[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.

[Cerebrospinal fluid dynamics in chronic obstructive hydrocephalus before and after successful endoscopic third ventriculostomy].

OBJECTIVE: to describe cerebrospinal fluid dynamics in chronic obstructive hydrocephalus before and after successful endoscopic third ventriculostomy (ETV). MATERIALS AND METHODS: 8 patients (7-21 years old) with chronic obstructive hydrocephalus due to tectal plate glioma were investigated before and after successful ETV. Apart from clinical and MRI assessment ICP-monitoring (ICP0) and intraventricular infusion studies were performed as well as upright ICP (ICP90) was investigated preoperatively and on 1st and 7th postoperative days (POD). Dynamic changes were assessed using Wilcoxon matched pairs test. RESULTS: There were no complications. MRI demonstrated functional ventriculostomy and reduced ventricle size in all cases. At follow-up all ETV's were considered clinically successful. By the 7th POD ICP0 showed tendency to reduction (p = 0.07) and ICP90 reduced significantly (p = 0.02). Significant reduction of Rcsf was evident by the 1st POD (p = 0.03) and was maintained until the 7th POD (p = 0.02). Elastance coefficient and compliance (as measured during infusion study) didn't change significantly in relation to ETV. In all the 3 cases when computerized ICP monitoring was used reduction of ICP pulse amplitude (AMP), AMP/ICP slope and RAP was noted by the 7-th POD which most probably reflects reduction of intracranial elastance. CONCLUSION: Effect of ETV in chronic obstructive hydrocephalus cannot be explained exclusively by its influence on ICP0; clinical improvement can possibly be attributed also to normalization of ICP90 and Rcsf, reduction of intracranial elastance and increase of cerebral blood flow reserve capabilities. There may be a pathophysiological ground for ETV in obstructive hydrocephalus with normal ICP.

[Choice of surgical approach in cervical spondylogenic myelopathy].

The purpose of this study was to provide a rationale for surgical decompression in degenetative stenosis in terms of differential electrophysiological evaluation of sensory and motor conduction. The study has provided an algorithm for a comprehensive preoperative examination of patients, which makes it possible to perform differentiated decompressive operations for cervical myelopathy with the higher efficiency of postoperative neurological recovery as compared with conventional methods.

[Results of endoscopic ventriculostomy of the III ventricle in the treatment of occlusive hydrocephalus]. / Rezul'taty éndoskopicheskoi ventrikulostomii III zheludochka v lechenii okkliuzionnoi gidrotsefalii.

The paper presents data of a retrospective analysis of the outcomes of endoscopic ventriculostomy of the 3rd ventricle, obtained in a consecutive series of 120 patients aged 5 months to 58 years who had occlusive hydrocephalus and operated on at the Research Institute of Neurosurgery, Russian Academy of Medical Sciences, in 1995-2000. In most cases (n = 112), hydrocephalus was caused by a block at the level of the cerebral aqueduct. In more than 50% of the patients, different tumors were responsible for occlusion. In 96 (80%) cases, the operation led to the elimination of occlusion and to the regression of symptoms just after surgery. Complications were few and observed in 19 patients, ventriculitis (n = 7) and intracranial hemorrhages (n = 6) being most common. No death occurred. Seventy three patients were followed up for 1 month to 5 years (mean 1.5 years). Eliminated occlusion and steady-state remission were found in 64 (87.7%) cases. Improvement was strongly correlated with an increase in the reserve craniovertebral content capacity estimated by measuring the pulse amplitude of blood flow in the tentorial sinus in body position-changing tests. In 9 patients, the symptoms of hydrocephalus remained or recurred after short-term improvement. In 3 of them, this occurred with anatomically competent anastomoses between the 3rd ventricle and cisterns. In the other 6 cases, the obliteration and anatomic incompetence of ventriculostoma were responsible for a relapse. In 8 of the 9 patients, shunting had to be made subsequently in the period of 1 to 6 months. The paper also considers some biophysical aspects of cerebrospinal fluid circulation and discusses indications for endoscopy. It is concluded that endoscopic ventriculostomy of the 3rd ventricle is the method of choice in the treatment of patients with obstructive hydrocephalus.

