[Bacterial contamination of autologous blood in reinfusion in neurosurgery: a phenomenon or a problem?] / Bakterial'naya kontaminatsiya autologichnoi krovi pri provedenii apparatnoi reinfuzii v neirokhirurgii: fenomen ili problema?

There is a problem of bacterial contamination of autologous blood despite long-term experience of intraoperative blood salvage and reinfusion. OBJECTIVE: To analyze safety of blood reinfusion with white blood cell filtration and X-ray irradiation for blood decontamination in neurosurgery. MATERIAL AND METHODS: The study included 57 patients with various neurosurgical diseases. We used intraoperative blood reinfusion in all patients considering high predictable risk of major blood loss due to neurosurgical diseases, features of neoplasm topography, anamnesis and examination data. Microbiological examination of autologous blood was carried out at different stages before reinfusion. RESULTS: Bacterial contamination of autologous blood samples was observed in 42% of patients. Enlargement of surgical access to paranasal sinuses in patients with craniofacial lesions poses a potential risk of bacterial contamination of autologous blood. Additional methods of decontamination including white blood cell filtration and X-ray irradiation reduced bacterial load. The above-mentioned methods were less effective for decontamination of microflora not typical for human skin compared to saprophytic ones. There were no postoperative infectious complications. CONCLUSION: Combination of white blood cell filtration and X-ray irradiation reduces bacterial contamination and increases safety of reinfusion although these methods do not completely free autologous blood from opportunistic microorganisms. Decontamination quality significantly depended on microflora and surgical approach.

[Hemostatic disorders in neurosurgical patients: diagnostics and correction]. / Narusheniya sistemy gemostaza u neirokhirurgicheskikh bol'nykh: diagnostika i korrektsiya.

The authors analyzed the main causes of perioperative hemostatic disorders in neurosurgical patients. The problem of preoperative hemostatic screening, intraoperative and postoperative factors contributing to hemostatic disorders are considered. The authors also discuss the methods for correction of hemostatic disorders.

[Pulmonary embolism in neurosurgical patients]. / Tromboemboliya legochnoi arterii u patsientov neirokhirurgicheskogo profilya.

Pulmonary embolism (PE) is a serious problem for neurosurgical patients because of high risk of mortality and the need to choose effective and safe anticoagulation. OBJECTIVE: To analyze the patients with PE after neurosurgical interventions. MATERIAL AND METHODS: A prospective study was performed at the Burdenko Neurosurgical Center between January 2021 and December 2022. Inclusion criteria were neurosurgical disease and PE. RESULTS: In accordance with inclusion criteria, we analyzed 14 patients. Mean age was 63 [45.8; 70.0] years. Four patients died. PE was a direct cause of death in 1 case. PE occurred in 5.14±3.68 days after surgery. Anticoagulation was safely implemented in 3 patients with PE on the first day after craniotomy. In a patient with massive PE several hours after craniotomy, anticoagulation resulted hematoma with brain dislocation and death. Thromboextraction and thrombodestruction were used in 2 patients with massive PE and high risk of mortality. CONCLUSION: Despite low incidence (0.1%), PE is a serious problem in neurosurgical patients due to the risk of intracranial hematoma under effective anticoagulant therapy. In our opinion, endovascular interventions with thromboextraction, thrombodestruction or local fibrinolysis are the safest in the treatment of PE after neurosurgery. Individual approach considering clinical, laboratory data, advantages and disadvantages of a particular anticoagulant drug is required when choosing the tactics of anticoagulation. Further analysis of a larger number of clinical cases is needed to develop the guidelines for the management of neurosurgical patients with PE.

[Sitting position in neurosurgery: realizing the risks]. / Neirokhirurgicheskie vmeshatel'stva v polozhenii sidya: real'no otsenivaya riski.

The author discusses potential intraoperative complications following neurosurgical interventions in sitting position: venous air embolism and paradoxical air embolism, postural hypotension, pneumocephalus, cervical flexion neuropathy, positional damage to peripheral nerves and others. Naturally, prevention of these complications is also considered, and the most effective approach is surgery in lying position.

[Congenital coagulation disorders in neurosurgical patients. Literature review and case series]. / Vrozhdennye narusheniya gemostaza u neirokhirurgicheskikh bol'nykh. Obzor literatury i opisanie serii nablyudenii.

