[Perimedullary arteriovenous fistula. Case report and literature review]

Arteriovenous fistula is a common vascular abnormality of spinal cord and meninges. This disease is more common in young men. Clinical manifestation includes progressive sensitive and motor disorders. However, acute symptoms including impaired consciousness, head or back pain are also possible. The authors describe a rare case. A 15-year-old boy experienced acute depression of consciousness accompanied by headache, vomiting, weakness in the upper limbs and sensitive disorders. The patient was hospitalized to the intensive care unit and examined for subarachnoid hemorrhage. MRI of the head and cervical spine and direct invasive angiography were performed. Perimedullary AVF of cervical spinal cord was diagnosed. Complete clinical regression was observed within a month. Microsurgical removal of AVF was performed in scheduled fashion. Postoperative follow-up period was over 6 months.

[Surgery of posterior cranial fossa tumors in children in the prone position. The surgical technique features]

Posterior cranial fossa tumors are the most common neuro-oncological pathology of childhood. More than half of them are located along the midline, occupying the cerebellar vermis and 4th ventricle cavity. Historically, most of these tumors were operated on with the patient in sitting position. This tendency has significantly changed in the last 30 years. For example, 95% of all operations in Japan are now performed with the patient in lying position; for the US and Europe, these figures are 80 and 60%, respectively. This global tendency of switching to the lying position is mainly associated with a high risk of venous air embolism in the sitting position. In the period between 1999 and 2013, the first author used only the sitting position for resection of PCF tumors. During this period, he performed 606 operations. In patients with large/giant tumors (usually, these were piloid astrocytomas with cysts), the surgeon often faced the problem of excessive retraction of the cerebellum and rupture of the bridging veins, sometimes outside the surgical approach area. This situation led either to massive blood loss or to venous air embolism.

MATERIAL AND METHODS

Therefore, beginning at 2013, we started to selectively use the prone position in cases of hemispheric piloid astrocytomas of the cerebellum. This initial experience allowed us to assess the surgical features of the procedure and use the experience in more complex interventions. Since the middle of 2016, given the tendency of using key-hole approaches, we have increasingly used the prone position in surgery of PCF tumors, sometimes removing tumors even through the burr hole. Since the end of 2016, we have routinely used the prone position for various tumors of the 4th ventricle. Between November 2016 and September 2017, the first author performed 113 surgeries for PCF tumors in children; of these, only 4 operations were performed in the sitting position. Thus, in less than a year, the prone position has become the main one in surgery for all PCF tumors in our practice. In this article, we would like to share our practical suggestions both about using the prone position and about its advantages and disadvantages that should be considered by a doctor who does not have experience of PCF surgery with the patient in prone position.

[Liquorrhea after removal of fourth ventricle tumors in children. Retrospective analysis of a series of 211 primary surgeries]

Wound liquorrhea is a serious and dangerous complication developing after neurosurgical interventions. The highest risk group includes patients operated on using approaches to the skull base. In pediatric neurosurgery, approaches to the posterior cranial fossa are some of the most common ones, with wound liquorrhea amounting to 33%. Studies devoted to the wound liquorrhea problem have been performed in heterogeneous patient groups, which complicates evaluation of the results and reduces their practical value.

MATERIAL AND METHODS

The analysis included pediatric patients operated on by a single surgeon for posterior cranial fossa (PCF) tumors in the period from 2009 to 2016. There were 472 patients. Criteria for inclusion in the study were as follows: age under 18 years; predominant tumor location in the fourth ventricle; primary surgery. According to the inclusion criteria, the study involved 211 patients. A search for the key words 'liquorrhea', 'pooling', 'meningocele', 'pseudomeningocele', and 'meningitis' was performed through electronic medical records of the involved patients. We analyzed the data on the total bed-day and the number of days spent in the critical care unit. Surgery protocols were the source of the following information: the presence of an external ventricular drain or ventriculoperitoneal shunt before tumor resection; information on DM closure; information on additional sealing of dura sutures. In addition, the patients were divided into two groups, the main difference between which was the use of additional sealing of dura sutures (Tachocomb, fibrin-thrombin glues, and their combination) to minimize the risk of wound liquorrhea.

