[The new algorithm for stratification of the risk of venous thromboembolic events in elective neurosurgery and its prognostic significance]

Early identification of risk groups is essential for effective and target prevention of venous thromboembolic events (VTE) in all areas of surgery. For this purpose, the authors has developed and put into practice an algorithm distinguishing the groups of low, moderate and high risk of VTE among neurosurgical patients.

OBJECTIVE

To assess predictive value of the developed algorithm for elective neurosurgical interventions.

MATERIAL AND METHODS

The study included 7914 patients who underwent surgery between January 2018 and December 2019. According to the algorithm, we identified the groups of low (1536 (19%) patients), moderate (4554 (58%) patients) and high risk (1824 (23%) patients). Moreover, patients were divided into subgroups depending on surgical procedure. We analyzed the incidence of VTE and mortality in all groups.

RESULTS. INCIDENCE

Of VTE with a 95% confidence interval in the low-risk group was 0.65% [0.26; 1.04], in the moderate risk group - 1.82% [1.47; 2.24], in the high-risk group - 12.61% [11.02; 14.09]. When comparing various surgical interventions, we revealed more common VTE after vascular microsurgery (15.62%), in patients with brain tumors (12.63%) and spinal cord tumors (6.52%).

CONCLUSION

The risk stratification algorithm has demonstrated its convenience and significant predictive value for determining the risk of VTE among elective neurosurgical patients. In addition, different incidence of VTE was demonstrated in patients with various neurosurgical diseases.

[Incidence and risk factors of venous thromboembolic events after resection of various brain tumors]

Venous thromboembolic events (VTE) can significantly complicate postoperative period in neurosurgical patients. It is known that patients with brain tumors are especially susceptible to VTE.

OBJECTIVE

To determine the incidence and risk factors of VTE in patients with various brain tumors.

MATERIAL AND METHODS

All patients with brain tumors underwent surgery in 2019 (n=610). They were divided into the groups depending on tumor type: sellar region, intracerebral, extracerebral neoplasms and metastases. All patients underwent screening and prevention of VTE in accordance with the protocol accepted in the hospital. We analyzed the incidence of VTE in each group and significance of various risk factors.

RESULTS

Overall incidence of VTE was 14.9% (91 cases). Deep vein thrombosis (DVT) was the most common - 85 cases (93.4%). Less common events were DVT combined with pulmonary embolism (PE) (n=5, 5.5%) and PE alone (n=1; 1.1%). PE caused death in 2 cases (0.3%). In patients with sellar tumors, incidence was 21.7% [13.4%; 29.35%], among intracerebral tumors - 13.8% [9.04%; 18.62%], extracerebral neoplasms - 15.4% [11.02%; 19.69%], metastases - 7.9% [1.32%; 11.84%]. Univariate and multivariate analysis revealed some risk factors of VTEs such as gender, age, surgery time, length of ICU-stay over 12 hours, body mass index >30 kg/m². Moreover, risk factors have different significance in patients with different types of tumors.

CONCLUSION

In this study, we found a high incidence of VTE among patients with brain tumors. Incidence and risk factors of VTE depend on the type of tumor.

Psychological status before and after surgery in patients with trigeminal neuralgia

OBJECTIVE

To analyze the psychological status in patients with trigeminal neuralgia before surgery and in the early postoperative period after microvascular decompression of the trigeminal nerve.

METHODS

Psychological features of personality were studied in 56 patients aged from 28 to 80 years with trigeminal neuralgia. To study the psychological status, such scales as Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale and Patient's Subjective Assessment of Treatment Effectiveness Scale (PSATES) were used with special attention paid to presence of suicidal thoughts.

RESULTS

The signs of anxiety were clinically significant in 7%, absent - in 66 % of the patients. There were no signs of depression in 63 % of cases, while 7% of the patients suffered from clinically significant depression. Pain catastrophizing was observed in 76.8 % of patients. None of the patients rated the intervention as "excellent" on PSATES despite the complete pain relief in the majority of patients (78.6 %), and only 16.1 % of the patients rated it as "good". The aggravation factor had a significant influence on this evaluation (p = 0.01).

CONCLUSIONS

General psychological status assessment can be used to objectify the indicators of the questionnaires and pain scales, as well as to determine the treatment tactics in this group, especially when it is necessary to clarify indications for an intervention and to decide on its proper time. Regardless of the outcome, the patients need time and psychological help for social adaptation due to changes in their social status.

