[To the origins of surgery for acoustic neuromas]. / K istokam khirurgii nevrinom slukhovogo nerva.

Acoustic neuroma is one of the most common tumors of the posterior cranial fossa. Its removal is always a challenge for the neurosurgeon and the patient. The history of surgery for acoustic neuromas is inextricably linked with the history of neurosurgery in general. The modern surgical community must know history and be able to use it. Only then will the development of surgery lead to the preservation of the quality of life of patients. In the history of surgery for acoustic neuromas, the stages of its development are clearly visible from the description of the clinical picture through the study of the anatomy of the cerebellopontine angle to modern microsurgical removal.

[Comparison of methods of treatment of meningiomas invading the superior sagittal sinus]. / Sravnitel'naya otsenka metodov lecheniya meningiom, invaziruyushchikh verkhnii sagittal'nyi sinus.

There are various approaches to the treatment of patients with parasagittal meningiomas. OBJECTIVE: To optimize treatment strategy for meningiomas invading the superior sagittal sinus. MATERIAL AND METHODS: The study included 87 patients with benign parasagittal meningiomas between 2010 and 2012. Of these, 34 patients underwent surgery alone, 27 - radiotherapy, 26 - surgery and subsequent radiotherapy. Both groups were comparable in male-to-female ratio, age and localization of tumors in relation to superior sagittal sinus. The follow-up period was at least 5 years. We analyzed the effect of treatment on neurological status, Karnofsky score and tumor growth control. RESULTS: Mean volume of tumors was 43.3 cm3 in patients undergoing surgery and 6.7 cm3 in the radiotherapy group. In the combined treatment group, mean volume was 65.8 cm3 before surgery and 8.8 cm3 before irradiation. General cerebral symptoms (84%), epileptic seizures (37%) and movement disorders (31%) prevailed. Surgery provided the best results in patients with small meningiomas (<14 cm3) causing focal neurological symptoms. Isolated radiotherapy was the most effective in asymptomatic patients. Large tumors required surgery with adjuvant irradiation. CONCLUSION: Benign parasagittal meningiomas followed by focal neurological symptoms require surgical intervention regarding the best functional outcomes and tumor growth control. Radiotherapy without surgery is advisable for progressive asymptomatic tumors. Resection followed by irradiation is preferable if total resection without the risk of damage to veins and cortex is impossible.

[Delta-He a new biomarker for a surgical clinic]. / Del'ta gemoglobina ­ novyi biomarker dlya khirurgicheskogo statsionara.

BACKGROUND: Delta-He the difference between hemoglobin content in reticulocytes and erytrocytes is a relatively new laboratory indicator that is easily measured in everyday practice. This parameter is directly related to iron bioavailability for hemoglobin synthesis and can reflect various conditions accompanied by cytokine expression including systemic inflammation. OBJECTIVE: To analyze the prospects for practical application of hemoglobin delta in assessment of neurosurgical patients throughout in-hospital treatment. MATERIAL AND METHODS: We analyzed complete blood counts (Sysmex XN-1000 analyzer) with optical determination of reticulocyte hemoglobin and automatic calculation of Delta-He in 82 neurosurgical patients. Exclusion criteria were severe decompensated comorbidities, exacerbation of chronic infectious processes, cancer of other organs. Blood sampling for analysis of delta-hemoglobin was carried out before all diagnostic and therapeutic measures. Reference interval is indicated by the analyzer manufacturer as 1.7-4.4 pg. RESULTS: Delta-He values at admission ranged from -1.8 to 6.1 pg. There was a consistent decrease of these values throughout 3-4 postoperative days. Then, the values could increase or continued to decrease. Increment of the index was noted in 76 patients (92.7%). Such dynamics was observed in case of uncomplicated postoperative period. Further decrease of Delta-He was observed in 6 patients (7.3%). These ones were characterized by a longer recovery after surgery, and the events required additional medical or surgical correction were recorded. Negative dynamics of Delta-He values could precede clinical manifestations of certain complication. Clarification of diagnosis and correction of therapy were accompanied by gradual increase of Delta-He values. CONCLUSION: Estimation of Delta-He values over time can be used for monitoring of patients and effectiveness of therapy. From a practical point of view, it is important that examination can be performed at any time of the day.

[Brainstem arachnoid cyst: case report and review]. / Arakhnoidal'naya kista stvola mozga: opisanie klinicheskogo sluchaya i obzor literatury.

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.

[Transcranial microsurgical decompression of the optic canal in surgical treatment of meningiomas of the sellar region]. / Transkranial'naya mikrokhirurgicheskaya dekompressiya kanala zritel'nogo nerva v khirurgii meningiom khiazmal'no-sellyarnoi oblasti.

