[Comparison of polymethyl methacrylate skull implant fixation by three types of titanium fasteners]

OBJECTIVE

To evaluate mechanical strength of three methods of polymethyl methacrylate skull implant fixation in two experimental models.

MATERIAL AND METHODS

The first experiment was performed on a plastic model that was as close as possible to bone in structural characteristics. The second experiment was performed on a biological specimen (a ram's head). We assessed the quality of implant fixation to bone window edges by craniofixes, ties and microscrews and lateral intercortical screws.

RESULTS

Craniofixes are feasible for small flat flaps, but not advisable for wide highly curved implants. They are also the most expensive method of fixation. Implant fixation by ties and microscrews is a universal method comparable in price to craniofix. Lateral intercortical fixation is effective both for small flat implants and wide implants with large curvature. However, this method is not always applicable.

CONCLUSION

Combined fixation by lateral intercortical screws and ties allows for the most effective fixation while reducing the overall price of consumables.

[Primary tumors of the brain stem. State of the problem]

Primary brainstem gliomas are still poorly studied in neurooncology. This concept includes tumors with different histological and genetic features, as well as variable clinical course and outcomes. Nevertheless, treatment implies radiotherapy without a clear idea of morphological substrate of disease in 80% of cases. Small number of studies and insufficient data on histological and genetic nature of brainstem tumors complicate clear diagnostic and treatment algorithms. This review provides current information regarding primary glial brainstem tumors. Appropriate problems and objectives are highlighted. The purpose of the review is to provide a comprehensive and updated understanding of the current state of brainstem glial tumors and to identify areas requiring further study for improvement of diagnosis and treatment of these diseases. Brainstem tumors are an understudied problem with small amount of data that complicates optimal treatment strategies. Further researches and histological verification are required to develop new methods of therapy, especially for diffuse forms of neoplasms.

[Chordoid gliomas of the third ventricle]

BACKGROUND

Chordoid glioma is a rare slow-growing tumor of the central nervous system. Available world experience includes no more than 200 cases (lesion of the third ventricle in absolute majority of cases). Recognition and treatment of chordoid glioma are currently difficult problems due to small incidence of this disease.

OBJECTIVE

To describe clinical manifestations and surgical treatment of chordoid glioma of the third ventricle considering literature data and own experience.

MATERIAL AND METHODS

There were 12 patients (6 men and 6 women) with chordoid glioma between 2004 and 2023 (10 patients with lesion of the third ventricle, 1 - lateral ventricle, 1 - pineal region). Only patients with tumors of the third ventricle were analyzed.

RESULTS

Total and subtotal resection was performed in 1 and 3 cases, respectively. Five patients underwent partial resection, 1 patient underwent biopsy. The follow-up data were available in 7 out of 10 patients (mean 25 months). Radiotherapy was performed in 4 patients (continued tumor growth in 2 cases). One patient died.

CONCLUSION

Chordoid glioma is a benign tumor predominantly localized in the third ventricle. Preoperative MRI and CT in some cases make it possible to suspect chordoid glioma and differentiate this tumor from craniopharyngioma, meningioma and pituitary adenoma by such signs as isointense signal in T1WI, hyper- or isointense signal in T2WI, homogeneous contrast enhancement and edema of basal ganglia in T2 FLAIR images. The only effective treatment for chordoid glioma is surgery. Total resection is often impossible or extremely dangerous due to location of tumor, large size and invasion of the third ventricle. Postoperative mental disorders and diabetes insipidus, including severe hypernatremia, are common that requires mandatory monitoring of water and electrolyte balance.

[Surgical treatment of intracranial aneurysms in acute period of hemorrhage in Hunt-Hess grade IV-V patients at Burdenko Neurosurgical Center between 2006 and 2020]

BACKGROUND

Management of patients in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V is still a complex and unsolved problem, especially regarding surgical treatment and various complications.

OBJECTIVE

To analyze postoperative outcomes in patients undergoing surgery in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V between 2006 and 2020, as well as to assess various factors influencing treatment outcomes.

MATERIAL AND METHODS

We analyzed 163 patients who underwent surgery within 21 days after aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V. All patients were divided into 2 groups depending on the period: 2006-2011 (group 1) and 2012-2020 (group 2).

RESULTS

Mortality reduced from 28.6% in group 1 to 8.3% in group 2. At the same time, incidence of vegetative state (GOS grade 2) increased from 4.8% to 17.4%. Incidence of outcomes GOS grade 3 - 5 was similar.

CONCLUSION

Large or giant aneurysm, repeated preoperative subarachnoid hemorrhage, intraoperative aneurysm rupture and prolonged temporary clipping can impair postoperative outcomes in patients with hemorrhage Hunt-Hess grade IV-V. External ventricular drainage, intraarterial injection of verapamil, intracisternal administration of calcium channel blockers and active surgical tactics improve postoperative outcomes and reduce mortality.

[Magnetic resonance imaging of saccular intracranial aneurysm wall]

BACKGROUND

Hemorrhage from intracranial aneurysms is associated with high risk of adverse outcomes. In this regard, surgical treatment of unruptured asymptomatic aneurysms has been actively developed in recent decades. One of the objectives is searching for predictors of aneurysm rupture to clarify the indications for surgery. Non-invasive analysis of vascular wall is actively discussed in last years.

OBJECTIVE

To evaluate the possibilities of MRI of ruptured and unruptured intracranial aneurysm walls and determine clinical significance of certain morphological patterns.

MATERIAL AND METHODS

The study included 111 patients with 158 ruptured and unruptured saccular aneurysms who underwent MRI according to a special protocol between November 2020 and September 2023. We analyzed each aneurysm regarding features of contrast enhancement and changes in SWAN images. After that, we compared these data with ruptures.

RESULTS

Wall of ruptured and unruptured aneurysms can accumulate contrast agent. We found 5 types of contrast enhancement. Thick-layer contrast enhancement was accompanied by 9.6-fold higher risk of aneurysm rupture compared to aneurysms without contrast enhancement. Dark MR signal from intracranial aneurysm wall in SWAN imaging is a significant sign of rupture.

CONCLUSION

MRI of the vascular wall is valuable to verify ruptured aneurysms. Unruptured aneurysms can accumulate contrast agent inside the wall, and pattern of accumulation differs from ruptured aneurysms. Morphological analysis is needed to confirm contrast enhancement as a marker of aneurysm rupture.

[Screening of patients with cerebral aneurysms: mathematical analysis and economic justification]

Subarachnoid hemorrhages due to rupture of cerebral aneurysms have a high risk of disability and mortality. Screening of the population to detect aneurysms in patients with risk factors is currently not carried out in Russia. However, the detection of clinically silent aneurysms and their subsequent prophylactic surgical treatment are justified, according to numerous studies.

BACKGROUND

Demonstrate the clinical and economic feasibility of screening the population (including first-line relatives) for cerebral aneurysms using an economic and mathematical model of the RF virtual population.

MATERIAL AND METHODS

Mathematical modeling was carried out using an algorithm that implements a discrete Markov chain. The virtual population consisted of 145 million people (the population of the Russian Federation). Magnetic resonance angiography 3DTOF was chosen as a screening method. Virtual patients underwent preventive surgical treatment in case of detection of aneurysm during screening. The number of aneurysms in the population, the number of aneurysmal subarachnoid hemorrhage (aSAH), the cost and outcomes of treatment, and the risk of disability were calculated.

