[The analysis of complications of surgical treatment of brain aneurysms in patients operated on in the late posthemorrhagic period].

UNLABELLED: Most patients with brain aneurisms were operated on in the late posthemorrhagic period at the Burdenko Neurosurgical Institute. OBJECTIVE: To investigate the rate and structure of complications of microsurgical and endovascular surgery for different topographic anatomic variants of cerebral aneurysms in patients operated on in the late posthemorrhagic period in order to assess the risk of intervention in these patients. MATERIAL AND METHODS: The study group comprised 1074 patients with single brain aneurysms who had been treated at the Burdenko Neurosurgical Institute (Russian Academy of Medical Sciences) for the period from 2005 to 2012. The exclusion criterion for the study was the acute stage--21 days after the date of hemorrhage. Age of patients ranged from 18 to 75 years, with the mean of 45.3 years. The number of female patients was 552 (51.4%); the number of male patients was 522 (48.6%). Microsurgical operations were performed in 887 (82.6%) patients, endovascular--in 187 (17.4%). RESULTS: Postoperative complications were observed in 163 (15.2%) patients. Most of the complications (14.2%) were associated with cerebral disorders. Pronounced deterioration was noted in 6% of cases, death--in 0.9%. Cerebral complications were revealed in 13.8% of the patients after microsurgery and in 16% after endovascular treatment; mortality was observed in 1% and 0.5%, respectively. CONCLUSION: The overall risk of disability and death associated with recurrent hemorrhage from the aneurysm, especially at young age, is significantly higher than risks of surgical intervention in patients in the late posthemorrhagic period. Thus, the presence of a brain aneurysm that caused hemorrhage is an indication for surgical treatment, regardless of the time of its rupture.

[Intra-arterial injection of verapamil in treatment of cerebral vasospasm in a patient with acute subarachnoid hemorrhage from an aneurysm: case report].

Cerebral vasospasm is a major cause of cerebral ischemia and neurological deficits in patients after SAH from the aneurysm. According to angiorraphy cerebral vasospasm in acute rupture of an aneurysm is detected in 50-70% of cases, and the risk of ischemia on it's background is 19-46%. One of the new trends of treatment of cerebral vasospasm is the intra-arterial injection of calcium channel blockers. The article presents a case of selective intra-arterial injection of verapamil for the treatment of cerebral vasospasm in patient after severe subarachnoid and parenchymal hemorrhage of the internal carotid artery bifurcation aneurysm with a good clinical outcome.

[Radiosurgical irradiation of patients with cerebral AVM on the Gamma knife].

UNLABELLED: Arterio-venous malformation (AVM) of the brain are congenital malformations of cerebral vessels in the embryonic period. Standards in AVM treatment is currently applying the endovascular technique, microneurosurgical removal and stereotactic radiation. MATERIALS AND METHODS: In the period from 2005 to 2011, in 139 patients with arteriovenous malformations of the brain were treated using "Gamma Knife". 89 (64%) of 139 patients suffered bleeding in anamnesis. Paroxysmal symptoms of varying severity dominated in the clinical picture of 35 (27%) patients. Previous microsurgical resection was performed in 10 patients. 28 patients experienced a partial embolization of vascular malformations before radiosurgery. A boundary value radiation dose ranged from 18 to 28 Gy (mean dose 20 Gy), day dose was in the range of 40-80% (average 50% isodose). Maximum dose ranged between 18-60 Gy (mean dose of 38 Gy.). RESULTS: Control angiography or spiral CT screening angiography was performed in all 85 patients who were treated with follow-up data for more than two years, showed that total obliteration occurred in 75% of cases. Frequency of symptomatic radiation reactions was less than 5%. After two years or more after treatment, complete obliteration was observed in 74% of patients. CONCLUSIONS: Higher frequency of AVM obliteration was seen with up to 2 cc. and the irradiation dose of at least 24 Gy.

[Damage to the cavernous segment of internal carotid artery in transsphenoidal endoscopic removal of pituitary adenomas (report of 4 cases)].

