[Minimally invasive surgical treatment of extramedullary tumors at the level of craniovertebral junction: experience of the Burdenko Neurosurgical Center]. / Minimal'no invazivnoe khirurgicheskoe lechenie patsientov s ekstramedullyarnymi opukholyami na urovne kraniovertebral'nogo perekhoda: opyt NMITs neirokhirurgii im. akad. N.N. Burdenko.

OBJECTIVE: To describe own experience of treating patients with extramedullary tumors at the level of craniovertebral junction using minimally invasive surgical approaches. MATERIAL AND METHODS: The study included 29 patients who underwent minimally invasive microsurgical resection of extramedullary tumors at the level of craniovertebral junction. We analyzed the main clinical and surgical parameters. RESULTS: Gross total resection was achieved in most patients with high degree of safety. Two patients required redo surgery due to CSF leakage and soft tissue cyst. Mean length of hospital-stay was 7 days. VAS score of pain syndrome at discharge was 2 points and 0 points after 3 months. No significant differences in neurophysiological monitoring indicators were observed (p=0.76). CONCLUSION: Minimally invasive posterior approaches to extramedullary tumors at the level of craniovertebral junction can significantly reduce surgical trauma with equal extent of resection.

[Autologous fibrin glue for endoscopic skull base repair in patients with cerebrospinal fluid leakage]. / Primenenie autologichnogo fibrinovogo kleya v endoskopicheskoi plastike defektov osnovaniya cherepa pri nazal'nykh likvoreyakh.

The main stages of endoscopic skull base repair in patients with cerebrospinal fluid (CSF) leakage are identification of bone boundaries of the fistula and its closure by auto- and allografts. Fibrin glue can be used to fix plastic materials and additionally seal skull base defect. OBJECTIVE: To analyze efficacy and safety of Vivostat autologous fibrin glue for endoscopic skull base repair in patients with nasal CSF leakage and to compare postoperative outcomes after defect closure by Vivostat fibrin glue and allogeneic fibrin glue. MATERIAL AND METHODS: A retro- and prospective analysis included 56 patients with nasal CSF leakage who were treated at the Burdenko Neurosurgery Center between January 2021 and June 2022. Patients were divided into 2 groups: Vivostat fibrin glue (n=27, 48.2%) and allogeneic fibrin glue (n=29, 51.8%). Demographic and clinical perioperative data were analyzed. RESULTS: No early postoperative recurrence of CSF leakage was registered in both groups, whereas meningitis occurred in 2 cases in each group. Recurrent CSF leakage in delayed postoperative period occurred in 1 patient (3.4%) of the control group (p>0.05). Incidence of perioperative complications, subfebrile temperature in early postoperative period, surgery time and hospital-stay were similar. CONCLUSION: Vivostat autologous fibrin glue is a safe and effective method for fixing the grafts in endoscopic skull base repair. The advantages of this approach are easy application, elimination of the risk of allergic, immunological and infectious complications, as well as acceleration of tissue regeneration.

[Decompression fusion surgery and minimally invasive microsurgical decompression in patients with single-segment lumbar spinal stenosis]. / Sravnitel'nyi analiz rezul'tatov primeneniya metodik dekompressii so stabilizatsiei i minimal'no invazivnoi mikrokhirurgicheskoi dekompressii u patsientov s monosegmentarnym poyasnichnym spinal'nym stenozom.