RESULTS

In the case of screening and preventive surgical treatment of aneurysms, there is a decrease in the number of aSAH by 14.3% (37.5% in first-line relatives (RPLR), which affects the reduction in mortality due to aSAH by 14.4% (24.1% in The total number of disabled people is reduced by 1.5% (5.1% for the RPHR). A shift in the structure of disability towards greater labor and social adaptation of patients was noted. An economic analysis for the entire population showed that screening saves 7.7 billion annually rubles, including in the population consisting of RPLR - 4.9 billion rubles.

CONCLUSION

The created mathematical model of the virtual population demonstrated that screening and prophylactic treatment of cerebral aneurysms makes it possible to reduce the number of aSAH and associated mortality among the entire population and in the RPLR group. The number of individuals with severe disabilities is decreasing. Thus, population screening for the detection of cerebral aneurysms may be clinically effective and cost-effective in the general population, especially in RPCR.

[Complicated course of the postoperative period with the development of epidural hygroma and intracranial hypotension after removal of cranio-orbital meningioma. Clinical case and literature review]

Surgical removal of cranio-orbital meningiomas is an effective method of treating this pathology. Modern surgical techniques and technologies make it possible to perform operations with a low risk of complications. Lumbar drainage or repeated lumbar punctures are often used intraoperatively or in the early postoperative period to prevent nasal CSF leak; this rarely leads to the development of significant neurological symptoms. We present a case of the development of severe intracranial hypotension with the formation of a subdural hygroma in the early postoperative period after removal of a cranio-orbital meningioma in a 41-year-old patient. The operation was performed using an individual model and molds for simultaneous reconstruction of the bone defect with an implant made of polymethyl methacrylate. On the 1st and 2nd days after surgery, lumbar punctures were performed. From the 2nd day there was a progressive deterioration with the development of symptoms characteristic of intracranial hypotension. Computed tomography revealed an increasing displacement of the midline structures of the brain and an increasing volume of epidural fluid accumulation in the area of surgical intervention. Magnetic resonance imaging revealed characteristic signs of intracranial hypotension. Conservative treatment (bed rest, active hydration) had no effect. On the 6th day after surgery, an epidural blood patch procedure was performed and closed external drainage of the epidural hygroma was performed, and a rapid regression of neurological symptoms was noted. Our experience and literature data indicate that it is necessary to remember the possibility of developing clinically significant intracranial hypotension even after a single lumbar puncture. The formation of hygromas in the surgical area is characteristic of intracranial hypotension, but in most cases does not require additional surgical intervention and does not have a negative impact on the outcome of treatment. Conservative treatment of intracranial hypotension is the first choice and often sufficient. If there is no effect and the patient's condition worsens, it is necessary to perform an epidural blood patch procedure.

[Spontaneous dural CSF fistula as a cause of intracranial hypotension syndrome. Case report and literature review]

Typical symptoms of spontaneous intracranial hypotension syndrome are severe headache, weakness, dizziness and inability to stay upright for a long time. Most often, this syndrome occurs due to CSF fistula in spinal space. Pathophysiology and diagnosis of this disease are poorly known for neurologists and neurosurgeons that can complicate timely surgical care. In case of correct diagnosis, we can identify the exact location of CSF fistula in 90% of cases. Treatment eliminates symptoms of intracranial hypotension and provides functional recovery. The purpose of this article is to describe the diagnostic algorithm and successful microsurgical treatment of a patient with spinal dural CSF fistula Th3-Th4 through posterolateral transdural approach.

[Spinal CSF-venous fistula: case report and literature review]

Syndrome of spontaneous intracranial hypotension is increasingly described in the literature as a multifactorial disease with impairment of the quality of life and risk of mortality. CSF-venous fistula as a cause of intracranial hypotension syndrome is extremely rare and requires complex diagnosis and timely surgical treatment.

OBJECTIVE

We present a 55-year-old patient with acute spontaneous intracranial hypotension and spinal CSF-venous fistula. Literature data are also analyzed.

RESULTS

Algorithm for diagnosis and efficacy of microsurgical resection of CSF-venous fistula is demonstrated.

CONCLUSION

Intracranial hypotension following spinal fistula requires careful examination. Accurate understanding of pathophysiological and anatomical features of this disease is necessary to select an effective treatment method.

[Surgical treatment of hemispheric and subcortical gliomas adjacent to corticospinal tract in children using MR tractography and intraoperative electrophysiological monitoring]

Difficult total resection of supratentorial gliomas adjacent to the corticospinal tract (CST) is due to the high risk of its injury and disability of patients. The main methods for preventing intraoperative CST damage are preoperative MR tractography and intraoperative electrophysiological monitoring. The problem of total resection of gliomas adjacent to the CST with preservation of high functional status is difficult due to immaturity and plasticity of brain structures in children. Moreover, the advantages of MR tractography combined with intraoperative monitoring have not been described. The authors present surgical treatment of supratentorial gliomas adjacent to the CST at different anatomical levels. Patients underwent preoperative and postoperative MR tractography and intraoperative electrophysiological monitoring. MR tractography provided preoperative data on CST lesion. Intraoperative monitoring made it possible to identify and preserve CST in the depth of surgical wound. MR tractography and intraoperative electrophysiological monitoring increase resection quality in patients with hemispheric and subcortical gliomas without postoperative functional deterioration.

[Neurosurgeon training: current problems and modern approaches]

Analysis of historical and modern approaches to teaching neurosurgery by professional communities and public authorities in the United States, the European Union and the Russian Federation makes it possible to develop a modern training program regarding content and duration. High-tech and dynamically developing specialty has acquired several large sub-specializations over the past decades. Each direction requires a long-term training and a special program. Training in neurosurgery in the modern world takes 5-7 years and involves acquisition of clinical and scientific knowledge. Some issues are brought up for discussion by professional community. Solution of these problems will provide an opportunity for international integration of the Russian training program for neurosurgeons. High level of neurosurgery in our country and a single educational space with the European community will allow exchanging students, adopting foreign experience and sharing our own experience.

[Intravascular hypothermia for cerebral ischemia after microsurgical clipping of complex MCA aneurysms]

Hypothermia for neuroprotection and correction of intracranial hypertension was described in both experimental and clinical studies. Effectiveness of hypothermia for improvement of functional outcomes in neurosurgical patients is still unclear despite the previous randomized trials. In available national and foreign literature, we found no trials devoted to hypothermia in patients with ischemia after surgical treatment of complex aneurysms of the middle cerebral artery (MCA).

OBJECTIVE

To analyze the effectiveness of intravascular hypothermia in patients with ischemic cerebrovascular accidents in early postoperative period after microsurgical clipping of complex MCA aneurysms.

MATERIAL AND METHODS

We present four patients with cerebral ischemia after microsurgical treatment of complex MCA aneurysms. In all cases, ischemic disorders developed immediately after surgery. We induced intravascular hypothermia 32-34 °C in all patients. CT-based volumetry of ischemia and edema foci was performed to objectively assess the dynamics of ischemic disorders. We carried out volumetry using segmentation of edema and ischemia foci (range 5-33 Hounsfield units).

RESULTS

According to brain CT data, all four patients had enlargement of postoperative ischemic brain damage. Nevertheless, ICP was stable that made it possible to avoid decompressive craniotomy.