[Cerebral low T3 syndrome]. / Mozgovoi sindrom nizkogo T3.

The authors studied the time course of changes in the parameters of the cerebral thyronergic system (total and free triiodthyronine (T3) and thyroxin (T4), thyroxine-binding globulin (TBG), thyroid-stimulating hormone (TSH) by radioimmunoassay (Immunotech, Czechia; CIS, France), proinflammatory cytokine of TNF-alpha by enzyme immunoassay (Innogenetic, Belgium) in the blood and cerebrospinal fluid (CSF) in 59 patients (37 males and 22 females whose age ranged from 21 to 64 years) in acute subarachnoidal hemorrhage due to arterial aneurysmal rupture. On admission, the condition of 47 (79.7%) was rated as grades III-VI according to the Hunt-Hess scale, which was responsible for high mortality rates (33.89% in the assessment of outcomes according to the Glasgow outcome scale). The causes of death were ischemic and hemorrhagic insults, edema of the brain, cerebral stem wedging. Laboratory findings were analyzed in relation to the clinical condition of patients, outcomes, and the degree of secondary vasospasm assessed by Doppler transcranial study by the average blood flow velocity in the middle cerebral artery. They revealed a significant depression of thyroidal metabolism with developed the total low T3 syndrome just before surgical treatment in patients with deterioration in the early postoperative period. The significant correlations found by the authors between the decreased blood T3 and TSH levels and 1) the severity of neurological disorders; 2) the degree of vasospasm, and 3) the outcome of disease, as well as negative correlations of elevated TNF-alpha levels not only in the blood, but also in CSF with the content of CT3, CT4 and with the severity of neurological symptomatology are indicative of the development of isolated syndrome in the brain, which is characterized by specific thyroidal metabolic disorders, which the author propose to call the cerebral low T3 syndrome (by taking into account the presence of the autonomic systems of thyroidal homeostatic provision).

Noninvasive assessment of the elastance and reserve capacity of the craniovertebral contents via flow velocity measurements in the straight sinus by TCD during body tilting test.

Invasive recording of intracranial pressure (ICP) changes during cerebrospinal fluid (CSF) infusion-drainage tests have been used to estimate elastance and reserve capacity of craniovertebral contents. The increase in ICP and its pulse-related oscillations lead to "cuff constriction" of cerebral veins. The purpose of this study is noninvasive assessment of elastance and reserve capacity of craniovertebral contents (RCCC) by measurement of flow velocity (FV) in the straight sinus by transcranial Doppler (TCD) during body tilt tests, which cause changes in ICP. The study was performed in 14 healthy volunteers (age 12-49 y, 6 men) and 32 patients with Intracranial Hypertension (IH) (Benign Intracranial Hypertension, n = 14; Brain Tumors, n = 18). The straight sinus was insonated through the occipital window during body tilt tests (BTT). Tilt table position was changed gradually from head up (+75 degrees) to head down (-45 degrees). It was established that systolic flow velocity and amplitude of FV pulsations (Amp) in horizontal position in patients is usually higher than in healthy volunteers. We found that reserve capacity of craniovertebral contents in patients with IH was usually exhausted. Elastance in patients was usually significantly higher than in healthy volunteers. Evaluation of cerebral venous circulation during body tilt tests clearly differs between the patients with IH and the healthy volunteers. The degree of this difference depends on the localization and character of the pathologic process.

[Cerebral hemodynamics and metabolism in the acute stage of cerebral aneurysm rupture]. / Tserebral'naia gemodinamika i metabolizm v ostroi stadii razryva anevrizm golovnogo mozga.

