[Safety of robot-assisted implantation of deep electrodes for invasive stereo-EEG monitoring]. / Bezopasnost' robot-assistirovannoi implantatsii glubinnykh elektrodov dlya provedeniya invazivnogo stereo-EEG-monitoringa.

Robot-assisted implantation of deep electrodes for stereo-EEG monitoring has become popular in recent years in patients with drug-resistant epilepsy. However, there are still few data on safety of this technique. OBJECTIVE: To assess the incidence of complications in patients with drug-resistant epilepsy undergoing robot-assisted implantation of stereo-EEG electrodes. MATERIAL AND METHODS: We retrospectively studied the results of implantation of stereo-EEG electrodes in 187 patients with drug-resistant epilepsy. All patients underwent non-invasive preoperative examination (video-EEG, MRI, PET, SPECT, MEG). In case of insufficient data, stereo-EEG monitoring was prescribed. We determined electrode insertion trajectory using a robotic station and MR images. Implantation of electrodes was carried out using a Rosa robot (Medtech, France). All patients underwent invasive EEG monitoring after implantation. RESULTS: There were 11.25±3 electrodes per a patient. Implantation of one electrode took 7.5±4.9 min. Postoperative MRI revealed electrode malposition in 2.3% of cases. None was associated with complications. The complication rate per electrode was 0.6%. Complications affected stereo-EEG monitoring only in 3 cases (1.6%). The mortality rate was 0.5%. Bilateral implantation (p=0.005), insular (p=0.040) and occipital (p=0.045) deep electrode implantation were associated with lower incidence of complications. Longer duration of the procedure influenced the incidence of electrode placement in the lateral ventricle (p=0.028), and implantation in the frontal lobe was more often associated with epidural placement of electrodes (p=0.039). CONCLUSION: Robot-assisted implantation of stereo-EEG electrodes is a safe procedure with minimal risk of complications. Rare electrode malposition does not usually affect invasive monitoring.

[Surgical treatment of focal drug-resistant epilepsy associated with temporal lobe encephalocele]. / Khirurgicheskoe lechenie patsientov so strukturnoi fokal'noi farmakorezistentnoi epilepsiei, assotsiirovannoi s visochnymi entsefalotsele.

BACKGROUND: In recent years, temporal lobe encephalocele has become more common in patients with focal drug-resistant epilepsy. Despite available experience, there are still no clear recommendations for choosing the extent of surgery in these patients. OBJECTIVE: To evaluate the effectiveness of diagnosis and surgical treatment of focal drug-resistant epilepsy associated with temporal lobe encephalocele. MATERIAL AND METHODS: The study included 21 patients with focal temporal lobe epilepsy and temporal lobe encephalocele. All patients underwent continuous video-EEG monitoring and MRI of the brain. There were 12 (57.4%) selective encephalocele resections and 9 (42.6%) anterior temporal lobectomies. The median follow-up period was 31 months. RESULTS: The overall effectiveness of surgical treatment with postoperative Engel class I was 76% (16 cases). Selective encephalocele resection was followed by postoperative Engel class I in 10 patients (83%). There were 6 (67%) patients with similar outcomes after temporal lobectomy. Mean volume of resected tissue adjacent to encephalocele was 8.3 cm3. CONCLUSION: Surgery is a highly effective treatment for patients with epileptic seizures following temporal lobe encephalocele. In our sample, favorable postoperative outcomes were achieved in 76% of patients (Engel class I). There were no significant differences in effectiveness between selective resection and temporal lobectomy. Further research is necessary for a clear protocol of surgical treatment of focal drug-resistant epilepsy associated with encephalocele.

[Modified posterior quadrant disconnection in surgical treatment of drug-resistant epilepsy in a patient with left temporal and occipital lobe malformation]. / Modifitsirovannaya zadnekvadrantnaya diskonnektsiya v khirurgicheskom lechenii farmakorezistentnoi epilepsii u patsienta s porokom razvitiya levykh visochnoi i zatylochnoi dolei.

Adults with large multilobar lesions of temporal, parietal and occipital lobes of the dominant hemisphere suffering from drug-resistant epilepsy were considered inoperable for a long time. OBJECTIVE: To demonstrate favorable postoperative outcome in a patient with massive periventricular heterotopia of the left temporal and occipital lobes complicated by drug-resistant epilepsy. MATERIAL AND METHODS: We analyzed localization of the brain malformation (massive periventricular heterotopia) and its relationship with surrounding structures in a 38-year-old patient considering preoperative MRI, functional MRI and MR tractography data. Quality of modified posterior quadrant disconnection was assessed within a day and 6 months after surgery in accordance with MRI data. Transcranial stimulation, direct cortical and subcortical monopolar stimulation were used for intraoperative monitoring of corticospinal tract. We also assessed neurological status and linguistic testing data before surgery, 4 days and 6 months after surgery. RESULTS: Modified posterior disconnection of temporal, parietal and occipital lobes was performed. Intraoperative neurophysiological cortical mapping (asleep-awake-sedation protocol) verified localization of Wernicke's area. There was an expected right-sided homonymous hemianopsia in postoperative period without speech disorders. Postoperative outcome Engel grade 1A under anticonvulsant therapy was obtained. CONCLUSION: The authors report successful surgical treatment of massive malformation of the left temporal, parietal and occipital lobes and literature review devoted to this issue.