RESULTS

A total of 211 patients were included in the study. Postoperative wound liquorrhea occurred in 6 (2.8%) patients; another 5 (2.4%) patients had significant pseudomeningocele. Most children spent no more than 1 day in the critical care unit - totally 176 (83.4%) patients; the other 35 (16.6%) children spent more than 1 day in the critical care unit. A group of patients without sealing of dura sutures consisted of 144 (68.2%) patients. Liquorrhea occurred in 4 (2.8%) cases; in 3 (2.1%) cases, there was symptomatic pseudomeningocele without liquorrhea. In a group of patients with the use of suture sealing (Tachocomb, fibrin-thrombin glue in various combinations - 67 (31.8%) patients), there was liquorrhea in 2 (3%) cases and pseudomeningocele without liquorrhea in 2 (3%) cases. On the basis of PSM algorithm application, 2 groups of 67 patients each were formed: the group with sealing (A) and the group without sealing (B) of the DM. Of the 67 cases of sealing, Tachocomb was used in 64 (95.5%) patients, and fibrin-thrombin glue was applied in 53 (59.1%) patients. Differences between the groups in the rate of liquorrhea (2 (3.0%) patients in group A and 4 (6.0%) patients in group B) and pseudomenigocele (3 (4.5%) patients in group A and 5 (7.5%) patients in group B) were statistically insignificant (p=0.68 and p=0.58, respectively).

CONCLUSION

Wound liquorrhea has remained a topical issue in surgery for posterior cranial fossa tumors and, if develops, doubles the postoperative bed-day. Our strategy of perioperative management of patients proved its efficacy in reducing the rate of postoperative liquorrhea up to 2.8%. A low percentage of liquorrhea did not allow unambiguous evaluation of the effect of additional sealing of dura sutures (Tachocomb and fibrin-thrombin glue).

[Intramedullary spinal cord tumors and hydrocephalus: an analysis of the results of surgical treatment in 541 patients]

The article addresses the problem of intramedullary tumors (IMTs) combined with hydrocephalus (HC).

PURPOSE

The study purpose was to explore, based on large clinical material, the occurrence of hydrocephalus combined with intramedullary tumors, possible pathogenetic mechanisms of its development, effect of tumor resection on the course of hydrocephalus, and need and timing of shunting surgery.

MATERIAL AND METHODS

We present and analyze the data of the largest individual series of patients of all age groups operated on for IMTs of the spinal cord: 541 patients; 586 operations; age from 2 months to 72 years.

RESULTS AND CONCLUSION

Our findings confirm a potential pathogenetic relationship between IMT and HC. The overall occurrence rate of HC in IMT patients was 6.3%. In patients with benign tumors (WHO Grade 1-2; 449 patients), HC developed in 25 (5.6%) cases; in patients with malignant tumors (WHO Grade 3-4; 84 patients), HC developed in 7 (8.3%) cases. A statistically significant prevalence of cervico-medullary tumors was found in HC patients: 19 (59.4%) cases. According to our data, dissemination of the tumor process is a potential factor of HC development.

[Spinal cord epidermoid cysts]

The article describes in detail a large modern clinical series of patients operated on for spinal cord epidermoid cysts.

AIM

the study aim was to comprehensively investigate the epidemiological and clinical peculiarities of spinal cord epidermoid cysts and evaluate immediate and long-term results of their surgical treatment.

MATERIAL AND METHODS

We describe and analyze surgical outcomes of 20 patients with spinal cord epidermoid cysts. This sample was selected from 554 patients with intramedullary tumors and 365 patients with spinal dysraphism (aged from 2 months to 72 years) who were operated on by the first author in 2002-2017.

RESULTS

Our findings confirm a high efficacy and low risk of surgical treatment of patients diagnosed with spinal epidermoid cysts. Severe complications of disease progression serve as indications for 'preventive' surgery even in asymptomatic cases. Complete resection of the tumor capsule without deterioration of the functional surgical result is the main goal of surgical treatment. Incomplete resection is associated with a high risk of recurrence. The most thorough follow-up with annual MRI examination is necessary for the first 6 years after surgery.

[Intramedullary spinal cord tumors and neurofibromatosis]

The article addresses the issue of a combination and relationship between intramedullary spinal cord tumors (IMSCTs) and neurofibromatosis (NF).

AIM

To study, based on large clinical material, features of the prevalence and biological nature of intramedullary spinal cord tumors in neurofibromatosis patients in different age groups.

MATERIAL AND METHODS

We analyzed the data of the largest series of patients from all age groups who underwent surgery for spinal cord intramedullary tumors (541 patients; 586 surgeries; age, 2 months to 72 years).

RESULTS

Our findings support a potential pathogenetic relationship between intramedullary tumors and neurofibromatosis. Astrocytoma was a predominant intramedullary tumor in patients with NF-1, while ependymoma predominated in patients with NF-2. IMSCTs combined with NF-1 occur predominantly in children and adolescents, while a combination with NF-2 is typical of young adults. Our findings confirm the fact that IMSCT surgery is required for a small number of NF patients.

[Application of resorbable plates for fixation of a laminotomy flap]

The paper describes a new technology - application of resorbable plates and pins for securing a laminotomy flap in children's neurosurgery. Four patients were operated on at our clinic. We describe in detail a surgical technique and compare it with a traditional fixation technique using ligatures.