There are few studies comparing clinical efficacy of decompression/fusion surgery (transforaminal lumbar interbody fusion (TLIF) + transpedicular interbody fusion) and minimally invasive microsurgical decompression (MMD) in patients with single-segment lumbar spinal stenosis. OBJECTIVE: To compare the results of TLIF + transpedicular interbody fusion and MMD in patients with single-segment lumbar spinal stenosis. MATERIAL AND METHODS: A retrospective observational cohort study included medical records of 196 patients (100 (51%) men, 96 (49%) women). Age of patients ranged from 18 to 84 years. Mean postoperative follow-up period was 20.1±6.7 months. Patients were divided into 2 groups: group I (control) included 100 patients who underwent TLIF + transpedicular interbody fusion, group II (study) included 96 patients who underwent MMD. We analyzed pain syndrome and working capacity using visual analogue scale (VAS) and Oswestry Disability Index (ODI), respectively. RESULTS: Analysis of pain syndrome in both groups after 3, 6, 9, 12 and 24 months clearly demonstrated stable relief of pain syndrome (VAS score) in the lower extremities. In group II, VAS score of lower back and leg pain was significantly higher in long-term follow-up period (after 9 months or more) compared to the 1st group (p<0.05). In long-term follow-up period (after 12 months), there was significant decrease in degree of disability (ODI score) in both groups (p<0.001) without between-group differences. We assessed achievement of treatment goal in 12 and 24 months after surgery in both groups. The result was significantly better in the 2nd group. At the same time, some respondents failed to achieve the final clinical goal of treatment in both groups (group I - 8 (12.1%), group II - 2 (3%) patients). CONCLUSION: Analysis of postoperative outcomes in patients with single-segment degenerative lumbar spinal stenosis revealed similar clinical effectiveness of TLIF + transpedicular interbody fusion and MMD regarding decompression quality. However, MMD was associated with less traumatization of paravertebral tissues, blood loss, fewer unwanted phenomena and earlier recovery.

[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.

[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.

[Surgical and combined treatment of patients with craniovertebral junction meningioma: a single-center retrospective study of 196 cases]. / Analiz rezul'tatov khirurgicheskogo i kombinirovannogo lecheniya patsientov s meningiomami oblasti kraniovertebral'nogo perekhoda: odnotsentrovoe retrospektivnoe issledovanie 196 sluchaev.

Treatment of craniovertebral junction meningioma is a difficult task. Surgical treatment is the gold standard for these patients. However, it is associated with high risk of neurological impairment, while combined treatment (surgery + radiotherapy) provides more favorable outcomes. OBJECTIVE: To present the results of surgical and combined treatment of patients with craniovertebral junction meningioma. MATERIAL AND METHODS: There were 196 patients with craniovertebral junction meningioma who underwent surgical or combined (surgery + radiotherapy) treatment at the Burdenko Neurosurgery Center between January 2005 and June 2022. The sample included 151 women and 45 men (3.4:1). Resection of tumor was performed in 97.4% of patients, craniovertebral junction decompression with dural defect closure - 2%, ventriculoperitoneostomy - 0.5%. As the second stage, 40 patients (20.4%) underwent radiotherapy. RESULTS: Total resection was achieved in 106 patients (55.2%), subtotal - 63 (32.8%), partial - 20 (10.4%), tumor biopsy was performed in 3 (1.6%) cases. Intraoperative complications occurred in 8 patients (4%), postoperative complications - in 19 (9.7%) cases. Radiosurgery was carried out in 6 (15%) patients, hypofractionated irradiation - 15 (37.5%), standard fractionation - 19 (47.5%) patients. Tumor growth control after combined treatment made up 84%. CONCLUSION: Clinical outcomes in patients with craniovertebral junction meningioma depend on tumor dimensions, topographic and anatomical localization of tumor, resection quality and relationship with surrounding structures. Combined treatment of anterior and anterolateral meningiomas of the craniovertebral junction is preferable compared to total resection.

[Quantitative analysis of orbit volume and eyeball position after resection of hyperostotic sphenoid wing meningioma and simultaneous orbital wall reconstruction using individual technologies]. / Kolichestvennyi analiz ob"emov glaznits i pozitsii glaznykh yablok posle udaleniya giperostoticheskikh meningiom kryl'ev osnovnoi kosti i odnomomentnoi rekonstruktsii stenok glaznitsy s ispol'zovaniem individual'nykh tekhnologii.