The relationship between lipid peroxidation products and the severity of arterial spasm was studied in 86 patients. For this, the level of radical production, the content of the end lipid peroxidation product malonic dialdehyde and the overall antioxidative activity of lumbar cerebrospinal fluid were determined during 24-hour Doppler monitoring of blood flow in the middle cerebral and internal carotid arteries. Following subarachnoidal hemorrhage, the activation of lipid peroxidation processes was shown to correlate with the severity of arterial spasm and it is likely to contribute to the development of late ischemias. Nimotop used to treat patients with significant arterial spasm caused a reduction in the rate of free radical lipid peroxidation to that characteristic for patients with moderate spasm. The findings suggest that it is expedient of including antioxidants into the combined therapy of patients with acute subarachnoidal hemorrhage.

[Quantitative assessment of the cerebrospinal fluid dynamic parameters in patients with the "benign" intracranial hypertension syndrome. 2]. / Kolichestvennaia otsenka parametrov u bol'nykh s sindromom "dobrokachestvennoi" vnutricherepnoi gipertenzii. Chast' 2.

The development of the benign intracranial hypertensive syndrome was shown to be followed by changes in liquorodynamic parameters and elastic properties of the brain. In 99% of patients, the baseline liquor pressure was elevated by 1.5-2.5 times as compared to normal values. Resistance of liquor resorption was enhanced in 82% of cases, suggesting impaired normal liquor outflow. The increased brain elasticity gradient suggests the exhaustion of cerebrospinal compensatory potentialities and correlates with the increased liquor resorption resistance. A correlation analysis of liquorodynamic parameters by taking into account clinical signs yielded a pathogenetic scheme of the development of the benign intracranial hypertensive syndrome.

[The noninvasive diagnosis of cerebral arteriovenous aneurysms by transcranial dopplerography]. / Neinvazivnaia diagnostika arteriovenoznykh anevrizm golovnogo mozga metodom trankranial'noi doplerografii.

An absolute increase of blood velocity in the arteries of brain arteriovenous aneurysms is of the greatest importance in their diagnosis by transcranial Doppler ultrasonography. If the branches of brain great vessels are involved in blood supply of arteriovenous aneurysms, there is an increase in blood velocity only in the initial portions of the great vessels up to the origin of these branches. A relative increase in brain great vasculature blood velocity is of great diagnostic value. Arteriovenous aneurysms whose blood supply is provided by the anterior cerebral artery are typified by higher blood velocity in the anterior cerebral artery than that in the middle cerebral artery, whereas the reverse is true for health.

[The prognosis of the outcomes of comatose states in the first 24 hours following craniocerebral trauma]. / Prognozirovanie iskhodov komatoznykh sostoianii v pervye sutki posle cherepno-mozgovoi travmy.

In 58 patients with disorders of consciousness in the first day after the trauma assessed by the Glasgow coma scale both favourable (31%) and fatal outcomes (69%) were observed. Some differences were revealed in the indices of the Moscow scale and Glasgow scale.

[The effect of visual deafferentation on changes in the cerebral blood flow during photic stimulation]. / Vliianie zritel'noi deafferentatsii na izmeneniia mozgovogo krovotoka pri svetovoi stimuliatsii.

With the aid of transcranial dopplerography, linear velocity of the blood flow was recorded in major cerebral vessels in resting and in photostimulation in 18 healthy subjects and 7 patients with unilateral lesion of visual pathway and exclusion of one half of the field of vision. The photostimulation accelerated the blood flow in middle cerebral arteries by 4.3% and in posterior cerebral arteries by 26.3% in healthy subjects. No acceleration of the blood flow occurred in posterior cerebral artery on the side of unilateral lesion of visual pathways.

Venous and cerebrospinal fluid outflow in patients with brain swelling and oedema.

67 patients with benign intracranial hypertension (BIH) and 44 with normal pressure hydrocephalus (NPH) were examined by employment of infusion tests. Brain swelling (decrease of ventricular size with normal or increased brain tissue density) was a characteristic feature of BIH. It may result from venous outflow disturbances leading to vascular engorgement. But later, the process appears to be independent from the increase of the dural sinus pressure. This was normal in patients with BIH and NPH. Despite absorption disturbances there was a strong positive correlation in NPH between cerebrospinal fluid- and dural sinus pressure, while in BIH such a correlation was absent. The data confirm a pathogenesis of brain swelling in BIH as an obstacle to venous outflow at the level of the bridging veins and venous lacunae, however, not at the level of the dural sinuses.