CONCLUSION

Early hypothermia for acute ischemic injury after surgery for complex MCA aneurysms can reduce ischemic perifocal edema. This approach effectively reduces ICP and can exclude the need for decompressive craniotomy in some cases. No side effects of hypothermia justifies further research in this field.

[Features of modeling a polymer implant for closing a defect after decompressive craniotomy]

BACKGROUND

Individual polymer implants are widespread for bone reconstruction after decompressive craniectomy. Despite the availability of customized titanium products, various specialists and hospitals prefer polymer implants.

OBJECTIVE

To compare the methods of modeling and manufacturing the polymethylmethacrylate implants and identify the features affecting the quality of reconstruction.

MATERIAL AND METHODS

We analyzed 14 patients with extensive skull defects after installation of polymethyl methacrylate implants. Software used for modeling of individual implants by different specialists was compared.

RESULTS

Satisfactory reconstruction result was obtained in all cases. There were no infectious complications. The authors outlined certain important aspects for modeling of individual polymer products: local use of anatomical thickness of the implant, leaving safe spaces, prevention of temporal retraction, template-based resection before reconstruction.

CONCLUSION

To date, skull defect closure with polymeric materials remains relevant, and even has certain advantages over customized titanium products.

[Surgical treatment of drug-resistant epilepsy following hippocampal sclerosis]

Surgery is an effective approach for drug-resistant temporal lobe epilepsy following hippocampal sclerosis. There is still no clear and unanimous opinion about advantages and disadvantages of certain surgical technique.

MATERIAL AND METHODS

There were 103 surgical interventions in 101 patients. Females prevailed (1.45:1). Age of patients ranged from 16 to 56 years (median 28). Anteromedial temporal lobectomy and selective amygdaloghippocampectomy were performed in 49 (47.6%) and 54 (52.4%) patients, respectively. In the latter group, 30 patients were operated via a 14-mm burr hole-subtemporal approach. Postoperative outcomes were assessed using the Engel grading system. The follow-up period ranged from 2 to 8 years (median 4 years).

RESULTS

By the 2^nd year, Engel class I was observed in 74 (72%) patients, Engel II, III and IV - in 20 (19.4%), 6 (5.8%) and 3 (2.9%) patients, respectively. Engel class I was achieved after anteromedial temporal lobectomy in 68% of cases, selective amygdaloghippocampectomy via standard approaches in 75% of cases, amygdaloghippocampectomy via subtemporal burr hole approach - in 80% of cases. Neurocognitive impairments after anteromedial lobectomy and selective amygdaloghippocampectomy were similar. At the same time, mental disorders de novo prevailed in the group of anteromedial lobectomy (p<0.05). There were no severe visual field disorders after subtemporal burr-hole access. In other cases, these disorders occurred in 36.2% of patients (p<0.05). There were 8 (7.8%) postoperative complications: 5 (10.2%) - after anterior temporal lobectomy, 3 (5.5%) - after selective surgeries via standard approaches. There were no complications after burr-hole surgery.

CONCLUSION

Selective amygdaloghippocampectomy is not inferior to anteromedial lobectomy. Moreover, this procedure is associated with a lower risk of complications and adverse events.

[Brainstem arachnoid cyst: case report and review]

There are no literature data on brainstem arachnoid cysts in humans.

OBJECTIVE

To describe the clinical case of brainstem (pontomesencephalic) arachnoid cyst and to analyze classification, pathogenesis, differential diagnosis and treatment of this pathology considering literature data and own experience.

MATERIAL AND METHODS

A 29-year-old patient with pontomesencephalic arachnoid cyst is reported. The disease manifested in childhood with a headache aggravated by bending and pushing. Later, syncope, vegetative-visceral paroxysms, mild oculomotor disturbances, transient paresthesia and numbness of the left half of the face occurred. Headaches became significantly more severe and resulted nausea and vomiting. Magnetic resonance imaging (MRI) revealed a two-chambered arachnoid cyst. A smaller chamber was localized in interpeduncular cistern, a larger one - in brainstem.

RESULTS AND DISCUSSION

Differential diagnosis included cystic glioma and Virchow-Robin space enlargement. Fenestration of the cyst wall within interpeduncular cistern was performed via right-sided pterional approach. The diagnosis was verified by histological examination. The follow-up period was 14 months. We observed postoperative cyst reduction confirmed by MR data and regression of all symptoms except for minimal signs of medial longitudinal fasciculus dysfunction.

CONCLUSION

Correct surgical approach for brainstem arachnoid cyst complicated by progressive neurological deterioration is confirmed by postoperative regression of cyst and symptoms.

[Hepatopulmonary syndrome: a rare manifestation of cirrhosis in patient with diencephalic obesity and nonalcoholic fatty liver disease after surgery for craniopharyngioma]

We describe a 15-year girl, who developed panhypopituitarism and diencephalic obesity after surgical excision of craniopharyngioma, followed by nonalcoholic fatty liver disease and cirrhosis 5 years after surgery. Cirrhosis in this case manifested by hypoxia due to hepatopulmonary syndrome, and despite cure of craniopharyngioma by surgery and radiosurgery treatment and adequate hormonal substitution therapy patient died 9 years after surgery. Growth hormone substitutional therapy in patients with hypopituitarism, and steatohepatitis may decrease liver triglyceride accumulation and prevent end-stage liver disease.

[Central neurocytomas: long-term treatment outcomes]

Central neurocytoma is a rare benign brain tumor. These tumors may be giant and accompanied by compression of ventricular system and surrounding structures. Modern treatment of brain neurocytoma includes extended resection and restoration of normal CSF circulation. Surgical treatment does not often lead to total resection of these tumors. Redo resection was preferred in patients with tumor progression for a long time. In the last decade, various authors report stereotactic irradiation for continued tumor growth to ensure local growth control. This study was aimed at evaluation of postoperative outcomes in patients with brain neurocytomas, as well as treatment of tumor progression in long-term period.

OBJECTIVE

To analyze recurrence-free survival in patients with brain neurocytomas, risk factors of recurrence-free survival, effectiveness of various treatments for tumor progression and delayed complications.

MATERIAL AND METHODS

Long-term postoperative follow-up data of patients with brain neurocytomas are reported in the manuscript. We analyzed recurrence-free survival and risk factors of recurrence-free survival, treatment outcomes in patients with progression of brain neurocytomas, long-term complications and their prevention.

RESULTS

Follow-up included 84 out of 115 patients with brain neurocytoma after surgical treatment in 2008-2017. Follow-up period ranged from 2 to 10 years (mean 6 years) after resection. Most patients had regression of neurological symptoms after surgery. Continued tumor growth within 12-96 months after surgery occurred in 26 (30.19%) out of 84 patients (19 cases after partial resection and 7 cases after total resection according to MRI data). Two-year recurrence-free survival was 94%, 5-year survival - 83%. Risk factors of continued tumor growth were resection quality and Ki-67 index. Redo resection was performed in 7 cases. Eleven patients underwent stereotactic irradiation for tumor progression. Indications for stereotactic irradiation of central neurocytoma are MR data on continued growth of lateral ventricle tumor without signs of ICH and CSF flow impairment. There were no cases of hemorrhage inside the residual tumor and CSF flow impairment in early postoperative period after redo resection. In all cases (n=11), stereotactic irradiation (mean follow-up 2.5 years) ensured satisfactory control of tumor growth with reduction of the neoplasm in 4 cases and no tumor growth in 7 cases.