Congenital coagulation disorders account about 1-2% and can pose a serious risk for neurosurgical patients. Indeed, coagulation management in these patients is essential to ensure normal hemostasis. Analysis of available literature devoted to this issue and case series of neurosurgical patients with congenital coagulation disorders. Literature data were obtained from the PubMed, Cochrane Library, Medline and Google Scholar databases for the period from 2019 to 2020. Over 200 reports devoted to our scientific issue were selected. We determined the key features of perioperative management of neurosurgical patients with congenital coagulation disorders. We have also analyzed 10 similar patients for the period from 2008 to 2020. Comprehensive analysis of anamnesis, adequate diagnosis, perioperative planning and multidisciplinary approach are essential for successful elective surgery in patients with congenital coagulation disorders.

[Local application of recombinant activated factor VII for massive surgical bleeding]. / Lokal'noe primenenie rekombinantnogo aktivirovannogo faktora svertyvaniya krovi VII dlya ostanovki massivnogo operatsionnogo krovotecheniya.

The authors report resection of anaplastic convexital meningioma in a middle-aged woman complicated by expected massive blood loss. The most intense bleeding occurred at the final stage of resection and it was impossible to stop it with traditional approaches. The surgeon pressed a standard tachocomb plate moistened with a diluted solution of recombinant activated factor VII (coagil, Russia) to the most bleeding area for 5 minutes. Subsequently, surgeon replaced finger pressure with a permanent napkin. Hemostatic effect of recombinant activated factor VII following its systemic administration is well known and convincingly proven in many surgical areas including neurosurgery. However, we do not know any descriptions of its local application in neurosurgical patients.

[Ischemic complications following surgical treatment of moyamoya disease: risk factors and prevention]. / Ishemicheskie oslozhneniya khirurgicheskogo lecheniya patsientov s bolezn'yu moiya-moiya: faktory riska i metody profilaktiki.

BACKGROUND: One of the most difficult problems in surgical treatment of moyamoya disease is prevention of ischemic perioperative complications. The risk of these events is significantly higher compared to other cerebrovascular diseases (up to 30%). OBJECTIVE: To identify unfavorable prognostic factors of perioperative cerebral ischemic complications, to determine the group of high-risk patients and to develop the guidelines for perioperative management of these patients. MATERIAL AND METHODS: We analyzed clinical and diagnostic data and postoperative outcomes in 80 patients with various forms of moyamoya disease. These patients underwent 134 different interventions. Staged revascularization of both hemispheres was performed in 40 patients (80 surgeries). Most patients (n = 55) underwent combined brain revascularization (79 surgeries). RESULTS: Persistent postoperative complications (ischemic stroke) developed in 7 cases (5.3%). Transient neurological impairment was observed in 36 cases (27%). Statistical analysis revealed the following risk factors of perioperative complications: critical stenosis/occlusion of posterior cerebral artery (OR 9.704), severe perfusion deficit (OR 5.393) and previous TIA or ischemic stroke within 3 months prior to surgery (OR 6.433). If at least two of these signs are present, sensitivity of prognosis for postoperative complications is 80.7% and 88.6%, respectively. CONCLUSION: Patients with moyamoya disease are at high risk of perioperative complications due to complex rearrangement of collateral cerebral circulation and high sensitivity of brain to local and systemic hemodynamic changes. Patients with risk factors require careful perioperative management to exclude pathogenetic factors provoking ischemia. Early surgical treatment is advisable to reduce the risk of ischemic and hemorrhagic lesions following natural course of disease and severe perioperative complications.

[Sensations of patients and their satisfaction during awake craniotomy]. / Oshchushcheniya patsientov i ikh udovletvorennost' pri provedenii kraniotomii v soznanii.

Awake craniotomy (AC) has gained fantastic popularity over the past years. This approach is no longer the destiny of only highly specialized neurosurgical centers. Technical features of AC are completely developed. However, certain aspects of patients' sensations and their satisfaction are still unclear. The review is devoted to these issues. It was shown that AC is positively evaluated by the vast majority of patients. Many patients would choose this technique for redo surgery. However, there are certain important details that can adversely affect satisfaction of patients. Thus, these features should be considered in AC.

[Broca's area intraoperative mapping with cortico-cortical evoked potentials]. / Intraoperatsionnoe kartirovanie rechevoi zony Broka metodom registratsii kortiko-kortikal'nykh vyzvannykh potentsialov.