OBJECTIVE: To conduct a quantitative analysis of orbit volume at different stages of preparation and surgical treatment of patients with cranio-orbital meningiomas undergoing resection with simultaneous orbital wall reconstruction using 3D modeling and 3D printing technologies. MATERIAL AND METHODS: A prospective cohort non-randomized study included 24 patients with cranio-orbital meningiomas. The volumes were measured by segmenting the orbital structures using the planimetric method in the Inobitec PRO software package. Three expert neurosurgeons independently performed these measurements. The implants were modeled in Blender software. We used the intraclass correlation coefficient (ICC) and global similarity index (GSI) to analyze interrater agreement and ensure reproducibility of analysis. RESULTS: Interrater agreement on orbital markings was very high for both metrics (ICC and GSI). The ICC (A,3) for intact orbit volume was 0.99 (95% CI 0.981; 0.996, p=1.9962018^{-33}), 0.99 (95% CI 0.983; 0.996, p=1.903203^{-34}) for damaged orbit volume at the preoperative stage, 0.99 (95% CI 0.979; 0.995, p=3.5939828^{-32}) for damaged orbit volume at the stage of modeling of resection and reconstruction, 0.99 (95% CI 0.978; 0.995, p=1.1048941^{-30}) for damaged orbit volume in postoperative period. The ICC for measurements related to EI was 0.94-0.97 (very high). This analysis revealed a strong inverse relationship between EI and volume index at the preoperative stage (rho= -0.55, p=0.004987), as well as between dynamics of EI and volume indexes in perioperative period (rho= -0.59, p=0.003). We found significant relationship (p=0.006757) between implant displacement in the area of lateral orbital wall and differences of actual and theoretical volumes. CONCLUSION: The proposed method of planimetric contouring and segmentation of orbital volumes is highly accurate and reproducible. Significant patterns allow us to develop predictive models for preliminary calculation of target volume of the damaged orbit.

[Predictors of postoperative remission of acromegaly. (Experience of the Burdenko Neurosurgical Center)]. / Prediktory posleoperatsionnoi remissii akromegalii. (Opyt FGAU «NMITs neirokhirurgii im. akad. N.N. Burdenko¼).

BACKGROUND: Treatment of acromegaly is still an unresolved problem. Overall postoperative remission rate ranges from 34 to 85%. These values are better for microadenomas (75-90%) and worse for macroadenomas (45-70%). Identification of predictors of acromegaly remission after surgical treatment is an urgent objective to improve the quality of medical care for these patients. OBJECTIVE: To analyze postoperative freedom from acromegaly and predictors of remission. MATERIAL AND METHODS: A retrospective single-center study included 227 patients with acromegaly who underwent resection of pituitary adenoma between August 2018 and August 2021. RESULTS: Remission (normalization of serum IGF-1) was achieved in 65 (55%) patients. Growth hormone and IGF-1 index decreased after surgery in all patients. Mean preoperative serum growth hormone was 12.45 [6.88, 29.85] ng/ml, early postoperative concentration - 1.54 [0.80, 3.38] ng/ml, in delayed period - 1.15 [0.57, 3.80] ng/ml. Mean IGF-1 index was 2.18 [1.69, 2.71], 1.47 [0.99, 1.90] and 0.99 [0.74, 1.43], respectively. CONCLUSION: Significant predictors of acromegaly remission after neurosurgical treatment were age, preoperative level of growth hormone, tumor size and location, growth hormone and IGF-1 index in early postoperative period and residual tumor after surgery. Multivariate analysis revealed a significant association of acromegaly remission with small tumor size, low postoperative level of growth hormone and no residual tumor within 3-6 month after surgery.

[Infectious complications in acute period after traumatic brain injury]. / Infektsionnye oslozhneniya u patsientov v ostrom periode cherepno-mozgovoi travmy.

Patients with traumatic brain injury (TBI) are at high risk of infection. OBJECTIVE: To delineate infections in acute period of TBI, association between intracranial lesion type and risk of infection, as well as to estimate treatment outcomes in these patients depending on infection. MATERIAL AND METHODS: This study included 104 patients with TBI (80 men and 24 women) aged 33.01±14.35 years. All patients met the inclusion criteria: admission within 72 hours after TBI, age 18-75 years, ICU-stay >48 hours, available brain MRI data. Mild, moderate and severe TBI were diagnosed in 7%, 11% and 82% of patients, respectively. Analysis of infections was performed in accordance with the definitions of the Centers for Disease Control/National Healthcare Safety Network (CDC/NHSN). RESULTS: Acute period of TBI is associated with high incidence of infection (73%), and prevalent infection is pneumonia (58.7%). Severe intracranial damage in acute period of TBI (grade 4-8 according to MR-based classification by A.A. Potapov and N.E. Zakharova) is associated with higher incidence of infection. Infectious complications more than twice increase duration of mechanical ventilation, ICU- and hospital-stay. CONCLUSION: Infectious complications significantly affect treatment outcomes in acute period of TBI increasing duration of mechanical ventilation, ICU- and hospital-stay.