RATIONALE: When removing the meningiomas of the sellar region, there is always a risk of visual impairment for various reasons, in particular, as a result of traction damage to the optic nerve. Decompression of the optic canal increases nerve mobility during tumor manipulation. In cases of meningioma growing into the canal, its decompression often seems necessary. AIM: Evaluation of the effectiveness and risks of performing decompression of the optic canal. MATERIALS AND METHODS: The study included patients with meningiomas of the parasellar location, who underwent surgical treatment at the Burdenko Neurosurgical Center for the period from 2001 to 2017. They were divided into two groups - main and control. The main group consisted of 129 patients who underwent decompression of the optic nerve canals when the tumor was removed. The tumor matrix in this group was most often located in the region of the tuberum sellae, supradiaphragmally, in the region of the anterior clinoid process and the optic canal. In 31 cases, decompression was bilateral - during one operation and using one access in 27 patients; in 4 cases, the decompression of the second canal was delayed for 1.5-3 months after the first operation. 160 decompressions were performed by the intradural and 7 - by extradural methods. During intradural decompression, the roof of the optic canal was resected, and during extradural decompression, the lateral wall of the canal was trephined. The control group consisted of 308 patients who did not undergo canal decompression when the tumor was removed. It included meningiomas with a predominant location of the matrix in the area of the tuberclum and diaphragm of the sella. Tumors in both groups were removed according to the same principles (matrix coagulation, mainly the gradual removal of the tumor, the use of ultrasonic aspirator, a situational decision on the radicality of the operation, etc.). The main difference between operations in these two groups was only canal related algorithms (with or without its trepanation), as well as the probable prevalence of significant lateral tumor growth in cases with canal trepanation. Visual functions in the «primary¼ group were evaluated before and after operations with trepanation of the canal depending on various factors - the initial state of vision and the radicality of the tumor excision, including removal from the canal. The differences in the postoperative dynamics of vision in the main and control groups were studied. The primary data processing was carried out using the program MSExcel. Secondary statistical processing was carried out using the program Statistica. To assess the statistical significance of differences in the results obtained in the compared patient groups, the Chi-square test was used, and in the case of small groups - the exact Fisher test was applied. RESULTS: In the main group postoperative vision improvement of varying degrees on the side of trepanation was registered in 36.9% (59 out of 160) cases, no vision changes were found in 36.9% (59 out of 160), and in 26,2% (42 out of 160) the eyesight deteriorated. If preserving vision is attributed to a satisfactory result, then in general the results of these operations should be considered good. A comparative study of the results of removal of meningiomas with trepanation of the canals (main group) or without it (control group) was carried out among patients with the most critical vision situation (visual acuity 0.1 and below, up to only light perception). These groups are comparable in the number of observations - 62 and 73 respectively. The predominance of cases with improved vision in the main group compared with the control group (50.0% versus 38.36%) and a lower incidence of vision impairment (22.58% versus 34.25%) were found. However, the revealed differences are statistically unreliable and make it possible for us to talk only about the trend. The complications associated with trepanation of the canal include mechanical damage to the nerve by the drill. In our series of observations, there was only 1 case of abrasion of the nerve surface with the burr, which did not lead to a significant visual impairment. With the intradural method of trepanation in the area of the medial wall of the canal, the sphenoid sinus may open (in our series, in 34 cases out of 160 trepanations). Immediately closure of these defects was performed by various auto- and allomaterials in various combinations (pericranium, fascia, muscle fragment, hemostatic materials, and fibrin-thrombin glue). A true complication - CSF rhinorrhea liquorrhea developed in only one case, which required transnasal plastic surgery of the CSF fistula using a mucoperiostal flap. CONCLUSIONS: 1. Trepanation of the optic canal in cases of meningiomas of parasellar localization is a relatively safe procedure in the hands of a trained neurosurgeon and does not worsen the results of operations compared with the excision of the same tumors without trepanation of the canal. 2. The literature data and the results of our study make it possible to consider the decompression of the optic canal as an optional, but in many cases, useful option that facilitates the transcranial removal of some meningiomas of the sellar region.

[Radiation-induced meningiomas: analysis of 33 cases]. / Radioindutsirovannye meningiomy: analiz 33 nablyudenii.