CONCLUSION

Resection of central neurocytoma ensures long-term recurrence-free period. The main causes of tumor recurrence are partial resection and high proliferative activity (Ki-67 index over 5%). Redo resection is advisable for tumor progression followed by CSF flow impairment. In case of continued growth of neurocytoma without signs of intracranial hypertension, stereotactic irradiation with various fractionation modes ensures effective and safe control of tumor growth.

[Stereotactic irradiation in the complex treatment of patients with intracranial pilocytic astrocytoma]

Complex management of patients with intracranial pilocytic astrocytoma (PA) consists of surgical treatment, drug therapy (mainly in young children) and radiotherapy. For many years, radiotherapy (RT) has been a standard for residual tumors, recurrence or continued growth of PA. Currently, stereotactic radiosurgery and radiotherapy are preferred for PA, because these procedures are characterized by high conformity and selectivity, precise irradiation of tumor with minimal damage to surrounding intact tissues. Stereotaxic approach is very important since PAs are localized near functionally significant and radiosensitive brain structures in most cases. There is significant experience of single-center studies devoted to radiotherapy of patients with PA at the Department of Neuroradiosurgery of the Burdenko Neurosurgery Center. In this research, the authors analyzed the results of stereotactic irradiation of 430 patients with PA for the period from 2005 to 2018.

[Combination of pituitary adenomas and intracranial aneurysms]

The combination of intracranial tumors and asymptomatic brain aneurysms is an urgent problem, since it can significantly affect surgical intervention. Aneurysms are common in patients with meningioma, glioma and pituitary adenoma. According to certain authors, combination of aneurysms with pituitary adenomas is 7 times more common than with other tumors. In these cases, a comprehensive examination of the patient and decision-making on surgical strategy are required. This review is devoted to epidemiology, diagnosis and treatment of patients with a combination of pituitary adenomas and intracranial aneurysms detected intraoperatively or at the preoperative stage. The manuscript is illustrated by cases observed at the Burdenko Neurosurgery Center.

[Unruptured asymptomatic brain aneurysms: modern approaches to the choice of surgical method and treatment outcomes]

BACKGROUND

In recent years, significant attention has been paid to preventive vascular neurosurgery. Treatment of unruptured asymptomatic brain aneurysms is one of the sections of this surgery.

OBJECTIVE

To evaluate treatment outcomes in patients with unruptured asymptomatic brain aneurysms who underwent treatment chosen on the basis of criteria adopted at the Burdenko Neurosurgery Center.

MATERIAL AND METHODS

There were 2814 unruptured asymptomatic brain aneurysms in 2334 patients for the period from 1995 to 2019.

RESULTS

Microsurgical operations for unruptured asymptomatic brain aneurysms were performed in 64.9% of cases, endovascular procedures - in 35.1% of patients. Endovascular operations were usually performed for ICA aneurysms and posterior aneurysms of circle of Willis. Microsurgical operations were mainly performed in patients with aneurysms of anterior and middle cerebral arteries. Favorable outcomes (GOS grade V-IV) were obtained in most patients (98.3%). Incidence of severe complications was similar in both groups, mortality rate was 0.3% and 0.4%, respectively.

CONCLUSION

Currently, there is a tendency towards annual increase in the number of surgeries for unruptured brain aneurysms. Anatomical and morphological characteristics of aneurysm should be considered to achieve favorable clinical results. At the same time, comprehensive analysis of each case and identification of individual risk factors will eliminate serious complications of surgical treatment.

[«Cavernous angiomas» of the brainstem. Clinical manifestations, diagnosis and treatment results]

Introduction

In the current literature, brainstem hematomas and various types of vascular micromalformations are combined into the one group of diseases under the general name «cavernous angioma» (CA). This approach does not make it possible to accurately determine the indications for surgery and predict postoperative outcomes.

Objective

To analyze our own experience in the diagnosis and treatment of patients with the brainstem CA.

Material and methods

There were 515 patients with CA of the brainstem (surgery - 322, conservative treatment - 193 patients) with a follow-up period of more than 5 years. Follow-up survey implied neurological examination, analysis of Karnofsky score, MRI and CT data.

Results

We identified two main groups of patients after comparison of MRI data, intraoperative findings and biopsy data: group 1 - hematomas (191 patients, 59%), group 2 - CA (131 patients, 41%). Each group was characterized by own clinical and radiological features. Postoperative outcomes depended on the disease. Debridement of hematoma ensured early postoperative improvement in 63% of patients, no changes in 21% of cases and impairment in 16% of patients. Less favorable results were observed in patients with CA and no signs of hemorrhage. Clinical impairment occurred in 73% of cases, improvement - only in 5% of patients. The most significant regression of neurological symptoms in long-term postoperative period was observed in patients with hematomas (92% of patients). These ones noted much better clinical state compared with preoperative condition.

Conclusions

The type of brain lesion is an important predictor to determine treatment approach. Postoperative outcomes differ significantly in patients with the brainstem hematoma and CA.

[Central neurocytomas: surgical treatment outcomes and new trends and approaches in the treatment]

AIM

Central neurocytomas of the brain are rare benign tumors of the cerebral lateral ventricles. The main treatment for them is surgical resection. Resection provides a long-term relapse-free period, but surgical intervention is associated with a number of significant difficulties due to the location, size, and blood supply features of these tumors. The postoperative period is often accompanied by hemorrhagic complications, impaired cerebrospinal fluid circulation, and worsening of neurological symptoms.

PURPOSE

The study purpose was to evaluate the effectiveness of surgical treatment in neurocytoma patients, assess the risk of complications after neurocytoma resection, and develop techniques for their prevention.

MATERIAL AND METHODS

The paper presents surgical treatment outcomes in 115 patients with central neurocytomas for the period from 2008 to 2017. The choice of a surgical approach and the surgical features are described in detail, and the radicality is assessed with allowance for the location and size of tumors. The immediate clinical outcomes of treatment are evaluated, complications are analyzed, and methods for prevention and treatment of complications are described.

RESULTS

Analysis of the data revealed that the tumor was resected totally in 41 (36%) patients, subtotally - in 37 (32%), and partially in 37 (32%). The most common and dangerous complications were as follows: CSF circulation occlusion with the development of hydrocephalus in 23 (20%) patients; hemorrhage into the residual tumor, which required immediate revision of the surgical wound in most cases, in 25 (22%) patients. In the early postoperative period after tumor resection, almost all patients developed deterioration of condition with transient worsening of cerebral and focal symptoms. The degree and duration of this worsening were different. In 50% of cases, the postoperative condition was characterized by reduced voluntary activity, drowsiness or jitteriness, and motor or speech anxiety.

CONCLUSION

We consider resection of neurocytomas as the main treatment option, despite the potential complications and effects of the operation.