[Anaplastic pleomorphic xanthoastrocytoma - single-center analysis of 42 patients]. / Anaplasticheskaya pleomorfnaya ksantoastrotsitoma ­ analiz 42 nablyudenii iz odnoi kliniki.

Anaplastic pleomorphic xanthoastrocytoma is a rare tumor. There are still no objective data on the incidence of its diagnosis. OBJECTIVE: To study neuroimaging, morphological features of tumors, as well as factors affecting treatment and prognosis. MATERIAL AND METHODS: A retrospective study enrolled 42 patients operated on at the Burdenko Neurosurgery Center between 2003 and 2020. MR characteristics of anaplastic pleomorphic xanthoastrocytoma were analyzed. All patients underwent resection of tumor (total resection in 83.3% of cases). Redo surgeries were performed in 1/3 of patients. Mutational status of BRAF V600E was assessed in all patients. Adjuvant radio- and chemotherapy was performed in more than 80% of cases. Tyrosine kinase inhibitors were administered in 19% of cases. The follow-up period was 152 months (median 34 months). RESULTS: We found no pathognomonic MR signs of this disease. Indeed, anaplastic pleomorphic xanthoastrocytoma have the same signal characteristics as other malignant gliomas. The BRAF V600E mutation status was positive in 54.8% of cases. None patient had IDH-1 mutation. Mean Ki-67 index was 12.5%. The overall survival was 79 months (range 4-152). Seven (17%) patients are alive for more than 90 months. Only Ki-67 index and BRAF mutation significantly influenced the treatment prognosis and overall survival regardless the use of tyrosine kinase inhibitors. CONCLUSION: Such well-known factors for malignant glioma as patient age, total resection and adjuvant therapy did not significantly affect overall survival. Perhaps, searching for new molecular genetic features will reveal additional significant factors of prognosis in patients with anaplastic pleomorphic xanthoastrocytoma.

[Role of TERT mutation for treatment prognosis in patients with IDH-negative anaplastic astrocytoma]. / Znachenie TERT-mutatsii v opredelenii prognoza lecheniya patsientov s IDH-negativnymi anaplasticheskimi astrotsitomami.

OBJECTIVE: To study the effect of TERT mutation on overall and relapse-free survival in patients with IDH-negative diffuse astrocytomas grade III (anaplastic gliomas). MATERIAL AND METHODS: The study included 45 patients aged 45.5 years. Forty-two patients underwent resection of tumor, other 3 ones - stereotactic biopsy. TERT mutation was identified in 21 patients. External beam radiation therapy was performed in 35 patients (60 Gy), chemotherapy - in 34 patients (mainly temozolomide). Follow-up data were available in 44 patients. RESULTS: Median of overall survival in patients with TERT mutation was 15.3 months, in patients with TERT-negative tumors - 65.1 months. Median of relapse-free survival in patients with TERT-positive anaplastic astrocytoma (AA) was 13.3 months, in patients with TERT-negative glioma - 57.7 months. These differences were not significant. Relapse-free survival was higher in patients with AA and no TERT mutation at all intervals, but especially at early stages (12 and 24 months). CONCLUSION: Inclusion of TERT mutation in mandatory examination panel for gliomas in general and, in particular, gliomas grade II/III without IDH mutation can lead to sub-classification of these tumors in the near future. Routine analysis of TERT mutation in these patients will be valuable for correct medical consultation regarding prognosis and adequate adjuvant treatment.

[Minimally invasive microsurgical decompression in patients with monosegmental lumbar spinal stenosis]. / Rezul'taty primeneniya minimal'no invazivnoi mikrokhirurgicheskoi dekompressii u patsientov s monosegmentarnym poyasnichnym stenozom.

