Plasticity of the central nervous system—a neurosurgeon's experience of cerebral compensation and decompensation

Summary Cerebral plasticity constitutes one of the most decisive factors in recovery and readaptation after cerebral lesions. In contrast to the considerable progress in current studies on normal neuronal plasticity including the idea of l'homme neuronal, the concept of plasticity postulated by Albrecht Bethe in 1929 received little attention. The author, as a neurosurgeon, has tried to describe cranial morphological plasticity, morphological and functional plasticity in infantile encephalopathies and especially in hemiatrophic lesions. It is supposed that a true morphological substrate exists due to compensatory hyperplasia of the uninvolved hemisphere.Modern neurosurgical techniques have demonstrated that the functional plastic capacity is much larger than has been supposed, even in the elderly. Some aspects of the mechanisms of compensation and decompensation of cortical and subcortical structures as well as of the central regulation systems are discussed. The full extent of the amazing recovery and functional reorganization is reached by plastic capacity, personal motivation, adequate training and sufficient time.The contribution ends with an exposition of a personal philosophy concerning psycho-somatic dualism, the body-mind problem, the future of the human brain and the ethical outlook, based on the progressive biological evolution of the basal neocortex and the immanent functional development (H. Spatz).In grateful memory of my paternal friends, the great German brain researchers Julius Hallervorden (1882–1965) and Hugo Spatz (1888–1969).     

腘窝直接皮动脉穿支蒂螺旋桨皮瓣转位修复腘窝软组织缺损

目的探讨腘窝直接皮动脉穿支蒂螺旋桨皮瓣转位修复腘窝软组织缺损的临床效果。方法采用回顾性病例系列研究分析2013年6月至2019年6月,上海交通大学医学院附属新华医院(崇明)收治的9例腘窝软组织缺损患者临床资料,男6例,女3例,年龄25~73岁,平均49.6岁,腘窝缺损创面为6.5 cm×3.5 cm~17.0 cm×8.5 cm。根据解剖学基础,结合腘窝缺损创面的位置、大小、形状,设计并切取腘窝直接皮动脉穿支蒂螺旋桨皮瓣转位修复腘窝缺损创面,皮瓣面积最大为18.0 cm×10.0 cm,最小为7.5 cm×4.5 cm。根据皮瓣成活、感染控制、弹性色泽、外观形态、供区瘢痕、皮肤感觉、膝关节活动功能、患者认可度等情况,对患者术后疗效进行综合评价。结果 9例皮瓣术后全部顺利成活,供、受区伤口一期愈合,其中2例皮瓣远端发生皮缘坏死,给予换药处理后完全愈合。术后均获6~60个月随访,平均33个月,皮瓣成活优良,形态满意,色泽、弹性、质地与周围正常皮肤接近,供区瘢痕较小。疗效评价:满意8例,一般1例,无不满意。膝关节功能优7例,良1例,可1例。皮瓣肿胀评级,早期:Ⅰ度6例,Ⅱ度2例,Ⅲ度1例,Ⅳ度0例;后期:Ⅰ度8例,Ⅱ度1例,Ⅲ度0例,Ⅳ度0例。结论腘窝直接皮动脉穿支蒂螺旋桨皮瓣移位修复腘窝缺损创面方法简便、安全可靠、损伤较小,易于推广,是修复腘窝皮肤软组织缺损的理想方法之一。     

Cranial floor fracture: A growing orbital roof fracture with encephalocele – Case Report

Orbital roof fractures are among the rarest of craniofacial fractures. The mechanism of injury is typically a high-impact blunt force vector directly to the orbit or forehead. Most patients are males between 20 and 40 years old, involved in motor vehicle accidents. Although most orbital roof fractures are managed conservatively, there is a significant risk of ophthalmologic and neurologic complications. Detailed craniofacial examination and high-resolution CT imaging is necessary for diagnosis. A multidisciplinary team approach is required for these challenging fractures.     

Mathematical study of the role of non-linear venous compliance in the cranial volume-pressure test

The role of the cerebral venous bed in the cranial volume-pressure test was examined by means of a mathematical model. The cerebral vascular bed was represented by a single arterial compartment and two venous compartments in series. The lumped-parameter formulation for the vascular compartments was derived from a one-dimensional theory of flow in collapsible tubes. It was assumed in the model that the cranial volume is constant. The results show that most of the additional volume of cerebrospinal fluid (ΔV_CSF) was accommodated by collapse of the cerebral venous bed. This profoundly altered the venous haemodynamics and was reflected in the cranial pressure P_CSF. The cranial volume-pressure curve obtained from the model was consistent with experimental data; the curve was flat for 0<-ΔV_CSF<-20 ml and 35<-ΔV_CSF<-40 ml, and steep for 20<-ΔV_CSF<-35 ml and ΔV_CSF>-40 ml. For ΔV_CSF>25 ml and P_CSF>5.3 kPa (40 mmHg), cerebral blood flow dropped. When P_CSF was greater than the mean arterial pressure, all the veins collapsed. The conclusion of the study was that the shape of the cranial volume-pressure curve can be explained by changes in the venous bed caused by various degrees of collapse and/or distension.     