[Successful combination treatment of giant bicameral fusiform partially thrombosed vertebral artery aneurysm at 12-year-old patient (practical case and literature review)]

Giant cerebral aneurysms are diagnosed more often in children than in adults. Treatment of giant aneurysms is carried out both by endovascular and microsurgical methods. Literature information on combination of microsurgical and endovascular operations of cerebral aneurysms at children is little. A clinical case of the combined treatment of a giant bicameral fusiform partially thrombosed aneurysm of the right vertebral artery at a 12-year-old patient and a literature review on this topic are presented. The patient underwent several complex neurosurgical interventions during two operations: 1) microsurgery including revascularization of the right posterior lower cerebellar artery, thrombectomy and trapping of the larger chamber of fusiform aneurysm of the right vertebral artery, and 2) endovascular, which consists in the installation of redirecting stent from the left vertebral artery to main artery. The uniqueness of the case which we presented lies in the fact that the tactics of stage combined treatment for a complex aneurysm at child was originally planned and successfully implemented. The treatment allowed to ensure a complete shutdown of aneurysm and to exclude postoperative cerebral complications.

[Pseudoprogression of intracranial pilocytic astrocytomas and other low-grade gliomas. Literature review and case report]

Tumor pseudoprogression is characterized by temporary tumor enlargement following radiotherapy with subsequent stabilization or regression without additional treatment. This phenomenon has been comprehensively described in patients with malignant gliomas. However, this phenomenon has not been sufficiently studied in patients with low-grade gliomas including pilocytic astrocytomas. In recent years, more and more researches devoted to this problem have appeared in the literature. It seems relevant to conduct a meta-analysis of these data in the modern literature.

[Surgical treatment of patients with cerebral aneurysms in the acute stage of rupture: dynamics of results during 2006-2018]

Treatment of cerebral aneurysms in the acute stage of subarachnoid hemorrhage (SRH) especially on the background of cerebral vasospasm continues to be a difficult task.

OBJECTIVE

Assessment of dynamics of the surgical treatment results of patients with cerebral aneurysms in acute period of SRH.

MATERIAL AND METHODS

A comparative analysis of the results of patients' surgical treatment in NMRCN Burdenko about aneurysm in 1-21 days after hemorrhage was made. The following periods were selected: 2006-2014 (343 patients) and 2015-2018 (356 patients). Most patients had microsurgical operations in both periods. The tactics of choosing the surgery time was the main difference between the periods: particularly in 2015-2018 period the surgery was not postponed at patients with severe.

RESULTS

Analysing the post surgical mortality, it was found that since 2006 there is a consistent trend towards a decrease in the number of patients who died after surgery. When calculating the average post surgical mortality for the studied periods this trend is confirmed - number of lethal cases in 2015-2018 reliably decreased when comparing with 2006-2014 - from 6.8 till 3.2%; p=0.03. At the same time, the number of patients with outcome of vegetative status (from 0.3 till 5%).

CONCLUSION

The tactics of surgical treatment of patients with cerebral aneurysms in the acute period of SRH regardless of severity of patient's condition and time of hemorrhage did not lead to worse treatment. In contrast, post surgical mortality rates show a consistent decline. We associate this fact with a number of changes that have occurred in the management and treatment of patients. In particular, we have high hopes for developing new approaches to the treatment of vasospasm, which remains the leading cause of lethal cases. More definite conclusions will be made at the end of the treatment analysis of the respective patient groups.

[Primary pineal melanocytoma: clinical case and literature review]

Primary pineal melanocytomas are extremely rare pathologies and predominantly are clinically manifested by nonspecific symptoms of a pineal affect, which could be characteristic for tumors of different histological nature located in the same region. Also these tumors differ from other melanocytic tumors by their slow growth and relatively favorable clinical prognosis.

[Individual preoperative 3D modeling of vascular brain pathology]

The possibility of segmenting three-dimensional objects by DICOM-series is well known and available both on specialized workstations and on personal computers. The technique, however, is relatively rarely used in clinical practice, and we believe that the benefits of preoperative preparation using segmented 3D models are underestimated. The article is devoted to our experience in using segmentation of anatomical structures based on CT and MRI for preoperative preparation for surgical operations performed in neurosurgical departments on patients with vascular pathology. The paper discusses the types and possibilities of segmentation, provides some examples describing the clinical use of the technique.

[Microsurgical treatment of aneurysms of vertebral and posterior-lower cerebellar arteries: surgical approaches, exclusion options, treatment results]

Aneurysms of vertebral (VA) and posterior inferior cerebellar arteries (PICA) are relatively rare pathologies and account for 3.4% of the total number of intracranial aneurysms.

MATERIAL AND METHODS

The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented.

RESULTS

Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes.

CONCLUSION

Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.

[A favorable outcome of surgical treatment and intensive care in a child admitted in a severe condition in the setting of aneurysmal subarachnoid hemorrhage (a clinical case and literature review)]

Treatment of children in the acute stage of hemorrhage from cerebral aneurysms is based on clinical cases reported in the literature and descriptions of small series of observations. There are no studies that enable the development of evidence-based approaches to intensive care in treatment of children with aSAH. We present a clinical case with a favorable outcome of complex treatment in a child admitted to the Burdenko Neurosurgical Institute at an extremely severe condition. The efficacy of treatment was based on a timely urgent neurosurgical intervention and adequate intensive therapy in the form of extended neuromonitoring with continuous measurement of intracranial pressure, which enabled using the whole complex of measures for timely management of intracranial hypertension. A favorable outcome (a GOS score IV) after this severe aneurysmal SAH indicates that there are no absolute contraindications for neurosurgical treatment of children with cerebral aneurysms.

[Oculomotor nerve neurinomas. Case reports and a literature review]

Oculomotor nerve neurinoma not associated with neurofibromatosis type II is an extremely rare pathology. According to the topography, cisternal, cisternocavernous, cavernous, orbitocavernous, and orbital tumor groups are distinguished. The clinical picture of the disease is characterized mainly by either oculomotor disorders or pyramidal symptoms, depending on the tumor localization. Neurinomas of the oculomotor nerve rarely occur without oculomotor disorders. However, in some patients with these tumors, the third nerve function remains intact. In this paper, we present clinical cases of two patients with oculomotor nerve neurinomas and analyze the relevant literature.

[Intracisternal administration of verapamil for the prevention and treatment of vasospasm in patients after microsurgical treatment of cerebral aneurysms in the acute period of hemorrhage]

The first results of intracisternal administration of verapamil for the prevention and treatment of cerebral vasospasm (CVS) in patients in the acute period of subarachnoid hemorrhage (SAH) after microsurgical clipping of cerebral aneurysms are presented.

OBJECTIVE

Safety assessment of the method of prolonged intracisternal infusion (PII) of verapamil.

MATERIAL AND METHODS

Over the period from May 2017 to December 2018, 42 patients were included in the study, who underwent clipping of aneurysm of the anterior segments of the Willis circle. Most patients (78.6%) were operated during the first 6 days after SAH. For each patient, a thin silicone catheter was installed, through which verapamil was infused. A prerequisite was the installation of external ventricular drainage and opening of the lamina terminalis. The daily dosage of verapamil varied from 25 to 50 mg of the drug diluted in 200-400 ml of isotonic sodium chloride solution. The indication for the use of the PII method was the presence of one of the following factors: a score on the Hunt-Hess scale from III to V, 3 or 4 points on the Fisher scale, confirmed angiographically by the CVS before the operation.

RESULTS

The PII procedure was performed from 2 to 5 days. The average dose of verapamil was 143.5±41.2 mg additionally, in the presence of an angiographically confirmed CVS accompanied by clinical manifestations, 14 (33.4%) patients received intra-arterial injection of verapamil in several stages, with individual selection of the drug dose. The formation of new cerebral ischemic foci of vasospastic genesis was observed in only 1 (2.4%) patient. No infectious intracranial complications were noted. The average follow-up period was 297.6±156.1 days. Long-term treatment outcomes, assessed by a modified Rankin scale from 0 to 2 points, were observed in 83.3% of patients. There were no outcomes such as vegetative status and no deaths. The frequency of liquorodynamic disorders, as well as epileptic syndrome did not exceed that among patients with SAH according to the literature.