Endoscopic endonasal transsphenoidal approach (EETA) is an effective and relatively safe to remove pituitary adenomas and other sellar region tumors. One of the most serious complications of transsphenoidal surgery is damage to the cavernous segment of the internal carotid artery, which by different authors occurs at 0 to 3.8%. In the period from 2005 to March 2013 in Burdenko neurosurgical institute 3,000 patients with pituitary adenomas were operated by standard endoscopic transsphenoidal approach. Damage to the internal carotid artery (ICA) occurred in 4 patients, which amounted to 0.13%. To all patients with damage of the ICA angiography was performed in which identified one case of occlusion of the ICA and three cases of false aneurysm formation. Three patients underwent endovascular treatment. Damage to the internal carotid artery may be associated with the wrong orientation in the surgical wound, or excessively aggressive manipulations in the cavernous sinus. Damage to the cavernous segment of the ICA during transsphenoidal surgery is a rare but potentially fatal complication. Extremely important is the correct localization of the middle line and ICA using navigation systems and Doppler ultrasound.

[The case of simultaneous use of direct and endovascular techniques for the reconstruction of occluded brachiocephalic trunk].

The article provides an example of successful surgical treatment of progressive chronic cerebral ischemia due to occlusion of the brachiocephalic trunk and critical stenosis of the right internal carotid artery (more than 85%). We describe a hybrid method of surgical treatment, which include direct access to the neurovascular bundle, retrograde endovascular recanalization following angioplasty and stenting of the brachiocephalic trunk during temporary occlusion of the distal internal carotid artery and carotid endarterectomy. We provide an analysis of indications for each phase of operation considering the features of compensatory collateral circulation in the basin of the occluded brachiocephalic trunk and the possible complications of surgery.

[Glioneuronal tumor with neuropil-like islands in a neonate]. / Glioneironal'naia opukhol' s uchastkami neiropilia u rebenka grudnogo vozrasta.

Glioneuronal tumor with neuropil-like islands - GTNI is a rare histopatological subtype of anaplastic astrocytoma. English-language literature contains only 43 observations, among them only 4 observations in children up to 18 years. Neuropil is an eosinophilic stained a cellular foci of tumor tissue. These cells demonstrate less proliferation activity than prevailing glial component, which is characterized by a high degree of atypia - Gr III according to WHO classification. Single reports about verification of the glioneuronal tumor with neuropil-like islands in children are supplemented with an observation of the case with tumor, located in lateral ventricular in infant with the onset of hypertension symptoms at the age of 11 months. The potential for complete removal of these tumors despite its large size and young age of the child is presented. However, the prognosis in infants with GTNI despite completeness of removal and chemotherapy might be extremely unfavorable - in case of intraventricular localization progression in the form of tumor implantation on ventricular ependyma is possible.

[Modern technology in the surgical treatment of head injury sequelae].

The paper presents main types of surgically relevant posttraumatic lesions in 4136 patients with skull vault as well as skull base defects, craniofacial deformities, recurrent CSF leaks, arterio-venous fistulas, aneurysms and pseudoaneurysms etc. Classification of TBI sequelae and complications as well as its clinical course grading is presented. The use of modern neuroimaging techniques for studying pathophysiologic mechanisms and complications of TBI has been demonstrated. Special emphasis was given to minimally invasive and reconstructive surgery; computer modeling with subsequent full-copy stereolitographic laser implant setup was shown which is of great importance in cases of large and complex skull base and craniofacial deformities. Patient selection for transcranial and endonasal CSF leak closure techniques was justified. Treatment of post-traumatic vascular injuries using Serbinenko balloon-catheters as well as modern techniques such as stents, coils and embolization has been demonstrated.

[Stepwise treatment of multiple cerebral aneurysms utilizing surgical and endovascular techniques].

