technique provides diagnostic features to discriminate lesional tissue with high specificity and is feasible for incorporation into the fluorescence-guided surgery workflow, particularly for patients with invasive brain tumors.

[The clinical application of primary sinus tract sinus establishment combined with holmium laser lithotripsy in elderly patients with choledocholithiasis and stricture]

Objective: To investigate the clinical efficacy and safety of one-time percutaneous transhepatic establishment of intrahepatic bile duct sinus, choledochoscope combined with holmium laser lithotripsy in elderly patients with hepatolithiasis combined with benign stricture. Methods: The clinical data of 56 elderly patients diagnosed with intrahepatic bile duct stones combined with stricture in our hospital from January 2018 to January 2019 were collected. All patients underwent PTCD puncture and drainage, and simultaneously expanded the punctured sinus channels step by step, intrahepatic bile duct stones lithotripsy and lithotomy were performed under choledochoscope combined with holmium laser. The intraoperative operation and postoperative complications were analyzed. Results: The sinus tract was established in 53 patients, the stones were removed, and the stenosis was relieved. Two cases of puncture bleeding and 1 case of bleeding when the stenosis was relieved by holmium laser and the surgery was timely transferred. The patients received 4(2-8) times of laser lithotripsy, and it took 30(28-32) min for each treatment. The T tubules were removed when colour Doppler ultrasound and choledochography were rechecked well. The patients were followed-up for an average of 6 months with the liver function and cholerythrin recovered. Conclusion: The one-time establishment of sinus tract combined with choledochoscope holmium laser provides a new therapeutic approach for the elderly patients with hepatolithiasis and benign stricture who cannot tolerate surgery.

Tailoring the surgical corridor to the basilar apex in the pretemporal transcavernous approach: morphometric analyses of different neurovascular mobilization maneuvers

BACKGROUND

The pretemporal transcavernous approach (PTA) provides optimal exposure and access to the basilar artery (BA); however, the PTA can be invasive when vital neurovascular structures are mobilized. The goal of this study was to evaluate mobilization strategies to tailor approaches to the BA.

METHODS

After an orbitozygomatic craniotomy, 10 sides of 5 cadaveric heads were used to assess the surgical access to the BA via the opticocarotid triangle (OCT), carotid-oculomotor triangle (COT), and oculomotor-tentorial triangle (OTT). Measurements were obtained, and morphometric analyses were performed for natural neurovascular positions and after each stepwise expansion maneuver. An imaginary line connecting the midpoints of the limbus sphenoidale and dorsum sellae was used as a reference to normalize the measurements of BA exposure and to facilitate the clinical applicability of this technique.

RESULTS

In the OCT, the exposed BA segment ranged from - 1 ± 3.9 to + 6 ± 2.0 mm in length in its natural position. In the COT, the accessible BA segment ranged from - 4 ± 2.3 to - 2 ± 3.0 mm in length in its natural position. Via the OTT, the accessible BA segment ranged from - 7 ± 2.6 to - 5 ± 2.8 mm in length in its natural position. In the OCT, COT, and OTT, a posterior clinoidectomy extended the exposure down to - 6 ± 2.7, - 8 ± 2.5, and - 9 ± 2.9 mm, respectively.

CONCLUSIONS

This study quantitatively evaluated the need for the expansion maneuvers in the PTA to reach BA aneurysms according to the patient's anatomical characteristics.

The Current State of Radiomics for Meningiomas: Promises and Challenges

Meningiomas are the most common primary tumors of the central nervous system. Given the fact that the majority of meningiomas are benign, the preoperative risk stratification and treatment strategy decision-making highly rely on the conventional subjective radiologic evaluation. However, this traditional diagnostic and treatment modality may not be effective in patients with aggressive-growing tumors or symptomatic patients with potential risk of recurrence after surgical resection or radiotherapy, as this passive “wait and see” strategy could miss the optimal opportunity of intervention. Radiomics, a new rising discipline, translates high-dimensional image information into abundant mathematical data by multiple computational algorithms. It provides an objective and quantitative approach to interpret the imaging data, rather than the subjective and qualitative interpretation from relatively limited human visual observation. In fact, the enormous amount of information generated by radiomics analyses provides radiological to histopathological tumor information, which are visually imperceptible, and offers technological basis to its applications amid diagnosis, treatment, and prognosis. Here, we review the latest advancements of radiomics and its applications in the prediction of the pathological grade, pathological subtype, recurrence possibility, and differential diagnosis of meningiomas, and the potential and challenges in general clinical applications. In this review, we highlight the generalization of shared radiomic features among different studies and compare different performances of popular algorithms. At last, we discuss several possible aspects of challenges and future directions in the development of radiomic applications in meningiomas.