[Surgical treatment of vertebral artery confluence aneurysms]. / Khirurgicheskoe lechenie anevrizm v oblasti sliyaniya pozvonochnykh arterii.

BACKGROUND: Aneurysms of vertebral artery confluence and proximal parts of basilar artery are extremely rare. They are usually combined with proximal fenestration of basilar artery. No timely surgical treatment of these aneurysms is associated with high risk of adverse outcomes, and their treatment is a challenge for neurosurgeons. MATERIAL AND METHODS: We analyzed postoperative outcomes in 17 patients with 21 aneurysms of vertebral artery confluence and proximal parts of basilar artery. RESULTS: Six patients with 10 aneurysms underwent microsurgical resection, 11 patients with 11 aneurysms - endovascular procedure. Persistent postoperative deterioration was observed in 5 (29.4%) patients: severe neurological symptoms (GOS grade 3) in 1 case (5.9%), minor bulbar disorders in 4 cases (23.53%). There were no lethal outcomes. CONCLUSION: According to our own and literature data, aneurysms of vertebral artery confluence are extremely rare. The risk of rupture of these aneurysms is extremely high. Endovascular approach is preferred in these patients. Microsurgical procedure is an acceptable alternative if endovascular surgery is impossible.

[A 20-year experience in surgical treatment of steno-occlusive lesion of craniocervical arteries at the Burdenko Neurosurgical Center]. / Dvadtsatiletnii opyt khirurgicheskogo lecheniya stenoziruyushchei i okklyuziruyushchei patologii brakhiotsefal'nykh arterii v FGAU «Natsional'nyi meditsinskii issledovatel'skii tsentr neirokhirurgii im. akad. N.N. Burdenko¼.

INTRODUCTION: Surgical treatment of cerebral ischemia at the Burdenko Neurosurgical Center for the period from 1999 to 2019 is analyzed in the paper. The details of the treatment strategy in patients with steno-occlusive lesion of craniocervical arteries followed by cerebral ischemia developed over 20 years are discussed in the article. We have analyzed the features of surgical interventions on the major craniocervical arteries in a neurosurgical clinic and the results of this treatment. OBJECTIVE: To demonstrate management of various lesions of major cerebral arteries in modern neurosurgical vascular hospital. MATERIAL AND METHODS: In total, there were 3098 interventions on the major cerebral arteries in 2527 patients for this period. Mean age of patients ranged from 1.5 to 91 years (58±14 years). Interventions included open reconstructions of the carotid arteries (2031 surgeries), reconstructions of the vertebrobasilar arteries (135 surgeries), brain revascularization (658 surgeries), excision of the tumors of neurovascular bundle on the neck compressing carotid arteries (51 interventions). Endovascular interventions were performed in 223 cases and consisted of angioplasty and stenting of the extracranial segments of craniocervical arteries (185 surgeries), stenting of the intracranial arteries (30 surgeries) and endovascular thrombextraction (8 cases). Staged surgeries were performed in 541 patients (22.3%). RESULTS: Favorable outcomes were obtained in 87.6% of cases, satisfactory results - in 9% of patients. Clinical deterioration due to long-term postoperative complications and recurrent strokes occurred in 2.9% of cases. Postoperative morbidity rate was 4.6%, persistent neurological deficit developed in 2.6% of cases. Mortality rate was 0.5%. CONCLUSION: Surgical treatment of stenotic and occlusive lesion of the major cerebral arteries is an interdisciplinary problem. Solution of this issue is closely associated with technological progress, new discoveries in normal and pathological physiology, as well as clinical researches. Individualized choice of surgical approach is one the main modern trends of neurosurgical approach to this problem. At the same time, own surgical experience is the most important factor determining the results of arterial reconstructions.

[Principles of surgical treatment for patients with asymptomatic aneurysms and cerebral aneurysms in the cold period after spontaneous intracranial hemorrhages]. / Printsipy vybora metoda khirurgicheskogo lecheniia bol'nykh s bessimptomnymi anevrizmami i anevrizmami golovnogo mozga v kholodnom periode posle spontannykh vnutricherepnykh krovoizliianii.