[The interaction of humoral, metabolic and myogenic regulation of the cerebral circulation in unilateral occlusion of the internal carotid artery]. / Vzaimodeistvie gumoral'noi, metabolicheskoi i miogennoi reguliatsii mozgovogo krovoobrashcheniia pri odnostoronnei okkliuzii vnutrennei sonnoi arterii.

Transcranial dopplerography revealed an asymmetry in middle cerebral arteries in unilateral occlusion of the inner carotid artery. The reactivity of cerebral vessels to carbonic acid diminishes on the side of the occlusion. In absence of the brain tissue infarction, surgical revascularization leads to a partial normalizing of the reactivity. The data obtained suggests a considerable alteration of the interaction among humoral, metabolic and myogenic regulations of cerebral blood flow in unilateral occlusion of the inner carotid artery.

[Surgical treatment of patients with cranio-cerebral trauma and the role of neurological symptoms in the prognosis of its outcomes]. / Khirurgicheskoe lechenie bo'lnykh s cherepno-mozgovoi travmoi i ro'l nevrologicheskoi simptomatiki dlia prognozirovaniia iskhodov.

Under examination there were 411 patients with cranio-cerebral traumas. A unified method was used at different medical institutions in order to study questions of prognosis of the outcomes. Surgical treatment was used in 117 of them. The investigations have shown that the state of trance-coma both before operation and in the postoperative period is absolutely unfavourable prognostically. The state of trance-coma and the value of 15 scores and less should be taken into consideration as a contraindication for the solution of the question of operation in patients with cranio-cerebral traumas.

[Use of a point-scale assessment of patient status in the surgical treatment of craniocerebral injuries]. / Ispol'zovanie ball'noi otsenki sostoianiia bol'nykh pri khirurgicheskom lechenii cherepno-mozgovoi travmy.

The indications and contraindications for surgical treatment in craniocerebral trauma (CCT) were based on estimation of the patient's condition in marks; the dynamics of changes of the results of the estimation in the pre- and postoperative periods were studied. A total of 375 patients with CCT were examined in different medical institutions according to a unified method. Neurosurgical interventions were carried out on 155 patients. All patients who underwent operation when their condition was rated below 15 marks died on the immediate postoperative days, whatever their age and whatever the time of the operation after the trauma. The probability of a favourable outcome increased to 40% in a condition rated 21-30 marks on the day of the operation and reached 69% when it was above 30 marks.

[Information value of initial clinical signs for the prognosis of outcome in the first 24 hours after craniocerebral injury]. / Informativnost' klinicheskikh priznakov dlia prognozirovaniia iskhodov v 1-e sutki posle cherepno-mozgovoi travmy.

The informativeness of clinical indicators for predicting lethal and favourable outcomes during the first 24 hours after a head trauma has been investigated. A pool of clinical findings about the status of 302 patients examined according to a uniform technique has been analyzed using a packet of the MEDSTAT-85 software. The authors present an optimal set of clinical signs for predicting fatal and favourable outcome within the first 24 hours after the trauma with an 83% probability rate.

[Prediction of the outcome of craniocerebral injuries in the acute period]. / Prognozirovanie iskhodov v ostrom periode cherepno-mozgovoi travmy.

Unified clinical findings in 302 patients were analysed to prognosticate the outcomes of severe craniocerebral trauma in the acute phase. The patients condition in the acute stage was evaluated in points according to four types of outcome: fatal, with coarse and moderate neurological disorders, and with a satisfactory compensation of the condition. In a condition rated 20-30 points the probability of a favourable or a fatal outcome was equal. In a condition rated less than 20 points the probability of a fatal outcome increases, in one-rated above 30 points the probability of a favourable outcome grew.