Surgical treatment of degenerative lumbar spinal stenosis is an actual problem of modern spinal surgery and orthopedics. OBJECTIVE: To analyze the results of minimally invasive microsurgical decompression (MI-MD) in patients with monosegmental lumbar spinal stenosis. MATERIAL AND METHODS: A retrospective observational cohort study was performed. We analyzed medical records of patients who underwent MI-MD for monosegmental degenerative lumbar spinal stenosis. Clinical and objective results of MI-MD, as well as the types and prevalence of adverse clinical events were studied. RESULTS: The study included 96 medical records (50 (52%) males and 46 (48%) females aged 18-84 years). Analysis of pain in lower back and lower extremities in 3, 6, 9, 12 and 24 months after MI-MD showed a significant decrease of this indicator (p<0.001). There was significant improvement of capacity according to ODI score up to 5-12% in 72.9% of patients in early postoperative period (p=0.055). In delayed postoperative period, we also observed significant improvement of working capacity according to ODI score and gradual decrease in disability index (p<0.001). Adverse clinical events occurred in 6 (6.2%) patients. CONCLUSION: MI-MD is a highly effective surgical method for monosegmental lumbar spinal stenosis with minimal incidence of adverse clinical events.

[Multiple skull base defects: features of pathogenesis, diagnosis and treatment]. / Mnozhestvennye defekty osnovaniya cherepa: osobennosti patogeneza, diagnostiki i lecheniya.

OBJECTIVE: To determine the risk factors of multiple skull base defects, as well as features of diagnosis and treatment of this pathology. MATERIAL AND METHODS: A retrospective analysis included 39 patients who underwent surgery for nasal CSF leakage at the Burdenko Neurosurgical Center in 2000-2019. The study recruited patients with multiple simultant skull base defects. RESULTS: Traumatic defects were observed in 23 (59%) patients, spontaneous defects - in 16 (41%) cases. All patients underwent endoscopic endonasal closure of skull base defects with autografts. CONCLUSION: Multiple defects are more common in severe traumatic brain injury. The main risk factors of multiple spontaneous defects are female sex and overweight. Adequate diagnosis implies high-resolution CT (slice width 0.5-1 mm), as well as intraoperative control of all suspicious and «weak¼ areas. Endoscopic endonasal technique is effective and safe for multiple skull base defects (efficiency 97%).

[Lessons learnt from 101 hemispherotomies in children with symptomatic epilepsy. Part I: seizure outcome]. / Uroki 101 gemisferotomii u detei s polusharnoi simptomaticheskoi epilepsiei. Chast' I. Iskhody lecheniya pristupov.

OBJECTIVE: To evaluate variables that may predict the outcome after hemispherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS: One hundred and one patients with refractory seizures and variable decline in development (n=78) underwent hemispherotomy (med. age - 43 months, med. epilepsy history - 30 months). Developmental pathology was the anatomical substrate of disorder in 42 patients, while the infantile post-stroke scarring and gliosis was its origin in the majority of 43 cases with acquired etiology. The progressive pathology (the Rasmussen encephalitis, Sturge-Weber angiomatosis and tuberous sclerosis) was the etiology in 16 children. Left-sided hemisphere was impaired in 54 cases; some contralateral anatomical and potentially epileptogenic MRI-abnormalities were noted also in «healthy¼ hemisphere in » of all cases. Eight patients needed second surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. - 1.5 years) and 73 of them were free of seizures (80.2%), but only 30 of 40 patients with FU > 2 years were still SF (75%). All but one of re-do hemispherotomies were successful. AED-treatment was discontinued in 46 cases and tapered in other 27 patients. Up to 90% of kids demonstrated some improvement in behavior and cognition. RESULTS AND CONCLUSION: Developmental pathology, infantile spasms and younger age onset of seizures are negative predictors for achievement of SF-status (p<0.05). Neither bilateral epileptic EEG-signs, nor MRI-abnormalities in «healthy¼ hemisphere had any relation to outcome, but focal seizure onset was associated positively with further SF-status (p = 0.03). Kids with multiple lobe unilateral CD do somewhat worse than their counterparts with hemimegalencephaly and acquired etiology. Post-hemispherotomy hemiparesis (either new or worsening of already existed one) has no relation either to the age at surgery, or to the age onset (p = 0.41). Children with left-sided lesions were less successful in every neurodevelopmental domain except maintaining expressive language. Patients with relapse or persisting seizures have good chances to become SF by re-doing hemispherotomy and should be evaluated for the possibly incomplete hemispheric isolation.