OBJECTIVE: Mapping of effective speech connections between the frontal and temporal lobes with cortico-cortical evoked potentials. MATERIAL AND METHODS: There were 3 patients with brain tumors in the left frontoparietal region. The neoplasms were localized in the dominant hemisphere near cortical speech centers and pathways. Cortico-cortical evoked potentials were intraoperatively recorded in response to bipolar stimulation with a direct current delivered through the subdural electrodes (single rectangular biphasic impulses with duration of 300 µs and frequency of 1 Hz). Stimulation intensity was gradually increased from 2 mA within 3-4 mA. Registration was carried out by averaging ECoG (30-50 stimuli in each session) in the 300-ms epoch after stimulus. Direct cortical stimulation was used to validate the results of cortico-cortical speech mapping with cortico-cortical evoked potentials. RESULTS: In our cases, we obtained cortico-cortical evoked potentials from inferior frontal gyrus after stimulation of superior temporal gyrus. In one case, this effective relationship was unidirectional, in the other two patients reciprocal. Mean latency of N1 peak was 65 ms (range 49.6-90 ms), mean amplitude 71 µV (range 50-100 µV). Cortico-cortical mapping data were confirmed by detection of Broca's area in 2 out of 3 cases out during direct cortical stimulation with maximum amplitude of N1 wave. «Awake craniotomy¼ protocol was applied. In one case, Broca's area was not detected during direct stimulation. No postoperative speech impairment was noted. CONCLUSION: Initial results of cortical mapping with cortico-cortical evoked potentials in a small sample confirmed its practical significance for analysis of cortical projections of effective speech communications between the frontal and temporal lobes. Further study of this method in large samples is required.

[Current trends in the development of neuroanesthesiology]. / Sovremennye tendentsii razvitiia neiroanesteziologii.

The paper presents the author's analysis of the main trends in the development of modern neuroanesthesiology over the past five to ten years. These, in the author\s opinion, include the introduction and elaboration of blood-sparing techniques, monitoring the depth of anesthesia, fast track concept, applying regional (conduction) anesthesia techniques, xenon anesthesia, development of effective and safe protocols for DVT and PTE prophylaxis for neurosurgical patients, study of the hemostatic system using bedside methods for assessing hemostasis (thromboelastogram) and correcting hypocoagulation by activated recombinant VII factor.

[Brain tissue relaxation in craniotomy: a modern view of the perennial problem]. / Relaksatsiia tkani mozga pri kraniotomii: sovremennyi vzgliad na vechnuiu problemu.

Intraoperative relaxation of brain tissue is one of the important factors affecting the quality and successful outcome of neurosurgical interventions. Despite many clinical studies on the problem of brain bulging, many issues remain not fully resolved. First of all, these are safety aspects of the preventive and therapeutic use of various strategies to fight this phenomenon, development of indications for introduction of hyperosmotic solutions, and use of hyperventilation or lifting of the head end of the operating table.

[Postoperative nausea and vomiting in neurosurgery: the approaches are varied but the problem remains unsolved]. / Posleoperatsionnaia toshnota i rvota v neirokhirurgii ­ podkhody meniaiutsia, problema ostaetsia.

Postoperative nausea and vomiting (PONV) can induce brain displacement and herniation, especially in patients with cerebral edema. OBJECTIVE: To evaluate the urgency of the problem associated with postoperative nausea and vomiting in current clinical practice (with modern approaches being used for its prevention) and to reveal the risk factors of PONV that are typically encountered in neurosurgical patients. MATERIAL AND METHODS: A prospective observational study involved 240 patients who had undergone elective surgeries at the N.N. Burdenko National Scientific and Practical Center for Neurosurgery between July and November 2017. The data were collected from the questionnaires filled out by the patients during the first 48 h after the surgery and from patients' medical records. RESULTS: The overall rate of PONV was 39.6%. Thirty-six out of 53 (68%) patients developed PONV after the posterior fossa surgeries. The risk of PONV in this group was significantly higher (p<0.05) compared to the rate of PONV after interventions at a different location. The rate of PONV after treatment of extracranial pathology was ~10.5%; for a different location, it was as high as 32-37%. Intraoperative dexamethasone was used in 156 (65%) patients; in this group, the rate of PONV was 39.9%. Patients received ondansetron at a dose of 8 mg for a preventive purpose at the end of the surgery. A total of 162 patients were given the drug; 59 (36.4%) of them developed POTV during 48 h post-administration. Seventy-eight patients did not receive ondansetron. Thirty-six of them (46.2%) (p>0.05) developed POTV. The rate of POTV assessed during the first 8 h after surgery was 22.8% in patients who had received ondansetron and 37.2% in those who had not received it (p<0.05). Patients who had not intraoperatively received a combination of these drugs developed POTV in 55 (45%) cases (p>0.05). CONCLUSION: The problem associated in POTV remains topical in neurosurgery. The current approaches are not absolutely effective for prevention of POTV, whose rate ranges between 10.5 and 68% depending on surgery location. Further studies focused on administration of NK-1 receptor antagonists and electrical stimulation of the median nerve are needed to enhance the effectiveness of POTV prevention.