[Pre-surgical Diagnosties in Patients with Intractable epilepsy]. / Predkhirurgicheskaia diagnostika u patsientov s farmakorezistentnoi épilepsiei.

PURPOSE: To conduct a systematic assessment of scientific publications devoted to pre-surgical examination of patients with intactable epilepsy. MATERIAL AND METHODS: We found, using PubMed and available Internet search tools, and analyzed 1.414 articles on pre-surgical diagnostics in patients with intractable epilepsy. RESULTS: Epilepsy is a chronic disorder caused by brain injury, which manifests as repeated epileptic seizures and is accompanied by a variety of personality changes. Mortality risks in the population of patients with uncontrolled intractable epilepsy significantly exceed those in the general population. Early onset of comprehensive treatment prevents pathological personality changes and reduces the risks of mortality. However, complete seizure control is not achieved in 30% of patients, and they develop pharmacoresistance later, which is the reason for considering these patients as candidates for surgical treatment. In the literature, many approaches to pre-surgical examination are described as each clinic has its own concept of pre-surgical diagnostics and its own approaches to surgical management. Based on the conducted analysis, we tried to summarize the received information and describe current ideas about pre-surgical examination of patients with intactable epilepsy. CONCLUSION: On the basis of analyzed literature, we performed a systematic assessment and the evaluated effectiveness of various approaches in the pre-surgical diagnostics of patients with intactable epilepsy.

[Treatment of syringomyelia associated with adhesive arachnoiditis]. / Lechenie siringomielii, assotsiirovannoi s adgezivnym arakhnoiditom.

The prevalence of syringomyelia (SM) caused by adhesive arachnoiditis (AA) is 2 to 4 cases per 100000 population. Surgical treatment of this pathology usually includes implantation of shunts into the cyst cavity or opening and drainage of the cavity. In this case, SM continues to progress in 72-100% of patients. Unsatisfactory outcomes of this surgical approach necessitate searching for other treatment options. PURPOSE: To define the optimal amount of surgery for SM associated with AA and the criteria for assessment of surgery outcomes. MATERIAL AND METHODS: The authors treated 47 SM patients in the period from 2010 to 2015. Of these, 34 (72.3%) patients underwent surgery; a total of 40 operations were performed. The patients' age ranged from 18 to 64 years (mean, 43.5 years). Tethering of the spinal cord was eliminated in 25 patients; 9 patients underwent cyst shunting. RESULTS: Among operated patients, 5 patients had grade 1 arachnopathy, 13 patients had grade 2 arachnopathy, 12 patients had grade 3 arachnopathy, and 4 patients had grade 4 arachnopathy. The minimal postoperative follow-up period was 11 months. After shunting, the condition improved in 8 of 9 patients; in 7 patients, the condition returned to the baseline level within the first postoperative year; in 6 (66.7%) of these patients, the disease continued to progress. After surgical release of spinal cord tethering, satisfactory long-term results were achieved in 13 (86.6%) patients with grade 1-2 arachnopathy. In 3 (50%) patients with grade 3 arachnopathy, the condition was stabilized. Among patients with grade 4 arachnopathy, progression of the disease was stopped in 1 patient; the condition worsened in 2 (50%) patients. Among all the operated patients, complications developed in 7 patients. There were no lethal outcomes. CONCLUSIONS: In grade 1-2 arachnopathy, progression of SM after release of spinal cord tethering occurs only in 13.4% of patients. Therefore, release of spinal cord tethering is recommended for these patients. In grade 3-4 arachnopathy, the rate of relapse after this surgery is more than 80%. Therefore, given the simplicity and a lower risk of complications of cyst shunting, this procedure is advisable for these patients.

[Surgical treatment of eloquent brain area tumors using neurophysiological mapping of the speech and motor areas and conduction tracts]. / Khirurgicheskoe lechenie opukholei funktsional'no znachimykh zon golovnogo mozga s primeneniem metoda neirofiziologicheskogo kartirovaniya rechevykh, motornykh zon i provodyashchikh putei.