CONCLUSION

The study has confirmed the safety of prolonged PII. The efficacy of the method, compared with other methods for CVS treatment requires further investigation. The first results look quite promising: the observation shows a low percentage of new foci of cerebral ischemia and the absence of deaths associated with it. In patients with severe CVS, the efficacy of the PII method is increased when combined with intra-arterial administration of verapamil.

[Technical features and complications of cranioplasty in patients after decompressive craniectomy in the acute period of subarachnoid hemorrhage]

Decompressive craniectomy is used for arresting hypertension-dislocation syndrome developing in seriuos patients in the acute period of subarachnoid hemorrhage. After stabilization of the patient's neurological and somatic status, cranioplasty is performed for protective, cosmetic, and therapeutic purposes. The most common surgery in these patients is skull repair using an autologous bone graft. Before cranioplasty, the patient's bone is preserved in two ways: cryopreservation or subcutaneous implantation to the anterior abdominal wall area. Recently, there have been numerous reports of early and delayed complications of cranioplasty with autologous bone grafts. The use of artificial grafts may reduce the risk of postoperative complications compared to an autologous bone graft. Previously, 'freely' or 'manually' simulated biopolymers were used. At present, they are rarely used for repair of extensive defects due to a poor cosmetic result. However, the advent of stereolithographic modeling and computer modeling of artificial grafts has improved the cosmetic result of this surgery. The purpose of this study is to assess the risk of postoperative complications of cranioplasty as well as to define the criteria for choosing a cranioplasty technique.

[Principles of surgical treatment for patients with asymptomatic aneurysms and cerebral aneurysms in the cold period after spontaneous intracranial hemorrhages]

Surgical treatment of patients with cerebral aneurysms still remains one of the most important issues of cerebrovascular neurosurgery, which is associated with both complexity of treatment and risks posed by the disease. The purpose of this publication is to discuss the recommendations and algorithms adopted at the Neurosurgical Institute for choosing surgical treatment of patients with single and multiple intracranial aneurysms based on the clinical course of disease and anatomical morphological classifications of aneurysms. The study was based on a large clinical material: we analyzed treatment outcomes in 1,621 patients (2009-2017); of these, 966 (59.5%) patients were operated on using microsurgical techniques, and 655 (40.4%) patients underwent endovascular surgery. Surgical treatment of patients with cerebral aneurysms has been performed in close cooperation between two vascular (microsurgical and endovasal) departments, using the latest technical innovations.

[Chiasm and optic nerve glioma manifested as hemorrhage (two clinical cases and a literature review)]

The article presents two rare clinical cases of low-grade (WHO grade I-II) glioma of the anterior visual pathway structures, the chiasm and optic nerves, in adults. The feature of these cases was the benign nature of a chiasm and optic nerve glioma in adults as well as its presentation in the form of hemorrhage to the tumor and parenchymal and subarachnoid space, which to some extent complicated making the correct diagnosis. Removal of an intracerebral hematoma and open tumor biopsy were performed in one case, and removal of a hematoma and partial tumor resection followed by radiotherapy were performed in the other case.

[Intracranial neurenteric cysts: experience of the Burdenko Neurosurgical Institute in the XXIth century]

We present a series of cases of a rare pathology, intracranial neuroenteric cysts, a review of the international literature, and the experience in treating this pathology.

MATERIAL AND METHODS

Seven patients with intracranial neuroenteric cysts underwent surgery at the Neurosurgical Institute in the period between 2000 and 2015.

CONCLUSION

The main and only technique for treatment of intracranial neurenteric cysts is their resection.

[Transient enlargement of craniopharyngioma cysts after stereotactic radiotherapy and radiosurgery]

Stereotactic radiotherapy/radiosurgery (RT/ES) is an effective technique for treating craniopharyngiomas (CPs). However, enlargement of the cystic part of the tumor occurs in some cases after irradiation. The enlargement may be transient and not require treatment or be a true relapse requiring treatment.

MATERIAL AND METHODS

In this study, we performed a retrospective analysis of 79 pediatric patients who underwent stereotactic RT or RS after resection of craniopharyngioma.

RESULTS

Five-year relapse-free survival after complex treatment of CP was 86%. In the early period after irradiation, 3.5 months (2.7-9.4) on average, enlargement of the cystic component of the tumor was detected in 10 (12.7%) patients; in 9 (11.4%) of them, the enlargement was transient and did not require treatment; in one case, the patient underwent surgery due to reduced visual acuity. In 8 (10.1%) patients, an increase in the residual tumor (a solid component of the tumor in 2 cases and a cystic component of the tumor in 6 cases) occurred in the long-term period after irradiation - after 26.3 months (16.6-48.9) and did not decrease during follow-up in none of the cases, i.e. continued growth of the tumor was diagnosed. A statistical analysis revealed that differences in the terms of transient enlargement and true continued growth were statistically significant (p<0.01).

CONCLUSION

Enlargement of a craniopharyngioma cyst in the early period (up to 1 year) after RT/RS is usually transient and does not require surgical treatment (except cases where worsening of neurological symptoms occurs, or occlusive hydrocephalus develops).

[Reasonability and efficacy of decompressive craniectomy in patients with subarachnoid hemorrhage after microsurgical aneurysm exclusion]

In recent years, the so-called primary or preventive decompressive craniectomy (DC) has been increasingly used in patients with aneurysmal subarachnoid hemorrhage (SAH). The main goal of the technique is prevention of refractory intracranial hypertension (ICH) and its consequences.

PURPOSE

The study purpose was to define the CT criteria for reasonability and efficacy of DC as well as clarification of the indications for preventive DC in patients with SAH after microsurgical aneurysm exclusion.

MATERIAL AND METHODS

The study included 46 patients who underwent microsurgical clipping of aneurysms and DC in the period between 2010 and 2016. All patients underwent surgery in the period of 1 to 12 days after SAH. Preventive DC (imultaneously with clipping of aneurysms) was performed in 38 patients. Secondary (delayed) DC was performed in 8 patients.

RESULTS

Mortality in a group of all patients with DC was 15.2%. Preventive DC was considered as 'reasonable' when the patient had signs of cerebral edema in the postoperative period. The X-ray criteria of reasonable DC included a more than 5 mm brain prolapse into the trephination defect or a lateral dislocation of more than 5 mm. If the patient had no prolapse and dislocation in the postoperative period, DC was considered 'unreasonable'. Among patients with ICH in the postoperative period, including 20 patients with reasonable preventive DC and 8 patients with delayed DC, mortality was 25%. The CT signs of efficient DC were found to be a more than 5 mm brain prolapse into the trephination defect in combination with a decrease in the lateral dislocation less than 5 mm. All seven patients with inefficient DC in our group died. To clarify the indications for preventive DC, we analyzed various preoperative factors in patients with reasonable and unreasonable DC.