[Central neurocytomas: surgical treatment outcomes and new trends and approaches in the treatment]. / Tsentral'nye neirotsitomy golovnogo mozga: rezul'taty khirurgicheskogo lecheniia i novye tendentsii i strategii v lechenii.

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.

[Primary juvenile nasal angiofibroma in a 38 year-old male (case report)]. / Pervichno vyiavlennaia iunosheskaia angiofibroma osnovaniia cherepa u muzhchiny 38 let (klinicheskoe nabliudenie).

Juvenile nasal angiofibroma (JNA) is a benign, fibro-vascular, locally aggressive tumor with invasive growth patterns and high probability of recurrence. JNA present exclusively in adolescent boys between 9 and 19 years of age, total about 0.05% of head and neck tumors. 143 patients with JNA had been treated surgically from 2002 to August 2018 at N.N. Burdenko National Medical Research Center for Neurosurgery. All patients (primary and recurrences) were males of the age 7-38 years (16.1 [11.3; 19] years). The age of patients with primary JNA was less than 18-year old, of the exception of presenting case. There are more and more publications about case reports and successful treatment series of JNA. However, after detailed review the literature we revealed some kind of confusion: there are case reports of JNA in women and elderly people, JNA in patients with some systemic diseases, JNA with different places of origin and different morphological structure. In this paper we present a very rare case of 38 year-old male with pure primary JNA, accidentally diagnosed on CT and pathologically proven after endoscopic removal. This case confirms the possibility of detecting the JNA in adult men and explains why proper diagnosis of angiofibromas is necessary. The unique case and the literature review are presented.

[Neurosurgery in conscious patients: forward to the past]. / Neirokhirurgiia v soznanii: vpered v proshloe.

We present an analytical review of various neurosurgical interventions in conscious patients. An analysis of the literature indicates growing interest in this problem. Craniotomy in conscious patients has been extensively used in resection of space-occupying cerebral lesions in the eloquent hemispheric areas and in epilepsy surgery. In recent years, there have been a number of reports on interventions in conscious patients with other neurosurgical pathologies, which may be regarded as a new emerging tendency in neurosurgery and neuroanesthesiology. Neurosurgery in conscious patients provides a special advantage because it enables highly functional neuromonitoring without use of complex devices.

[Severe postoperative intracranial hemorrhagic complications in a neurosurgical patient with von Willebrand disease not diagnosed before surgery (a case report and literature review)]. / Tiazhelye posleoperatsionnye intrakranial'nye gemorragicheskie oslozhneniia u neirokhirurgicheskogo bol'nogo s ne diagnostirovannoi do operatsii bolezn'iu Villebranda (klinicheskoe nabliudenie i obzor literatury).

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.

[Endoscopic transnasal surgery for giant fibrous dysplasia of the skull base, spreading to the right orbital cavity and nasopharynx (a case report and literature review)]. / Endoskopicheskaya transnazal'naya khirurgiya gigantskoi fibroznoi displazii osnovaniya cherepa, rasprostranyayushcheisya v polost' pravoi orbity i nosoglotku (opisanie nablyudeniya i obzor literatury).