AIM: To evaluate the efficacy of intraoperative neurophysiological mapping in removing eloquent brain area tumors (EBATs). MATERIAL AND METHODS: Sixty five EBAT patients underwent surgical treatment using intraoperative neurophysiological mapping at the Pirogov National Medical and Surgical Center in the period from 2014 to 2015. On primary neurological examination, 46 (71%) patients were detected with motor deficits of varying severity. Speech disorders were diagnosed in 17 (26%) patients. Sixteen patients with concomitant or isolated lesions of the speech centers underwent awake surgery using the asleep-awake-asleep protocol. Standard neurophysiological monitoring included transcranial stimulation as well as motor and, if necessary, speech mapping. The motor and speech areas were mapped with allowance for the preoperative planning data (obtained with a navigation station) synchronized with functional MRI. In this case, a broader representation of the motor and speech centers was revealed in 12 (19%) patients. During speech mapping, no speech disorders were detected in 7 patients; in 9 patients, stimulation of the cerebral cortex in the intended surgical area induced motor (3 patients), sensory (4), and amnesic (2) aphasia. In the total group, we identified 11 patients in whom the tumor was located near the internal capsule. Upon mapping of the conduction tracts in the internal capsule area, the stimulus strength during tumor resection was gradually decreased from 10 mA to 5 mA. Tumor resection was stopped when responses retained at a stimulus strength of 5 mA, which, when compared to the navigation data, corresponded to a distance of about 5 mm to the internal capsule. Completeness of tumor resection was evaluated (contrast-enhanced MRI) in all patients on the first postoperative day. RESULTS: According to the control MRI data, the tumor was resected totally in 60% of patients, subtotally in 24% of patients, and partially in 16% of patients. In the early postoperative period, the development or aggravation of a motor neurological deficit was detected in 18 patients: worsening of paresis was observed in 11 patients, and worsening of speech disorders occurred in 7 patients. After 4 months, motor and speech disorders regressed in 10 patients. Therefore, a persistent neurological deficit developed after surgery in 8 (12%) patients (motor deficit in 5 cases; speech deficit in 3 cases). CONCLUSION: Resection of eloquent brain area tumors using intraoperative neurophysiological monitoring enables complete resection of the tumor at a low risk of persistent neurological deficits, which ultimately improves the patient's life prognosis.

[Results of surgical treatment of syringomyelia associated with Chiari 1 malformation. An analysis of 125 cases].

UNLABELLED: The rate of Chiari malformation (CM) in a population ranges from 3 to 8 per 100,000 population. In 62-80% of cases, CM is accompanied by the development of syringomyelia (SM) at various levels. The clinical picture in these patients is a combination of CM and SM manifestations; however, SM symptoms often prevail, which creates some problems in the diagnosis of the disease and in the choice of optimal treatment. OBJECTIVE: On the basis of our own experience of surgical interventions, we aimed to clarify the indications for surgical treatment of SM associated with CM and to determine the optimal amount of surgery and the criteria for evaluation of treatment outcomes. MATERIAL AND METHODS: Two hundred twenty five patients with a combination of syringomyelia and Chiari 1 malformation were examined in the period from 2011 to February 2015. Of them, 125 patients were operated on. The mean age of the operated patients was 56±8 years. The mean time from the appearance of the first signs of the disease to surgery was 75±82 months. All operations were performed by a single surgeon. The operations were carried out in the half-sitting (89.6%) or prone (10.4%) position. The operation included sparing suboccipital craniectomy, C1 arch resection, recovery of the cerebrospinal fluid (CSF) circulation along the posterior surface of the cerebellum, and reconstruction of the dura mater in the craniovertebral junction region. RESULTS: Exploration of the arachnoid mater of the cisterna magna after dura opening revealed no arachnopathy in 78 (62.4%) patients (Chiari 0 malformation according to Klekamp). The type 1 arachnopathy (by Klekamp) was detected in 31 patients (24.8%), and the type 2 arachnopathy was observed in 16 (12.8%). The condition of 109 (88%) patients was evaluated one year after the surgery. Sixty one (56%) patients had partial or complete regression of preoperative neurological symptoms. The disease stopped progressing in 44 patients (40%). The disease was progressing in 4 (3.7%) patients. No recurrence of a CSF circulation disturbance at the craniovertebral level was observed during follow-up. Early postoperative complications occurred in 4 (3.2%) patients: wound CSF leakage in 1 (0.8%) patient, acute epidural hematoma in 1 (0.8%) patient, and aseptic meningitis in 2 (1.6%) patients. Temporary deteriorations in the condition (headache worsening, meteosensitivity) were detected in 11 (8.9%) patients. These symptoms regressed by the end of the 1st postoperative month. There were no deaths. CONCLUSIONS: The indication for surgery in patients with a combination of CM and SM is the presence of neurological symptoms associated with syringomyelia and their progression as well as headache caused by herniation of the cerebellar tonsils, which significantly deteriorates the patient's quality of life. The main criteria for evaluating the efficacy of treatment include stabilization of the clinical symptoms and/or improvement in the patient condition. Suboccipital craniectomy followed by reconstruction of the dura mater and recovery of the CSF circulation in the craniovertebral region is an effective treatment of syringomyelia associated with Chiari 1 malformation.