To evaluate results of combined treatment of multiple intracranial aneurysms utilizing microsurgical clipping with endovascular techniques. Study group comprised 60 patients with 230 multiple aneurysms (MA) of different location. Most common were aneurysms of ICA--49% and MCA--24%. Single-side ICA aneurysms were found in 11 (18.3%) patients, two-sides ICA lesions in 25 (41.7%); single-side ICA aneurysm with posterior circulation aneurysm--11 (18.3%) and two-sides ICA aneurysm with posterior circulation aneurysm in 13 (21.7%). All patients were treated with endovascular coiling followed by direct surgery. Eight patients treated in acute stage of SAH. Two-stage surgery was performed in 49 cases, three-stage treatment--in 11 cases yielding 131 operations total. Time break between surgeries was 1 day to 4 month. Total occlusion was achieved in 95.3% cases, 98 aneurysms were clipped, 64 (33.4%) coiled. In 15 (7.8%) patients aneurysms were excluded with stent or balloon assisting techniques. Six aneurysms were treated with flow diverters (Pipeline Embolisation Device). Palliative treatment (ICA occlusion with balloon or coils and aneuryms wrapping) were performed in 4.7%. There were no fatal outcomes or complications required repeated surgery in the group. Multimodal approach that combines endovascular techniques with microsurgery is an effective option in multiple aneurysm treatment. Updated endovascular modalities and direct surgery together become a treatment of choice for MA patient improving radical exclusion rate and outcomes. Combined treatment is specifically indicated for elaborate MA cases requiring multiple approaches.

[Microsurgical treatment of cerebral arteriovenous malformations in Burdenko Neurosurgical Institute (recent experience)].

Recently the number of AVM resections in Burdenko Neurosurgical Institute has been increased dramatically. Aim of this study was to assess the results of open surgery in our clinic in modern neurosurgical era. Consecutive series if 160 patients with AVM treated using microsurgical technique since 2009 till 2011 was analyzed. Spetzler-Martin score distribution was: grade I--29 (18.1%) cases, grade II--84 (52.5%), grade III--38 (23.8%), grade IV--9 (5.6%). Patients with grade V AVMs were not operated. Treatment options included: AVM resection in 143 (89.4%) cases, embolization followed by resection in 15 (9.3%) and clipping of afferents in 2 (1.3%). Glasgow outcome scale score distribution was the following: V (good recovery)--70 (43.7%), IV (moderate disability)--71 (44.4%), III (severe disability)--16 (10%), II (vegetative state)--1 (0.6%) and I (death)--2 (1.3%). Microsurgery remains the primary option for radical treatment of cerebral AVMs. Careful selection of patients and planning of surgery are crucial for good outcomes.

[Substantiation of differentiated management of patients with multiple cerebral aneurysms].

The study was performed to substantiate optimal tactics of management of patients with multiple cerebral aneurysms based on analysis of surgical results. This study included 233 (20%) patients with multiple cerebral aneurysms who were treated in Burdenko Neurosurgical Institute since 1995 till 2007. We analyzed results of single-stage (microsurgical technique) and multistage (microsurgical technique and step-by-step application of endovascular and microsurgical techniques) approaches. The following factors were investigated: severity of subarachnoid hemorrhage (Hunt-Hess scale), localization of aneurysms in different arterial systems, quantity and size of aneurysms.. Postoperative mortality was 4.7%. Poor outcomes were observed in 37 (16%) patients. In multi-stage surgical treatment the number of totally occluded aneurysms was significantly higher (92% vs. 79%, p < 0.05) as the number of palliative operations and untreated aneurysms was lower (5.8% vs. 16%, p < 0.05). The best technical and clinical results were obtained in the group of patients who were treated using step-by-step application of endovascular and microsurgical techniques. Despite coexistence of aneurysms of both carotid systems with vertebrobasilar aneurysms in 15% of this group, poor outcomes were not observed and total occlusion of aneurysms was performed in 91.4% of cases. Obtained technical and clinical results of treatment of multiple aneurysms prove that multi-stage surgical management is the therapy of choice in surgery of multiple aneurysms. Our data demonstrate high effectiveness of multimodal approach with integration of endovascular and microsurgical methods. Combination of both techniques is preferential in coexistence of aneurysms of carotid and vertebrobasilar systems.

[Arteriovenous malformations of the Galen vein: results of treatment].

UNLABELLED: We performed retrospective and prospective analysis of surgical treatment of arteriovenous malformations of vein of Galen. Since 1987 till 2009 90 patients were operated in Burdenko Neurosurgical Institute. Age varied between 1 month and 38 years, 69 patients were children below 10. The paper describes main techniques for early diagnosis of the disease, its manifestation depending on age and type of malformation, treatment modalities, early postoperative and follow-up results. Endovascular treatment was applied in 75 (83.3%) patients. Complications with persistent neurological deficit after endovascular occlusion were observed in 10 (16%) patients, 2 patients died shortly after surgery. CONCLUSION: endovascular surgery is the treatment of choice in arteriovenous malformations of vein of Galen; optimal age for endovascular procedure is 4-5 months; observation in asymptomatic course is ineffective.