BACKGROUND: An extended endoscopic endonasal approach is increasingly used in surgical treatment of space-occupying skull base lesions. The international literature reports only 20 cases of surgical treatment for fibrous dysplasia (PD) of the skull base using the endoscopic endonasal approach. We present our experience with the endoscopic endonasal approach in surgical treatment for giant fibrous dysplasia of the skull base, spreading to the right orbital cavity and nasopharynx. CLINICAL CASE: A 26-year-old male patient presented with cranial pain, Vth nerve dysfunction on the right, right keratopathy. OD=0.2 (near acuity - 0.3), OS=1.0, OD - incomplete eyelid closure of 2 mm, conjunctival injection, mucous discharge, corneal opacity in the lower pole and paracentrally, OS - normal appearance. Severe right-sided exophthalmos (more than 15 mm), impaired nasal breathing on the right, nasal (hemorrhagic) discharge. Magnetic resonance imaging and spiral computed tomography scans revealed a bone density lesion located in the area of the orbit, nasal cavity, maxillary sinus on the right, and labyrinth of the ethmoid bone. The patient underwent endonasal endoscopic resection of the lesion. RESULTS: The lesion was resected totally, which was confirmed by control SCT. Right-sided exophthalmos partially regressed (on the right: exophthalmos of 8 mm; protrusion: OD=23 mm, OS=15 mm; the eyeball was displaced downward and outward). The visual and oculomotor functions did not change. The neurological status remained at the preoperative level. CONCLUSION: Fibrous dysplasia of the skull base is an extremely rare disease. Modern techniques expand the indications for surgery of giant tumors of the skull base using minimally invasive approaches, in particular the endoscopic endonasal approach.

[Surgical treatment of a pregnant female with AVM hemorrhage]. / Khirurgicheskoe lechenie patsientki s krovoizliyaniem iz AVM vo vremya beremennosti.

Hemorrhages from arteriovenous malformations (AVMs) in pregnant females are rare, but they are known to lead to high maternal and infant mortality. There are no standards for AVM treatment in pregnant females. Many authors believe that AVM resection before delivery improves the prognosis for life and health of the mother and fetus. In this paper, we present a case of successful surgical treatment of a female patient with AVM hemorrhage at 20 weeks and address management issues of these patients.

[Neurosurgery in a patient on dual antiplatelet therapy. Case report and the review of the literature]. / Neirokhirurgicheskoe vmeshatel'stvo u patsienta, nakhodiashchegosia na dvoinoi dezagregantnoi terapii. Opisanie sluchaia i obzor literatury.

INTRODUCTION: A neurosurgical intervention in a patient on dual antiplatelet therapy is a serious challenge for both the neurosurgeon and anesthesiologist.. MATERIAL AND METHODS: The article describes a clinical case of a successful urgent neurosurgical intervention (ventriculoperitoneostomy for obstructive hydrocephalus caused by a large meningioma of the posterior surface of the petrous pyramid) in a patient on dual antiplatelet therapy (DAT) due to a recently placed coronary stent.. CONCLUSION: Given a high risk of coronary stent thrombosis, the surgery was performed in the presence of ongoing DAT. There were no intracranial hemorrhagic complications, but subcutaneous hemorrhagic complications developed. The article discusses the features of managing similar patients whose number is growing.

[Neurophysiological identification of the cranial nerves in endoscopic endonasal surgery of skull base tumors]. / Neirofiziologicheskaya identifikatsiya cherepnykh nervov v endoskopicheskoi endonazal'noi khirurgii opukholei osnovaniya cherepa.

INTRODUCTION: Intraoperative identification of the cranial nerves is a useful technique in removal of skull base tumors through the endoscopic endonasal approach. Searching through the scientific literature found one pilot study on the use of triggered electromyography (t-EMG) for identification of the VIth nerve in endonasal endoscopic surgery of skull base tumors (D. San-Juan, et al, 2014). AIM: The study objective was to prevent iatrogenic injuries to the cranial nerves without reducing the completeness of tumor tissue resection. MATERIAL AND METHODS: In 2014, 5 patients were operated on using the endoscopic endonasal approach. Surgeries were performed for large skull base chordomas (2 cases) and trigeminal nerve neurinomas located in the cavernous sinus (3). Intraoperatively, identification of the cranial nerves was performed by triggered electromyography using a bipolar electrode (except 1 case of chordoma where a monopolar electrode was used). Evaluation of the functional activity of the cranial nerves was carried out both preoperatively and postoperatively. RESULTS: Tumor resection was total in 4 out of 5 cases and subtotal (chordoma) in 1 case. Intraoperatively, the IIIrd (2 patients), Vth (2), and VIth (4) cranial nerves were identified. No deterioration in the function of the intraoperatively identified nerves was observed in the postoperative period. In one case, no responses from the VIth nerve on the right (in the cavernous sinus region) were intraoperatively obtained, and deep paresis (up to plegia) of the nerve-innervated muscles developed in the postoperative period. The nerve function was not impaired before surgery. CONCLUSION: The t-EMG technique is promising and requires further research.