影响鼻咽癌病人受损颅神经恢复的因素分析

目的：探讨影响鼻咽癌病人受损颅神经恢复的相关因素。方法：１９８９年１月至１９９１年１月我科收治鼻咽癌伴颅神经受损病人１２８例,共２４５条颅神经受损。对影响受损颅神经功能恢复的可能因素进行单因素及多因素Ｃｏｘ模型分析。结果：放疗后１年内受损颅神经中有６５．７％（１６１／２４５）完全恢复,１９．２％（４７／２４５）部分恢复,１５．１％（３７／２４５）无变化,总的有效率为８４．９％（２０８／２４５）。单     

翼点入路显微手术切除颅中窝底肿瘤

目的探讨颅中窝底肿瘤的手术治疗的经验.方法利用CT、MRI、CAG及X线平片等以确定肿瘤的部位、大小、形状、供血,明确其与用邻结构关系;选择翼点入路,采用显微手术切除颅中窝底肿瘤.结果显微手术切除颅中窝底肿瘤15例,肿瘤全部切除14例,全切除率93.33%,无手术死亡.10例经7个月～5年随访,平均4.1年,肿瘤无复发.结论采用显微手术能正确辨认肿瘤与周邻结构的关系,提高了肿瘤全切除率.     

Periventricular- intraventricular hemorrhage in the premature infant- A historical perspective

The objective of this chapter is to trace the evolution of intraventricular hemorrhage in the premature infant highlighting the importance of the germinal matrix, a critical role for cerebral blood flow changes in the genesis of hemorrhage, clinical factors that increase the bleeding risk, and potential preventative strategies. In 1976, neuropathological studies demonstrated capillary rupture within the germinal matrix as the precursor of hemorrhage. In 1980, introduction of cranial ultrasound facilitated diagnosis of intraventricular hemorrhage. In 1979, loss of cerebral autoregulation in sick newborn infants was demonstrated. In the 1980’s, studies demonstrated the importance of intravascular factors in provoking hemorrhage. In 1983, the association of cerebral blood flow velocity fluctuations and subsequent hemorrhage was demonstrated. In 1994, antenatal steroids use to accelerate lung development was recommended. This was associated with an unanticipated reduction in hemorrhage. In the mid 1990’s early indomethacin administration was associated with a reduction of severe hemorrhage.     

Clivus ependymoma

Summary An 8-month-old girl had an ependymoma in the clivus, 2x6 cm in size, connected with the fourth ventricle by a cord of tissue 0.5 cm thick. There were no indications to make us suspect the origin of the tumour in the fourth ventricle, or that it was a case of ependymoma.     

Dermoid and epidermoid cysts of the midline in the posterior cranial fossa

Clinical features and surgical outcome of 16 patients with dermoid or epidermoid cysts on the midline of the posterior cranial fossa are compared. Salient points in the comparison are the younger age, presence of associated malformations and better prognosis of dermoid cyst.     

Primary intracranial arachnoidal cysts

Sixty-seven cases (41 males and 26 females) of arachnoidal cysts in children under 11 years are reported. About 53% of cases were diagnosed before 1 year of life. Thirty-one (42.2%) were supratentorial (interhemispheric 9, temporal fossa 10, convexity 5, sylvian fissure 3, supra- and/or retrosellar 4); 31 (46.2%) infratentorial (supra- and/or retrocerebellar 22, foramen of Magendie 3, quadrigeminal cistern 5, pontocerebellar 1); 5 (7.5%) supra-and infratentorial. Macrocephaly was the presenting symptom in 48 cases (71.5%). Associated features were frequent: cranial asymmetry in 24; aqueductal stenosis in 10; agenesis of corpus callosum in 8; deficient cerebellar lobullation in 4; Chiari I malformation in 2; neurofibromatosis type 1 with dysgenetic zones of the brain in 1; arteriovenous malformation in 1. Diagnosis was made at autopsy in six cases in the days before computed tomography and magnetic resonance: three patients had a cyst in the supra-and retrocerebellar midline; two had a cyst in the quadrigeminal cistern and the sixth was a rare case with the cyst passing from the posterior fossa to the left lateral ventricle through a hole in the basal surface of the brain. Small and some middle-sized cysts were not treated. Big and some middle-sized cysts were usually treated by cysto- and/or ventriculoperitoneal shunts. Arachnoidal cysts of the quadrigeminal cistern usually present with aqueductal stenosis and have to be treated with ventriculoperitoneal shunt. Craniotomy and fenestration of the cysts were performed in some cases with good results. The average mental level of these children is usually moderately low.