Surgical treatment of patients with cerebral aneurysms still remains one of the most important issues of cerebrovascular neurosurgery, which is associated with both complexity of treatment and risks posed by the disease. The purpose of this publication is to discuss the recommendations and algorithms adopted at the Neurosurgical Institute for choosing surgical treatment of patients with single and multiple intracranial aneurysms based on the clinical course of disease and anatomical morphological classifications of aneurysms. The study was based on a large clinical material: we analyzed treatment outcomes in 1,621 patients (2009-2017); of these, 966 (59.5%) patients were operated on using microsurgical techniques, and 655 (40.4%) patients underwent endovascular surgery. Surgical treatment of patients with cerebral aneurysms has been performed in close cooperation between two vascular (microsurgical and endovasal) departments, using the latest technical innovations.

[Nasal schwannoma with skull base destruction in a child (a case report and literature review)]. / Nazal'naia shvannoma s destruktsiei osnovaniia cherepa u rebenka (sluchai iz praktiki i obzor literatury).

Schwannomas (neurinomas) are benign, encapsulated, and slow-growing neoplasms developing from any peripheral, cranial, or vegetative nerve that has the Schwann sheath. Schwannomas of the nasal cavity and paranasal sinuses in adults occur rarely, less than 4% of cases. The world literature lacks similar data for the pediatric age group because these tumors in children are unique and extremely rare. The most common clinical symptoms of sinonasal schwannoma are nasal breathing disorders, hyposmia or anosmia, and snoring at night. Other symptoms are associated with intranasal schwannoma invasion of neighboring organs and tissues and include exophthalmos, epiphora (lacrimation), headaches, and anesthesia in the facial area. In this article, we describe a rare case of diagnosis and successful surgical treatment of a child with intranasal schwannoma destructing the skull base.

[Tactics of surgical treatment of patients with unruptured asymptomatic cerebral aneurysms]. / Taktika khirurgicheskogo lecheniya bol'nykh s nerazorvavshimisya bessimptomnymi anevrizmami tserebral'nykh sosudov.

AIM: To clarify the indications for surgical treatment and the principles for choosing a surgical technique for patients with unruptured asymptomatic aneurysms (UAAs) based on the results of direct and endovasal operations performed at the Burdenko Neurosurgical Institute and on the literature data. MATERIAL AND METHODS: The study included 694 UAA patients (481 females (69.3%) and 213 males (30.7%)) operated on at the Burdenko Neurosurgical Institute from 1997 to 2013. The patients' age ranged from 1 to 74 years (mean age, 48.3 years). Multiple aneurysms were in 126 (18.2%) patients. Anterior circle of Willis aneurysms were in 92.8% of cases. Among these, internal carotid artery (ICA) aneurysms (46.3%) and middle cerebral artery (MCA) aneurysms (30.8%) were predominant. Microsurgical and endovascular interventions on aneurysms were performed in 665 patients (95.8%). RESULTS: Complete aneurysm exclusion was achieved in 94.8% of cases. A pronounced neurological deficit developed in 8 (1.2%) patients, and a moderate neurological deficit developed in 62 (9.3%) patients. Postoperative mortality was 0.5%. CONCLUSION: Surgical treatment of UAAs is associated with low disability and mortality rates. All UAAs need to be operated on, especially in young and middle age patients, if surgery is technically possible, and there are no concomitant diseases contraindicating the intervention. The choice of an UAA exclusion technique is made based on the general principles of surgical treatment of cerebral aneurysms. At present, the method of choice is endovascular surgery for most cases of vertebrobasilar basin and ICA aneurysms and a microsurgical intervention for anterior cerebral artery and MCA aneurysms.

[The principles for choosing a surgical technique for patients with acute cerebral aneurysm rupture]. / Printsipy vybora metoda khirurgicheskogo lecheniya bol'nykh v ostrom periode razryva tserebral'nykh anevrizm.