CONCLUSION

In most cases, preventive DC in microsurgical aneurysm exclusion is indicated for patients in an extremely grave condition (Hunt-Hess Grade V), a lateral displacement of the mline structures of more than 5 mm, an intracranial hematoma of over 30 mL, and symptoms of acute cerebral ischemia (pronounced cerebral vasospasm and emerging ischemic foci).

[MR tractography in diagnosis and choice of a neurosurgical approach to basal ganglia tumors]

We describe two cases of surgical treatment of well-circumscribed basal ganglia tumors. The choice of a neurosurgical approach to a deep tumor was based on the MR tractography data and depended on the course and dislocation extent of the corticospinal tract. MR tractography provides information on the course and dislocation or destruction extent of the corticospinal tract running in the internal capsule and brainstem and clarifies the exact location of a tumor within the basal ganglia. This information promotes the choice of an optimal approach for radical resection of well-circumscribed tumor, leading to improvement in neurological symptoms and patient's quality of life.

[Preoperative and postoperative ophthalmic symptoms in patients with space-occupying lesions of the midbrain and pineal region]

The most common clinical manifestations of space-occupying lesions of the midbrain and pineal region are oculomotor and pupil disorders and ophthalmoscopic signs of intracranial hypertension.

PURPOSE

To identify patterns of neuro-ophthalmic symptoms before and after surgical treatment in patients with space-occupying lesions of the midbrain and pineal region.

MATERIAL AND METHODS

We analyzed neurological symptoms in 231 patients with space-occupying lesions of the midbrain and pineal region before and after surgical treatment. Malignant tumors were detected in 121 patients; benign tumors were present in 73 patients; 37 patients were diagnosed with pineal gland cysts. Patients with suspicion of germinoma underwent a tumor biopsy only; the other patients underwent tumor resection.

RESULTS AND DISCUSSION

Before surgery, oculomotor and pupil disorders were detected in more than half of the (67%) patients; ophthalmoscopic signs of intracranial hypertension were present in 38% of the patients. Neuro-ophthalmic symptoms significantly more often occurred in patients with malignant tumors. Midbrain symptoms were significantly more pronounced in germ cell tumors than in other malignant neoplasms. In the early postoperative period after tumor resection, deterioration of oculomotor and pupillary functions occurred in 46% of cases; there were no changes in 51% of cases; improvement occurred in 3% of cases. After tumor biopsy, symptoms in all patients with germinomas remained at the preoperative level. Developed symptoms partially regressed in the long-term period, and finally, only 29% of patients had deterioration of oculomotor and pupillary functions compared to the preoperative level.

[Severe postoperative intracranial hemorrhagic complications in a neurosurgical patient with von Willebrand disease not diagnosed before surgery (a case report and literature review)]

The article describes a rare clinical case of a patient with previously undiagnosed von Willebrand disease and basal meningioma; an intracranial neurosurgical intervention was complicated by delayed intracranial hematomas, both at the resected tumor site and distantly. The diagnosis of von Willebrand disease was established only after special hematology tests and only after surgery. Despite the use of specific therapy, the patient died due to intracranial hemorrhagic complications in the postoperative period. The paper discusses the problem of preoperative diagnosis of asymptomatic hemostasis disorders in neurosurgical patients and potential ways of its solution.

[Intra-arterial administration of verapamil for prevention and treatment of cerebral angiospasm after SAH due to cerebral aneurysm rupture]

AIM

The study purpose was to analyze the efficacy of intra-arterial administration of verapamil (IAV) in the treatment of angiospasm in SAH patients and to determine optimal parameters of the procedure. A number of studies demonstrated the efficacy of intra-arterial administration of vasodilators, in particular verapamil, in the treatment of angiospasm after aneurysmal SAH, which served the basis for inclusion of this method in the recommended protocol for treatment of SAH patients [1-7].

MATERIAL AND METHODS

We analyzed the efficacy of IAV in 35 patients in the acute period of SAH, with 77.2% of the patients having a Hunt-Hess score of III-V. The inclusion criteria were as follows: IAV within two weeks after SAH; excluded aneurysm; verapamil dose per administration of at least 15 mg; follow-up for at least three months. Efficacy endpoints were as follows: changes in spasm according to angiography and transcranial dopplerography (TCDG); development of ischemic lesions; clinical outcome according to the modified Rankin scale.

RESULTS

A total of 76 IAV procedures were performed. The verapamil dose per procedure was 36.7±9.7 mg, on average; the number of procedures varied from 1 to 5. One arterial territory was treated in 12 cases, two arterial territories were treated in 48 cases, and three arterial territories were treated in 15 cases. Typical adverse reactions included decreased blood pressure, a reduced heart rate, and elevated ICP. In all cases, TCDG revealed signs of reduced angiospasm - a 20-40% decrease in the LBFV in the M1 MCA. Four (11.4%) patients died; of these, only one died due to angiospasm progression. On examination at 3 months or more after discharge, favorable outcomes were observed in 74.3% of cases.

CONCLUSION

IAV is associated with a low risk of significant complications. IAV should be performed under control of systemic hemodynamics and ICP. The indications for IAV include signs of moderate worsening or severe angiospasm according to TCDG and/or angiography. The IAV procedure may be performed every day. Further clarification of the IAV procedure and evaluation of clinical outcomes under prospective study conditions are required.

[A rare case of diencephalic cachexia in an adult female with cranio-pharyngioma]

Diencephalic cachexia (DС) is progressive weight loss despite a normal caloric intake and a satisfactory state of health, which is caused by hypothalamic lesions. This is a rare (about 100 cases were reported) and potentially fatal disorder of unknown pathogenesis. At present, there is no effective pharmacological therapy for the disorder. Cachexia may regress only if the tumor reduces in size, therefore the timely diagnosis and treatment are of vital importance for the patient. DС is typical of early childhood, and only a few cases have been reported in adults. We present a rare case of DС in a 24-year-old female with papillary craniopharyngioma.

[On the classification of large and giant paraclinoid internal carotid artery aneurysms]

Large and giant intradural ICA aneurysms or the so-called paraclinoid aneurysms are a surgical challenge requiring high qualification of the neurosurgeon. Despite numerous publications on this topic, there is still no generally accepted classification of paraclinoid aneurysms. In this paper, we analyzed the definitions and classifications of paraclinoid aneurysms, which were available in the medical literature. The paper presents our own surgical classification of paraclinoid ICA aneurysms, which has been developed by Prof. Sh.Sh. Eliava and co-authors at the Burdenko Neurosurgical Institute. The classification is based on the aneurysm neck position relative to the ICA wall, aneurysm dome direction, and type of aneurysm clipping.

[Gene mutations in patients with hereditary cavernous malformations]

AIM

To identify mutations in cerebral cavernous malformation (CCM) genes in patients with hereditary and sporadic CCMs in the Russian population.

MATERIAL AND METHODS

Blood samples from 73 randomly selected patients, including 29 MRI-confirmed familial cases, 8 clinically confirmed familial cases and 38 so-called sporadic cases, were examined. A search for large deletions/duplications was performed using multiplex ligation-dependent probe amplification (MPLA). For MLPA-negative samples, the whole genome sequencing was performed to search for single nucleotide polymorphisms (SNP).