[Lessons learnt from 101 hemispheric pediatric epilepsy surgeries part ii: pitfalls and complications]. / Uroki 101 gemisferotomii u detei s polusharnoi simptomaticheskoi epilepsiei. Chast' II: oslozhneniya i oshibki.

OBJECTIVE: To evaluate the spectrum of pitfalls and complications after hemisherotomy basing on a retrospective study of a large consecutive pediatric cohort of patients from a single institution. MATERIAL AND METHODS: One hundred and one patients (med. age - 43 months) with refractory seizures underwent hemispherotomy. Developmental pathology was the anatomical substrate of disorder in 42 patients. The infantile post-stroke scarring and gliosis was the origin of epilepsy in the majority of 43 cases with acquired etiology. The progressive pathology (RE, S-W and TS) was the etiology in the rest of children (16 cases). The lateral periinsular technique was used to isolate the sick hemisphere in 55 patients; the vertical parasagittal approach was employed in 46 cases. Median perioperative blood loss constituted 10.5 ml/kg, but was markedly larger in kids with hemimegaly (52.8 ml/kg); 57 patients needed hemotransfusion during surgery. Median length of stay in ICU was 14.7 hours, and the length of stay in the hospital until discharge - 6.5 days. Eight patients underwent second-look surgery to complete sectioning of undercut commissural fibers. FU is known in 91 patients (med. length - 1.5 years). RESULTS: Major surgical complications with serious hemorrhage and/or surgery induced life-threatening events developed in 7 patients (one of them has died on the 5th day post-surgery for the causes of brain edema and uncontrolled hyponatremia). Various early and late infectious complications were noted in 4 cases. Ten patients experienced new not anticipated but temporary neurological deficit. Nine patients needed shunting for the causes of hydrocephalus within several first months post-hemispherotomy. Early seizure onset was associated with probability of all complications in general (p=0.02), and developmental etiology - with intraoperative bleeding and hemorrhagic complications (p=0.03). CONCLUSION: Children with developmental etiology, particularly those with hemimegalencephaly, are most challengeable in terms of perioperative hemorrhage and serious complications. Patients with relapse or persisting seizures should be evaluated for the possibility of incomplete hemispheric isolation and have good chances to become SF by re-doing hemispherotomy.

[Endoscopic endonasal reconstruction of skull base defects in the lateral recess of the sphenoid sinus: evaluation of computed tomograms for planning operations]. / Endoskopicheskaya endonazal'naya plastika defektov osnovaniya cherepa v oblasti lateral'nogo karmana klinovidnoi pazukhi: otsenka komp'yuternykh tomogramm dlya planirovaniya operatsii.

OBJECTIVE: Determine the influence of the anatomical features and sizes of the lateral pocket with a defect on the choice of surgical access and the quality of the performed plastics. MATERIAL AND METHODS: A retrospective analysis of computed tomograms of 38 patients who underwent surgical treatment at the Burdenko National Medical Research Center for Neurosurgery of the Ministry of Health of Russia about defects of the skull base in the area of the lateral pocket of the sphenoid sinus. The patients were divided into three groups depending on the approach used (the 1st group), the recurrence rate (the 2nd group), and the characteristics of intraoperative visualization of the defect (the 3rd group). RESULTS: There were no statistically significant differences in anatomical features in patients who underwent trans-pterygoid and transsphenoidal approaches, as well as in patients of the 2nd group. Patients of the 3rd group (with visualization features) showed statistically significant differences between the distance from the defect to the VR line (p=0.007). In patients with good visualization of the defect using direct optics, this distance was shorter than in patients in whom the defect was visualized with an angled endoscope. No other anatomical differences were noted. CONCLUSIONS: The anatomical features of the lateral pocket structure (type of pneumatization, size and volume) did not affect the choice of access to the defect and the frequency of recurrence. When comparing the approaches, it was noted that the trans-pterygoid access, providing direct visualization of defects, minimizes the risk of recurrence in the postoperative period. An objective anatomical indicator for choosing an access to the defects of the lateral pocket can be the distance from the defect to the VR line: at a distance of more than 0.7 cm, it is advisable to perform a trans-pterygoid approach; at a distance of less than 0.7 cm, it is possible to achieve direct visualization of the defect and perform high-quality plastic surgery with a transsphenoidal access.