BACKGROUND: Development of meningiomas correlating with irradiation has been described in the last century. Different biological features of radiation-induced meningiomas depending on dose and type of irradiation have been observed in recent years. MATERIAL AND METHODS: There were 8848 patients (women - 74.3%) with intracranial meningiomas for the period from 2000 to 2014 who underwent surgery at the Burdenko Neurosurgical Center. Radiation-induced meningiomas were identified in 33 patients (13 (38%) men and 20 (62%) women) aged 16-76 years (median 56 years). Medical data were retrospectively analyzed. Follow-up period ranged from 5 to 22 years (median 12) after verification of histological diagnosis. Meningiomas were preceded by X-ray irradiation of the scalp for ringworm (microsporia or trichophytosis) in 26 cases (79%) (group A). Group B enrolled 7 (21%) patients after previous radiotherapy for other tumors (retinoblastoma, chiasmal glioma, pituitary adenoma, basalioma). Data were compared using Mann-Whitney and Fisher's exact tests. RESULTS AND DISCUSSION: Incidence of radiation-induced meningiomas was 0.37% in our sample. Meningioma diagnosis dates after X-ray epilation (median 52 years) significantly differed from that after radiotherapy (median 22 years) (Mann-Whitney test, p=0.0003). Primary multiple meningiomas were diagnosed only in the 1st group (Fisher's exact test, p=0.0005). Recurrent meningiomas after the first surgery were more common in the first group (58%) compared to the second one (14%) (Mann-Whitney test, p=0.0003). CONCLUSIONS: The latency period is shorter after radiotherapy (median 22 years compared to 52 years after X-ray epilation). Incidence of atypical and malignant meningiomas directly correlates with irradiation dose. Approximately equal incidence of radiation-induced meningiomas after X-ray epilation in women and men can indicate other mechanisms of development of these tumors in comparison with spontaneous ones. Radiotherapy is followed by occurrence of meningiomas within the irradiated area. These tumors are usually single. In case of X-ray epilation, the tumors may be localized anywhere within the intracranial space (convexital and/or parasagittal localization in 77% of cases). Multiple neoplasms occur in 42% of cases. Refusal of head X-ray epilation for the treatment of a ringworm for the last 50 years may be followed by reduced incidence of radiation-induced meningiomas, especially multiple ones. However, extended indications for radiotherapy of various brain diseases can result an increase of the incidence of meningiomas within the irradiated area.

[Neurological semiotics of benign craniofacial tumors]. / Nevrologicheskaia semiotika dobrokachestvennykh kraniofatsial'nykh opukholei.

AIM: To identify the most frequently occurring symptoms resulting from the affection of internal and external skull base in patients with benign tumors of the anterior and middle cranial base. MATERIAL AND METHODS: The authors analyzed a complex of history, clinical, and instrumental data as well as results of combined treatment of 642 patients with benign tumors of the anterior and middle cranial base operated Medical Research between 2007 and 2011. RESULTS: Neurological signs and symptoms in patients with benign tumors of the anterior cranial base, parasellar region, and middle cranial fossa were studied. In the majority of cases, the tumor extended extracranially. The most common groups of symptoms were identified and described, the most important groups are presented in the diagrams. The proposed scheme is applicable also for malignant tumors or other mass lesions of the same localization. CONCLUSION: Effective treatment and selection of the best management of a patient depends on modern medical approaches and techniques including neuroimaging. Careful assessment of symptoms is crucial in detection of tumors in the early stage. Dynamic monitoring of the patient using the proposed scheme will contribute to early detection of tumor recurrence or progression.

[The management of patients with new epileptic seizures in the early period after resection of hemispheric tumors: two case reports and a literature review]. / Taktika vedeniia patsientov s vpervye épilepticheskimi pristupami v rannem periode posle udaleniia opukholei bol'shikh polusharii: dva nabliudeniia i obzor literatury.

Epileptic seizures developing for the first time after a neurosurgical intervention (de novo seizures) are a challenge for choosing an optimal treatment. The pathogenesis of these seizures is often associated with factors that become inactive in the early postoperative period. These seizures can not serve the basis for diagnosing symptomatic epilepsy and should be regarded as a brain response to surgery, and patients do not need anticonvulsant therapy that reduces the quality of life. But in some situations, new early postoperative seizures serve the onset of symptomatic epilepsy and require prolonged anticonvulsant therapy. To date, one of the main techniques to identify the nature of newly developed seizure and to plan further treatment (whether or not to use anticonvulsant therapy) is video EEG monitoring. We present two clinical cases of patients who developed de novo convulsive seizures in the early postoperative period in similar situations after resection of intracerebral tumors. The use of video EEG monitoring allowed avoiding unreasonable use of anticonvulsant therapy in one of the patients.