The article describes the principles for choosing a surgical technique for patients with cerebral aneurysms in acute subarachnoid hemorrhage. The principles were developed based on the experience gained at the Burdenko Neurosurgical Institute. Microsurgical and endovascular treatment options are considered.

[Results of deconstructive endovascular surgery in treatment of large and giant intracranial aneurysms]. / Rezul'taty dekonstruktivnykh endovaskulyarnykh operatsii pri lechenii krupnykh i gigantskikh intrakranial'nykh anevrizm.

AIM: To clarify the indications for deconstructive endovascular surgery in patients with large and giant intracranial aneurysms and to evaluate short-term and long-term postoperative outcomes. MATERIAL AND METHODS: The study was based on a retrospective analysis of the treatment results in 50 patients with large (15-25 mm) and giant (more than 25 mm) intracranial aneurysms, aged from 18 to 75 years, who were treated at the Burdenko Neurosurgical Institute in 2002-2014. The patients underwent a balloon occlusion test (BOT) in various modifications before stationary occlusion of the carrier artery. For vascular occlusion, we used detachable latex balloon catheters (33 cases) and microcoils (17 cases). The condition of patients in the pre- and postoperative period was assessed by using the modified Rankin Scale. RESULTS: There were no deaths due to occlusion of the internal carotid artery (37 patients). Postoperative complications occurred in 5 patients. On the basis of BOT, revascularization surgery involving placement of an extra-intracranial microanastomosis (EICMA) was performed in 6 cases. In more 4 cases, EICMA was placed in the early postoperative period due to developing signs of ischemia. Two of 7 patients underwent occlusion of both vertebral arteries (VAs) in the vertebrobasilar basin, which led to fatal outcomes. One more patient died of aggravation of brainstem compression after VA occlusion. There was no worsening of neurological symptoms among survivors. There were no deaths and persistent neurological disorders upon occlusion of branches of the main cerebral arteries, starting with the first order arteries (6 patients). Thirty one patients (66%) were followed-up in the period from 1 to 104 months. There were no deaths associated with artery occlusion. Two patients experienced delayed ischemic disorders. CONCLUSION: Occlusion of the carrier artery should be performed in a carefully selected group of BOT-negative patients. This surgery can be indicated for aneurysms with a complicated configuration, the topographic and anatomical features of which exclude reconstructive surgery.

[Giant partially thrombosed aneurysm of the vertebral artery: a case report and literature review]. / Gigantskaia chastichno trombirovannaia anevrizma pozvonochnoi arterii: opisanie klinicheskogo nabliudeniia i obzor literatury.

INTRODUCTION: Giant partially thrombosed aneurysms of the vertebral artery are recalcitrant to treatment by microsurgical trapping and thrombectomy. Application of endovascular interventions is limited due to substantial brainstem compression and cranial nerve neuropathy. Combined endovascular exclusion and microsurgical excision provides an approach to treatment of these lesions. CLINICAL CASE: A 48-year-old female patient presented with progressive complaints of ataxia, diplopia in left lateral gaze, and dysphagia. Imaging studies (CT, MRI, angiography) revealed a giant partially thrombosed aneurysm of the right vertebral artery and pronounced brainstem compression. TREATMENT: The initial phase of treatment involved endovascular occlusion of the vertebral artery and aneurysm trapping that did not lead to changes in the postoperative patient's neurological status. MRI demonstrated complete aneurysm thrombosis and a weak TOF signal in the vertebral artery near the proximal aneurysm neck region. Because of persistent brainstem compression, the patient underwent right suboccipital craniectomy and hemilaminectomy of the CI arch for aneurysm excision one week after endovascular occlusion. After isolating the aneurysmal sac, the vertebral artery was transected, and two small branches extending from the aneurysm neck to the brainstem were also coagulated and transected, followed by aneurysm excision. Numerous vasa vasorum in the wall of the proximal vertebral artery and aneurysm neck were coagulated to stop bleeding. After surgery, the patient developed neurological symptoms (right leg ataxia and dysphagia worsening) due to lateral medullary infarction (confirmed by MRI) that presumably resulted from coagulation of two small perforating branches coming from the aneurysm neck to the brainstem. Recovery of the patient's neurological functions was observed during conservative treatment. The patient was discharged with mild right leg ataxia and preoperative left-sided abducens paresis. CONCLUSION: Medulla oblongata compression associated with a giant thrombosed aneurysm of the vertebral artery can be eliminated by endovascular trapping followed by surgical excision of the aneurysm. Preserving the vasa vasorum feeding the brainstem is crucial for prevention of ischemic complications.