[Clinical and MRI predictors of coma duration, intensive care and outcome of traumatic brain injury]. / Klinicheskie i magnitno-rezonansnye tomograficheskie prediktory dlitel'nosti komy, ob"ema intensivnoi terapii i iskhodov pri cherepno-mozgovoi travme.

OBJECTIVE: This research is aimed to study the clinical and MRI predictors of coma duration, the intensity of critical care, and outcome of traumatic brain injury (TBI). MATERIAL AND METHODS: The data from 309 patients with TBI of varying severity were included in the analysis, of whom 257 (86.7%) were treated in the intensive care unit (ICU), including 196 (63.4%) patients admitted in a comatose state lasting longer than 1 day. All patients underwent brain MRI within 21 days after the injury. MRI findings were classified according to MRI grading scale of brain damage level and localization proposed previously. RESULTS: The proposed MRI grading significantly correlated with the Glasgow coma (GCS, r=-0.67; p<0.0001) and Glasgow outcome (0.69; p<0.001) scores in the entire group. In a subgroup of comatose patients (GCS<9) it correlated with coma duration (r=0.52; p<0.0001). Spearman correlation analysis showed a significant relationship between the MRI classification and a number of parameters: ICU length of stay (r=0.62; p<0.0001), the duration of artificial ventilation (r=0.47; p<0.0001), the rate of artificial ventilation, sedatives, analgesics, mannitol, hypertonic saline and vasopressors usage (p<0.01). These data confirm the relationship between higher grades of MRI classification (deep brain damage) and the need for the escalation of intensive care main components. CONCLUSION: Our results support the hypothesis that the levels and localization of brain damage, estimated by the proposed MRI grading scale, might be predictors of coma duration, intensity and duration of intensive care, and TBI outcomes. A prognosis based on clinical and neuroimaging data comparison can be valuable for planning and efficient use of the hospital beds and ICU resources, for optimizing the patient flow and timing of patient transfer to neurorehabilitation facilities.

[Comparative analysis of mono- and bipolar pyramidal tract mapping in patients with supratentorial tumors adjacent to motor areas: comparison of data at 64 stimulation points]. / Sravnitel'nyi analiz potochechnogo mono- i bipolyarnogo kartirovaniya piramidnogo trakta u patsientov s supratentorial'nymi opukholyami, prilezhashchimi k motornym zonam golovnogo mozga: sravnenie dannykh v 64 tochkakh stimulyatsii.

OBJECTIVE: To compare monopolar and bipolar mapping in point-by-point fashion by using of threshold amperage, frequency of positive motor responses and the number of muscles involved in response. MATERIAL AND METHODS: A prospective non-randomized study included 14 patients with supratentorial tumors who underwent surgery in 2018-2019. All neoplasms were localized within 2 cm from the motor cortex and pyramidal tract. Age of patients ranged from 25 to 74 years. There were 9 women and 5 men. Eight patients had malignant glioma (grade III - 4, grade IV - 4), 6 patients - meningioma. Motor functions were assessed in all patients before and after surgery (1, 7 days and 3 months later) by using of a 5-point scale. In addition to routine neurophysiological monitoring, comparative mono- and bipolar mapping of the pyramidal tract within the bed of excised tumor was carried out at the end of surgery. The points of motor responses were marked. Comparative analysis of mono- and bipolar stimulation at identical points included threshold amperage, frequency of positive motor responses and the number of muscles involved in response (leg, forearm, hand, facial muscles). Brain MRI was performed in early postoperative period for assessment of resection quality. RESULTS: There were 64 points of motor responses in 14 patients. The number of these points ranged from 2 to 8 per a patient (mean 5 points). Motor responses were recorded in 57 points during monopolar and bipolar stimulation, in other 7 points - only during monopolar stimulation. Amperage of monopolar stimulation was 3-15 mA, bipolar stimulation - 2.5-25 mA. Threshold amperage (7.37 mA for monopolar stimulation and 8.88 mA for bipolar stimulation; p=0.12), frequency of positive motor responses and the number of muscles involved in response (p=0.1 and p=0.73) were similar. Seven (50%) patients had neurological deterioration in early postoperative period (4 patients with glial tumors and 3 patients with meningiomas). At the same time, only 2 patients (14.3%) had persistent neurological deficit (both patients with infiltrative meningioma). According to postoperative MRI in T1+C mode, resection volume was 100% in 1 patient with contrast-enhanced glioma and 94% in another one. According to FLAIR MRI data, resection volume exceeded 70% in 2 patients with non-enhancing glioma and less than 70% in 2 patients. Meningioma resection volume was estimated according to postoperative T1+C MRI data and made up over 90% in 4 patients. CONCLUSION: Monopolar stimulation is a reliable method of pyramidal tract identification in supratentorial brain tumor surgery.