[Epidemiology, diagnosis, clinical symptoms, and classification of malignant primary skull base tumors]. / Épidemiologiia, diagnostika, klinicheskaia simptomatika i klassifikatsiia pervichnykh zlokachestvennykh opukholei, porazhaiushchikh osnovanie cherepa.

A review of literature presents up-to-date information on the prevalence, incidence, clinical manifestations, diagnosis, and classification of malignant primary skull base tumors (MPSBTs). In the structure of total cancer incidence, malignant head and neck tumors account for 5% of all annual cancer deaths in the USA and are among the 5 most common groups of tumors in males worldwide. These tumors develop most often in the sixth decade of life, occurring 2 times more often in males than in females. In Russia, the MPSBT incidence (as of 2012) was 0.62% out of all newly diagnosed malignant tumors. The incidence rate amounts to 0.66 per 100 000 population and is significantly higher than the global rate (0.44 per 100 000). About half of all malignant skull base tumors have the epithelial nature and affect the anterior parts of the skull base. The most frequent histological types of malignant skull base tumors are squamous cell carcinoma, adenocarcinoma, and non-Hodgkin's B cell lymphoma. Treatment of skull base tumors is an interdisciplinary problem and the area of interest of otolaryngologists, dentists, ophthalmologists, neurosurgeons, plastic surgeons, radiologists, and chemotherapists. Physical and endoscopic examinations, endoscopic transnasal biopsy, CT, MRI, PET/CT, and ultrasound are typically used for verification of the diagnosis, tumor staging, and selection of the treatment approach. The review describes the criteria for TNM staging of malignant tumors of the nasal cavity and paranasal sinuses in accordance with the 7th version of the TNM recommendations of the American Joint Committee on Cancer (AJCC). The TNM-based staging depends on the location (maxillary sinus, nasal cavity, or ethmoid labyrinth) and histological structure of the tumor, which, in turn, determines the tactics of comprehensive treatment and a prognosis group.

[Life quality of patients with benign tumors of the anterior and middle part of the skull base after surgery and during follow-up].

The results of surgical and combination therapy of 302 patients with benign tumors of the anterior and middle regions of the skull base with allowance for the functional outcomes (immediately after surgery and during the catamnestic follow-up) are reported. The Karnofsky and Rankin scales and the Anterior Skull Base Questionnaire (ASBQ) were used for the analysis. Radical tumor resection, as compared to partial resection, reduces the quality of life in the early postoperative period but increases it in future; the use of radiation therapy in combination treatment for patients with radically inoperable tumors does not worsen their quality of life in the late postoperative period.

[Surgery of skull base tumors extending into the orbit, paranasal sinuses, nasal cavity, pterygopalatine and infratemporal fossas: treatment principles in certain types of tumors].

Following the paper focused on surgery of skull base tumors invading the orbit, paranasal sinuses, nasal cavities, pterygopalatine and infratemporal fossae, the authors discuss particular issues of surgical treatment of the most common craniofacial mass lesions, including meningiomas, juvenile angiofibromas, trigeminal nerve tumors, chondroid tumors, and others.

[Tumors of the skull base, extending into the orbit, paranasal sinuses, nasal cavity, pterygopalatine and infratemporal fossa].

The first of two papers focusing on surgery of skull base tumors invading orbit, sinonasal cavities, pterygopalatine and infratemporal fossae the authors described foundation and development of craniofacial oncology as a new discipline in skull base surgery, modern approaches to diagnostic evaluation of craniofacial mass lesions and basic principles of surgical management.

[Orbitosphenopetroclival meningeomas: clinical and topographic features and results of combined treatment]. / Orbitosfenopetroklival'nye meningiomy: kliniko-topo-grafi-cheskie osobennosti i rezul'taty kombinirovannogo lecheniia.

UNLABELLED: The aim of the study was to access clinical and topographic features of orbitosphenopetroclival meningeomas and the results of surgical and combined treatment in patients with meningeaomas of that location. Orbitosphenopetroclival meningeomas comprise a peculiar group of tumors and are the result of infiltrative sphenopetroclival meningeomas progression, when the latter extend into the orbit and temporal fossa. Development of neurosurgery, use modern approaches and adjuvant therapies such as stereotaxic radiosurgery and radiotherapy in the past years markedly improve treatment results in these patients. However, difficulties in treatment strategy choice remain. One attempting to excise a tumor radically encounters with the risk of damage to critically important neurovascular structures. When a tumor is excised partially the risk of complication dwindles, however risk of relapse increases. Palliative surgery improve patients' quality of life. Radiosurgery and irradiation of residual tumors allow to establish control on a tumor growth. MATERIAL AND METHODS: Twenty three patients were studied, of them 20 received surcery, 9 - stereotaxic irradiation, 5 - conventional irradiation. The follow-up interval comprised 8-84 months (median 37 months). RESULTS: Manifestations of orbitosphenopetroclival meningeomas are combined from signs and symptoms of cranioorbital and petroclival meningeomas, and in many patients include signs of skull base external surface involvemevt, marked cosmetic deficits and psychological distress. Orbitosphenopetroclival meningeomas originate from cavernous sinus and medial parts of sphenoid bone wings. During its progression a tumor extends onto orbit and onto clivus, and then onto infratemporal and sphenopalatine fossae, nasopharynx and posterior cranial fossa. CONCLUSION: If a residual tumor is present patients with orbitosphenopetroclival meningeomas should undergo adjuvant irradiation after the first surgery.