[Application of robotized radiosurgical system CyberKnife for the treatment of neurosurgical patients].

Robotized system for radiosurgery CyberKnife (Accuray Inc., USA) is the first device dedicated and optimized for advanced irradiation during 1-7 fractions (i.e. radiosurgery and hypofractionation). CyberKnife is characterized by elaborate guidance system, high precision of dose delivery, possibility of conformal dose distributions with high gradient of target borderline dose which is most important in proximity of critical structures. The first CyberKnife system in Russia was installed in Burdenko Neurosurgery Institute. The paper presents 2-year experience of treating patients using CyberKnife. From April 2009 till October 2011 896 patients were treated using CyberKnife. Mean age was 48 years. Overall number of sessions was 2626. Radiosurgical procedures were performed in 21.8% of patients. 91% of cases were treated for intracranial lesions. Limited follow-up period in all kinds of pathology demonstrated results consistent with standard fractionation or radiosurgery. The rates of observed complications were also comparable with accepted techniques. CyberKnife system plays significant role in everyday activity of department of radiation therapy. In careful and thorough selection of patients it allows efficient and high-quality treatment of patients with neurosurgical diseases.

[First experience of radiosurgical treatment of arteriovenous malformations using CyberKnife].

Radiation treatment techniques are essential in complex management of selected neurooncological, neurovascular and functional brain pathology. Stereotactic radiotherapy provides sufficient damage to the target (tumor, AVM, functional structures) with minimal impact on surrounding brain tissue. Development of stereotactic methods with X-ray guidance lead to expansion of indications for irradiation of intracranial and extracranial lesions. This paper represents the first experience of treating patients with AVMs using CyberKnife system in Russia. The technique of stereotactic radiotherapy (SRT) and radiosurgery (SRS) is described in details, as well as indications for SRT and SRS in different regiment of fractionation, possibilities of planning systems, with additional emphasis on specific complications, radiation-induced reactions and capabilities of neurovisualization methods in evaluation of radiation-induced damage of brain tissue.

[Treatment principles of brain arteriovenous malformations of supratentorial localization in children].

Treatment of arteriovenous malformations (AVM) in children is an important problem of children surgery. An aim of the study was to determine an optimal method of treatment. We analyzed the results of examination and treatment of 300 children, aged from 3 months to 18 years, with brain AVM who were admitted to the Burdenko Neurosurgery Institute in 1995-2010. AVM of large brain hemispheres were found in 223 children and 77 children had AVM of deep brain structures. The results of the following surgeries are reviewed: endovascular surgery (64 patients), dissections of AVM (87), radiosurgery (77), combined treatment (42). Surgeries were not performed in 30 cases. The total post surgery lethality was 0,7%. It has been concluded that the method of AVM treatment in children should be chosen individually for every child on the basis of the complex analysis of several criteria (age of the child, AVM localization and angioarchitectonics as well as a variant of clinical course of the disease).

[Linear accelerator-based stereotactic radiotherapy and radiosurgery in treatment of neurosurgical patients].

Radiation methods are essential in management of certain types of neurooncological, neurovascular and functional brain pathology. Application of stereotactic technique of irradiation allows sufficient damaging impact on target (tumor, AVM, functional structures) and maximal protection of surrounding brain tissues. Indications to radiation treatment of intracranial lesions are expanding with evolution of stereotactic methods. The paper deals with the first experience of linear accelerator-based treatment of patients with intracranial neurosurgical pathology in this country. Techniques of stereotactic radiotherapy (SRT) and radiosurgery (SRS), indications to SRS and SRT in different modes of fractioning are described in details. Additionally specific complications, radiation reactions and feasibility of neurovisualization in diagnosis of radiation-induced brain damage are discussed.

[Cognitive disturbances in patients with arteriovenous malformations, cerebellar cavernomas and hematomas].