[Experience of the use of gasserian ganglion balloon compression in patients with trigeminal neuralgia associated with multiple sclerosis]

AIM

To evaluate the efficacy of gasserian ganglion balloon compression in patients with trigeminal neuralgia associated with multiple sclerosis (MS).

MATERIAL AND METHODS

Eight patients (3 men, 5 women), aged from 46 to 66 years (mean age 55 years), with trigeminal neuralgia associated with MS underwent surgery. An average duration of the pain syndrome was 8,4 years. Six patients had previous surgeries due to facial pain. Percutaneous balloon compression of gasserian ganglion was performed to all patients. Follow up period was from 2 to 24 months.

RESULTS

Six patients (75%) reported 100% of pain relief right after the surgery, 2 patients (25%) reported a significant decrease of pain (2-3 points on VAS). Pain recurrence occurred in 3 patients: in 4 months, in 12 months and in 6 months. All of them were operated repeatedly. After the surgery, hypoesthesia on the side of surgery was observed in all patients with a trend towards regression. There was no keratopathy or any complications.

CONCLUSION

Percutaneous balloon compression of gasserian ganglion is an effective and minimally invasive method which can be performed repeatedly in patients with trigeminal neuralgia associated with MS.

Motor Cortex Stimulation for Deafferentation Pain

PURPOSE OF REVIEW

Since the early 1990s, motor cortex stimulation (MCS) has been a unique treatment modality for patients with drug-resistant deafferentation pain. While underpowered studies and case reports have limited definitive, data-driven analysis of MCS in the past, recent research has brought new clarity to the MCS literature and has helped identify appropriate indications for MCS and its long-term efficacy.

RECENT FINDINGS

In this review, new research in MCS, repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS) are analyzed and compared with historical landmark papers. Currently, MCS is effective in providing relief to 40-64% of patients, with decreasing analgesic effect over time addressed by altering stimulation settings. rTMS and tDCS, two historic, non-invasive stimulation techniques, are providing new alternatives for the treatment of deafferentation pain, with rTMS finding utility in identifying MCS responders. Future advances in electrode arrays, neuro-navigation, and high-definition tDCS hold promise in providing pain relief to growing numbers of patients. Deafferentation pain is severe, disabling, and remains a challenge for patients and providers alike. Over the last several years, the MCS literature has been revitalized with studies and meta-analyses demonstrating MCS effectiveness and providing guidance in identifying responders. At the same time, rTMS and tDCS, two time-honored non-invasive stimulation techniques, are finding new utility in managing deafferentation pain and identifying good MCS candidates. As the number of potential therapies grow, the clinician's role is shifting to personalizing treatment to the unique pain of each patient. With new treatment modalities, this form of personalized medicine is more possible than ever before.

What Tactics Should a Surgeon Choose to Treat a Black Extracerebral Tumor? A Case Report of Psammomatous Melanotic Schwannoma of the Meckel Cave and Literature Review

BACKGROUND

Neoplasms located in the Meckel cave account for 0.2%-0.5% of all intracranial tumors. This area is the site of many types of pathologic lesions, most often trigeminal nerve schwannomas and meningiomas. Melanin-containing tumors are rare in this area. These tumor types can be suspected if the magnetic resonance characteristics of a tumor has some differences in comparison with other types of central nervous system neoplasms. In fact, differential diagnosis of melanotic tumors is based mainly on the histopathologic criteria and immunohistochemical profile. This article presents a case report of melanotic schwannoma of the Meckel cave and a literature review of the problem.

CASE DESCRIPTION

A 23-year-old man underwent a 2-stage surgery for a dumbbell pigmented mass lesion located in the Meckel cave. No signs of recurrence were seen on follow-up magnetic resonance imaging (MRI) 3.5 years after the operation.

CONCLUSIONS

Melanin-containing tumor can be suspected in the presence of radiologic characteristics, such as a hyperintense MRI signal on T1-weighted images and a hypointense signal on T2-weighted images. If a black extracerebral tumor is detected, the main course of surgical treatment is maximal excision despite it possibly being a malignant melanoma and the temptation to perform partial resection because of an unfavorable prognosis. Chemotherapy can be justified in the presence of an aggressive melanotic schwannoma.