[Transformation of trigeminal nerve tumor into malignant peripheral nerve sheath tumor (MPNST)].

Malignant peripheral nerve sheath tumor (MPNST) is a rare entity with only 18 cases of trigeminal nerve MPNST described by now and only one report of malignant transformation of trigeminal nerve tumor into MPNST published up to date. One more case of malignant transformation of trigeminal nerve (1st division) tumor into MPNST is demonstrated.

[Differential diagnosis between melanotic schwannoma of gasserian ganglion and metastatic melanoma of middle cranial fossa].

We present a case of a rare tumor--melanotic schwannoma of trigeminal nerve root and gasserian ganglion. Differential diagnosis between metastatic melanoma and melanotic schwannoma (MS) is associated with serious difficulties and high responsibility. Metastatic melanoma is a high grade tumor while most MS are benign lesions with good outcome. By the date 105 cases of these tumors are described in the world literature, 3 of them originated from trigeminal nerve root and gasserian ganglion. MS predominantly occur in relatively young patients, they are characterized by presence of Carney's complex and psammomatous bodies and absence of primary focus. MS and metastatic melanoma have similar appearance on MRI due to presence of melanin granules. Indirect signs evident for MS include cystic structure and dumbbell-shaped growth. Metastatic melanoma of cranial nerves is more typical in people older than 40, primary focus in the face in the zone of innervation of affected nerve is common. In case of absence of the listed features differential diagnosis is based on immunohistochemical analysis and electron microscopy of tissue samples.

[CyberKnife stereotactic radiosurgery in the treatment of patients with trigeminal neuralgia].

Trigeminal neuralgia (TN) is a disabling disease with severe impairment of quality of life and everyday activity of patients. Range of treatment modalities is wide and includes conservative therapy, surgical methods and stereotactic radiosurgery (SRS). SRS is a minimally invasive technique which provides good results and minimal rate of complications. High geometrical and clinical precision of frameless SRS using CyberKnife system allows its application in TN when high dose is delivered to a small volume. The given paper focuses on the first Russian experience of frameless SRS of TN using robotized system CyberKnife. Since April 2009 till June 2011 4 patients with TN were treated in department for radiation therapy of Burdenko Neurosurgical Institute using CyberKnife system. Mean age was 63 years. Mean and maximal target dose reached 70 and 90 Gy, respectively. Data of catamnestic clinical examination were available in all 4 patients. Follow-up period reached 8 months. Response to treatment was observed in all cases. In 2 (50%) patients full effect was reached while in the rest only partial effect was present. No complications were encountered. Effectiveness and safety of SRS using CyberKnife system is comparable with framed SRS.

[Intraosseous cranioorbital hemangiomas].

The authors describe 2 cases of primary intraosseous cavernous hemangioma (PICH). PICH are extremely rare tumors that represent less than 1% of all tumors of the bone. Only 20% of them involve skull. In both cases clinical findings were presented by proptosis, oculomotor disorders and chronic daily headaches. Surgery is the most recommended method of treatment. The best surgical management is gross total resection within intact tissue. In both cases tumor was removed completely.

[Rare observation of hyperostotic cranial lesions in osteogenesis imperfecta].

A rare case of hyperostotic skull deformity in a patient with congenital bone defect--osteogenesis imperfecta--is described. In this case typical symptoms encountered in adults were observed: decreased body length caused by shortened extremities due to multiple pathological fractures in childhood, deformities of thorax, spine, facial bones and teeth, skull lesions with craniobasal and brainstem symptoms, bluish hue of sclera, hypoacusis etc.). In this patient non-typical abnormalities were found: visual deficit due to optic nerve atrophy caused by bilateral optic canal stenosis on the background of densitometrically proven hyperostotic skull base deformity.