A clinical-neuropsychological study using Luria's method has been conducted in 13 patients with arteriovenous malformations (AVM) and 12 patients with cerebellar cavernomas and hematomas. The syndromes were similar to lesions of the large hemisphere cortex, more often of premoter regions and less often of the cortex of posterior hemispheric regions. After a surgery on the right cerebellar hemisphere, some patients had perseverations and micrographia in writing. These syndromes were principal similar with findings described in the literature. However there were differences including the absence of marked cognitive disturbances even after the surgery. The disturbances of verbal memory were found in the lesion of both right and left cerebellar hemispheres that is the functional asymmetry of cerebellar hemispheres was not pronounced. The inactivity of speech and agrammatism in writing, even in patients with large duration of hemorrhage, were not observed. In some patients with the lesion of right cerebellar hemisphere, the disinhibition of speech, similar to that in patients with the lesion of right frontal lobe, was found. There were no marked mental disturbances. The most distinct cognitive disturbances were found after surgeries of the superior cerebellar artery. Possible mechanisms of the cerebellum's role in cognitive functions are discussed.

[Complication due to invasive hemodynamic monitoring: formation of vast hematoma of the thigh].

The paper describes a case of the hemorrhagic event--as high as 1500 ml hematoma--resulting from femoral arterial catheterizing puncture for invasive hemodynamic monitoring in a seriously ill neurological care unit patient. The causes of this complication and possible ways of its prevention are discussed.

[Protocol of examination and surgical management of patients with stenosing lesions of the major brain arteries].

The paper contains the protocol of examination and surgical management of patients with stenosing lesions of mail cerebral arteries. Diagnostic algorithm including evaluation of clinical and instrumental data is presented. Indications for ultrasonic (duplex scanning, transcranial Doppler study) and neuroradiological (CT, spiral CT angiography, MRI) methods of assessment of stenosing lesions are described. Indications for digital subtraction angiography as well as CT- and MR-angiographic studies in postoperative period are to be specified. Variants of reconstructive surgical procedures on carotid, vertebral and subclavial arteries, surgical revascularization of the brain and endovascular procedures on brachiocephalic arteries are discussed. Indications and contraindication to different kinds of surgical treatment and selection of anesthesia are listed. Methods of intraoperative multimodal and neurodynamic monitoring and criteria of application of temporary intraluminal shunt on the main stage of carotid reconstructions are described. Tactics of step-by-step surgical management of multiple stenosing lesions of brachiocephalic arteries is presented. The paper also contains recommendations for preoperative preparation and early and delayed postoperative management of patients.

[Stage-by-stage treatment of multiple cerebral aneurysms using endovascular and microsurgical techniques].

Aim of the study was to substantiate effectiveness of stage-to-stage application of microsurgical and endovascular techniques in treatment of patients with multiple cerebral aneurysms (MA). 22 patients with MA were included in this study. 70 aneurysms of different location were found in this series. Aneurysms of MCA were the most frequent. Unilateral aneurysms were found in 6 patients, bilateral -- in 7, unilateral with aneurysm of vertebro-basilar system -- in 4, bilateral with aneurysm of vertebro-basilar system -- in 5. All 22 patients underwent surgical treatment with stage-to-stage application of endovascular and microsurgical techniques. 6 patients were operated in acute period of SAH. In 16 cases two-stage surgeries were made, in 5 -- three-stage. Totally 42 operations were performed. Intervals between stages varied from 1 day to 4 months. Total occlusion of aneurysms was achieved in 91.4% of cases. 40 aneurysms were clipped and 22 were coiled. In 2 cases aneurysms were occluded using coils and stent. Enforcement of aneurysmal walls by oxycellulose and different glue compositions was used in 4 cases. There was no mortality in the series. In 1 female patient with 6 aneurysms transient neurological deficit occurred after third stage of surgical treatment (stenting of basilar artery with coiling of aneurysm of this artery). We did not observe complications demanding wound revision. Obtained results of stage-to-stage surgical treatment of MA are the evidence of high effectiveness of multimodal approach with integration of endovascular and microsurgical techniques. This tactics allows to decrease mortality and disability in acute period of SAH as well in cold period. Described approach can be the treatment of choice in surgical management of MA.