[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.

[Liquorrhea after removal of fourth ventricle tumors in children. Retrospective analysis of a series of 211 primary surgeries]. / Likvoreia posle udaleniia opukholei IV zheludochka u detei. Retrospektivnyi analiz posledovatel'noi serii 211 pervichnykh operatsii.

Wound liquorrhea is a serious and dangerous complication developing after neurosurgical interventions. The highest risk group includes patients operated on using approaches to the skull base. In pediatric neurosurgery, approaches to the posterior cranial fossa are some of the most common ones, with wound liquorrhea amounting to 33%. Studies devoted to the wound liquorrhea problem have been performed in heterogeneous patient groups, which complicates evaluation of the results and reduces their practical value. MATERIAL AND METHODS: The analysis included pediatric patients operated on by a single surgeon for posterior cranial fossa (PCF) tumors in the period from 2009 to 2016. There were 472 patients. Criteria for inclusion in the study were as follows: age under 18 years; predominant tumor location in the fourth ventricle; primary surgery. According to the inclusion criteria, the study involved 211 patients. A search for the key words 'liquorrhea', 'pooling', 'meningocele', 'pseudomeningocele', and 'meningitis' was performed through electronic medical records of the involved patients. We analyzed the data on the total bed-day and the number of days spent in the critical care unit. Surgery protocols were the source of the following information: the presence of an external ventricular drain or ventriculoperitoneal shunt before tumor resection; information on DM closure; information on additional sealing of dura sutures. In addition, the patients were divided into two groups, the main difference between which was the use of additional sealing of dura sutures (Tachocomb, fibrin-thrombin glues, and their combination) to minimize the risk of wound liquorrhea. RESULTS: A total of 211 patients were included in the study. Postoperative wound liquorrhea occurred in 6 (2.8%) patients; another 5 (2.4%) patients had significant pseudomeningocele. Most children spent no more than 1 day in the critical care unit - totally 176 (83.4%) patients; the other 35 (16.6%) children spent more than 1 day in the critical care unit. A group of patients without sealing of dura sutures consisted of 144 (68.2%) patients. Liquorrhea occurred in 4 (2.8%) cases; in 3 (2.1%) cases, there was symptomatic pseudomeningocele without liquorrhea. In a group of patients with the use of suture sealing (Tachocomb, fibrin-thrombin glue in various combinations - 67 (31.8%) patients), there was liquorrhea in 2 (3%) cases and pseudomeningocele without liquorrhea in 2 (3%) cases. On the basis of PSM algorithm application, 2 groups of 67 patients each were formed: the group with sealing (A) and the group without sealing (B) of the DM. Of the 67 cases of sealing, Tachocomb was used in 64 (95.5%) patients, and fibrin-thrombin glue was applied in 53 (59.1%) patients. Differences between the groups in the rate of liquorrhea (2 (3.0%) patients in group A and 4 (6.0%) patients in group B) and pseudomenigocele (3 (4.5%) patients in group A and 5 (7.5%) patients in group B) were statistically insignificant (p=0.68 and p=0.58, respectively). CONCLUSION: Wound liquorrhea has remained a topical issue in surgery for posterior cranial fossa tumors and, if develops, doubles the postoperative bed-day. Our strategy of perioperative management of patients proved its efficacy in reducing the rate of postoperative liquorrhea up to 2.8%. A low percentage of liquorrhea did not allow unambiguous evaluation of the effect of additional sealing of dura sutures (Tachocomb and fibrin-thrombin glue).