RESULTS

Deletions in three genes (ССМ1, ССМ2, ССМ3) were identified in 14 patients, including 5 without definitely established familial type, in whom the familial character of disease was not confirmed by clinical and neuroimaging results. SNP mutations were found in 13 patients, CCM gene mutations in 27. Mutations were detected in 91.7% of familial cases. In two patients, new CCM3 deletions were identified. Gene distribution was as follows: 60.7 for CCM1, 32.2 for CCM2 and 7.1% for CCM3. In two members of a family with hereditary CCMs, no high effect mutations in the known CCM genes were found. Patients with mutations had greater severity of disease. Two patients with CCM3 mutations demonstrated the most aggressive clinical course. De novo formation and growth of CCM were observed only in patients with mutations.

CONCLUSION

The distribution of pathogenic mutations in known CCM genes is consistent with other large-scale studies. Familial CCMs are associated with more severe disease course and may be caused by mutations beyond the known CCM genes.

[A clinical and neuropsychological study of patients before and after resection of third ventricle colloid cysts]

The literature lacks studies of cognitive impairments in large groups of patients after resection of third ventricle colloid cysts.

AIM

To evaluate cognitive impairments in patients before and after resection of third ventricle colloid cysts.

MATERIAL AND METHODS

We performed a clinical and neuropsychological study of 52 patients with third ventricle colloid cysts using the Luria method (1962). Forty three patients were examined before and after cyst resection in the early postoperative period (three patients in this group were also examined in a long-term period of 3-7 months after surgery). Forty one patients were operated on using the transcallosal approach, and two patients were operated on using the subtentorial-supracerebellar transchoroidal approach. The other patients were examined only before or after surgery. The patients' age ranged from 14 to 61 years; the mean age was 33.8 years; the median age was 29 years.

RESULTS

On examination before surgery, cognitive impairments were minimal in 5 patients without clear signs of hydrocephalus. Impairments of memory and dynamic praxis, mild spatial disorders, and psychological inertia were observed in other patients with hydrocephalus. There was no significant difference in the state of cognitive functions between patients with and without stagnation in the fundus. On examination on day 3-6 after transcallosal surgery, several groups of patients were identified. Eight patients had an improvement in cognitive functions, which might be related to postoperative resolution of hydrocephalus. In 15 patients, changes in mnestic functions were insignificant. This group consisted of the youngest patients with a median age of 24 years. Korsakoff syndrome and disorientation were detected in 5 patients. This was the oldest age group, with a median age of 48 years. In other 13 patients, aggravation of mnestic disorders was moderate. Similar memory impairments were detected in the case of the subtentorial-supracerebellar approach. Memory disorders progressively regressed in all patients.

CONCLUSION

Postoperative memory impairment of a varying degree was found in 21 out of 43 patients, with adhesions between the cyst capsule and fornix being observed only in 5 patients. In this case, no injury to the fornix was intraoperatively observed. We discuss the role of the age factor, cyst size, and technical surgical difficulties in the pathogenesis of memory disorders in the absence of injury to the calvarium during colloid cyst resection.

[Application of intraoperative electromagnetic frameless navigation in transcranial and endoscopic neurosurgical interventions]

The paper summarizes the experience in using a system of electromagnetic intraoperative frameless navigation in various neurosurgical pathologies of the brain. The electromagnetic navigation technique was used for 102 operations in 98 patients, including 36 transnasal endoscopic interventions. There were no intraoprtative and postoperative complications associated with the use of the system. In the process of using the system, factors influencing the accuracy of navigation and requiring additional control by the surgeon were identified.

PURPOSE

The study purpose was to evaluate the use of electromagnetic navigation in surgical treatment of patients with various brain lesions.

MATERIAL AND METHODS

The system of electromagnetic navigation was used for 102 operations in 98 patients (42 males and 56 females, including 18 children; median age, 34.8 years (min, 2.2 years; max, 69 years)) in the period from December 2012 to December 2016. In 36 patients, the system was used for endoscopic interventions. In 19 patients, electromagnetic navigation was used in combination with neurophysiological monitoring.

RESULTS

In our series of cases, the frameless electromagnetic navigation system was used in 66 transcranial operations. The mean error of navigation was 1.9±0.5 mm. In 5 cases, we used the data of preoperative functional MRI (fMRI) and tractography for navigation. At the same time, in all 7 operations with simultaneous direct stimulation of the cortex, there was interference and significant high-frequency noise, which distorted the electrophysiological data. A navigation error of more than 3 mm was associated with the use of neuroimaging data with an increment of more than 3 mm, image artifacts from the head locks, high rate of patient registration, inconsequence of touching points on the patient's head, and unsatisfactory fixation to the skin or subsequent displacement of a non-invasive localizer of the patient. In none of the cases, there was a significant effect of standard metal surgical tools (clamps, tweezers, aspirators) located near the patient's head on the navigation system. In two cases, the use of massive retractors located near the patient's localizer caused noise in the localizer and navigation errors of more than 10 mm due to significant distortions of the electromagnetic field. Thirty-six transnasal endoscopic interventions were performed using the electromagnetic frameless navigation system. The mean navigation error was 2.5±0.8 mm.

CONCLUSION

In general, electromagnetic navigation is an accurate, safe, and effective technique that can be used in surgical treatment of patients with various brain lesions. The mean navigation error in our series of cases was 1.9±0.5 mm for transcranial surgery and 2.5±0.8 mm for endoscopic surgery. Electromagnetic navigation can be used for different, both transcranial and endoscopic, neurosurgical interventions. Electromagnetic navigation is most convenient for interventions that do not require fixation of the patient's head, in particular for CSF shunting procedures, drainage of various space-occupying lesions (cysts, hematomas, and abscesses), and optimization of the size and selection of options for craniotomy. In repeated interventions, disruption of the normal anatomical relationships and landmarks necessitates application of neuronavigation systems in almost mandatory manner. The use of electromagnetic navigation does not limit application of the entire range of necessary intraoperative neurophysiological examinations at appropriate surgical stages. Succession in application of neuronavigation should be used to get adequate test results.

[Surgical management of venous compression causing trigeminal neuralgia]

Venous compression is a rare cause of trigeminal neuralgia (TN). Vascular decompression of the trigeminal nerve root, as the only etiopathogenetic treatment of trigeminal neuralgia, is a well-known procedure that is extensively used at various neurosurgical clinics. As the number of interventions for TN increases, the absolute number of surgeries for eliminating venous compression of the trigeminal nerve also grows. Five hundred TN patients underwent surgery at the Neurosurgical Institute in the period from 2000 to 2015. The diagnosis was made based on the criteria of the International Classification of Headache Disorders, the 3rd edition, (ICHD-3) and the Burchiel classification. The study included 211 males and 289 females. The median age was 57 years. All patients had typical TN pain with a unilateral distribution. Two or more branches were affected in 90 patients; one branch was predominantly affected in 10 patients. The median disease duration was 16 months. The median visual analog scale (VAS) score was 8 (very severe persistent pain). In all cases, the patients underwent surgery using the retrosigmoid suboccipital approach. The median postoperative follow-up was 36 months. The aim of this work is to summarize the first experience of the Neurosurgical Institute in surgical treatment for venous compression of the Vth nerve root and suggest methods increasing the efficacy of vascular decompression in patients with this disease.

[The principles for choosing a surgical technique for patients with acute cerebral aneurysm rupture]

The article describes the principles for choosing a surgical technique for patients with cerebral aneurysms in acute subarachnoid hemorrhage. The principles were developed based on the experience gained at the Burdenko Neurosurgical Institute. Microsurgical and endovascular treatment options are considered.