[Endovascular treatment of large and giant intracranial aneurysms using flow-diverting stents].

OBJECTIVE: The objective was to evaluate the efficacy of treatment of patients with large and giant cerebral arterial aneurysms using flow-diverting stents (FDSs). MATERIAL AND METHODS: The treatment outcomes of 210 patients with large and giant intracranial aneurysms were analyzed. The study included patients with both asymptomatic and symptomatic aneurysms (manifested by SAH or pseudotumorous course). The rate of giant aneurysms was 62.3%. RESULTS: The technical success rate was 96%. In the perioperative period, the rate of clinically significant complications was 2.8%; the postoperative mortality was 3.3%. In the long-term period, total thrombosis of the aneurysm was observed in the majority of cases (80%) in the period from 4 to 12 months. Complete regression of clinical symptoms was observed in 26% of the cases, partial regression in 35%, and deterioration in 6% (of them, 4.9% of the cases were clinically significant). The long-term mortality was 2.5%. CONCLUSION: FDS is a highly efficient device for remodeling of the arterial lumen at the level of large, giant and fusiform intracranial aneurysms that significantly reduces the number of deconstructive operations and decreases the risk of ischemic complications of endovascular treatment for this complex vascular pathology.

[Endovascular treatment of large and giant intracranial aneurysms using stent assistance].

OBJECTIVE: The study objective was to evaluate the efficacy of occlusions of large and giant intracranial aneurysms with microcoils using stent assistance (SA). MATERIAL AND METHODS: The study is based on analysis of treatment outcomes in 37 patients with large (15-25mm) and giant (more than 25mm) intracranial aneurysms, aged 18 to 72 years, who were hospitalized at the Burdenko Neurosurgical Institute in the period between 2004 and 2014. Selection of patients for endovascular treatment using SA was based on the anatomical parameters of the aneurysm and carrier vessel. The main determining factor was the index of the aneurysm body to neck size ratio. Occlusion of aneurysms was performed with microcoils of different configurations, including those with a biologically active coating. Self-expanding stents with both an open-cell and closed-cell design were used for SA. The results of intervention for large and giant aneurysms were evaluated using control angiography immediately after occlusion of the aneurysm. The condition of patients with unruptured aneurysms as well as with ruptured aneurysms in the "cold" period was evaluated using the modified Rankin scale. The condition of patients in the acute period of SAH was evaluated on the Hunt and Hess scale. RESULTS: The technical success (successful implantation of stents and coils with total or subtotal aneurysm occlusion) was 94.5%. The postoperative disability was 2.7%; mortality was 2.7%. 28 patients were followed up for the period of 5 to 84 months (the mean was 20 months.). In the long-term period, the total and subtotal occlusion rate, including the results of re-operations, amounted to 90%. Delayed disability was 10.7%, and mortality was 3.5%. CONCLUSION: Stent assistance enables achieving total or subtotal occlusion of large and giant aneurysms in 90% of cases. In certain clinical situations, it is an alternative to other existing methods.

[Surgical treatment of cerebral vascular diseases].

Theoretical and practical aspects of the complex treatment of brain and spinal vascular diseases using microsurgical, endovascular and radiosurgical methods are considered. Authors present the data demonstrating that, due to the implementation of the program of development of vascular centers in the Russian Federation, considerable progress was made in the treatment of cerebral aneurisms and hemorrhagic stroke. In author's opinion, wide introduction of surgical methods in the treatment of occlusive lesions of the blood vessels supplying the brain is needed.