[Stepwise treatment of multiple cerebral aneurysms utilizing surgical and endovascular techniques].

To evaluate results of combined treatment of multiple intracranial aneurysms utilizing microsurgical clipping with endovascular techniques. Study group comprised 60 patients with 230 multiple aneurysms (MA) of different location. Most common were aneurysms of ICA--49% and MCA--24%. Single-side ICA aneurysms were found in 11 (18.3%) patients, two-sides ICA lesions in 25 (41.7%); single-side ICA aneurysm with posterior circulation aneurysm--11 (18.3%) and two-sides ICA aneurysm with posterior circulation aneurysm in 13 (21.7%). All patients were treated with endovascular coiling followed by direct surgery. Eight patients treated in acute stage of SAH. Two-stage surgery was performed in 49 cases, three-stage treatment--in 11 cases yielding 131 operations total. Time break between surgeries was 1 day to 4 month. Total occlusion was achieved in 95.3% cases, 98 aneurysms were clipped, 64 (33.4%) coiled. In 15 (7.8%) patients aneurysms were excluded with stent or balloon assisting techniques. Six aneurysms were treated with flow diverters (Pipeline Embolisation Device). Palliative treatment (ICA occlusion with balloon or coils and aneuryms wrapping) were performed in 4.7%. There were no fatal outcomes or complications required repeated surgery in the group. Multimodal approach that combines endovascular techniques with microsurgery is an effective option in multiple aneurysm treatment. Updated endovascular modalities and direct surgery together become a treatment of choice for MA patient improving radical exclusion rate and outcomes. Combined treatment is specifically indicated for elaborate MA cases requiring multiple approaches.

[Complex intracranial vascular pathology: multiple aneurysms combined with ICA aplasia].

Rare case of multiple aneurysms of posterior circulation associated with right ICA aplasia in 39 year old female patient is described. Detailed description of ICA aplasia is enclosed. Modern diagnostic methods (MRI-SWI) were performed to identify the bleeding source. Ruptured PCA aneurysm was successfully treated with clipping. The case carries clinical interest from the standpoint of rarity and management.

[Surgical treatment of patients with supratentorial cavernomas manifested with seizures].

UNLABELLED: Supratentorial compartment is the most frequent cavernomas location associated with seizures in 50-79% cases. Surgical removal of some cavernomas remains a delicate decision. To assess long-term epilepsy results in consecutive series of patients treated for supratentorial cavernomas. PATIENTS AND METHODS: Single-center retrospective study of 302 patients (2002-2010) with operated supratentorial cavernomas was performed. Male: female ratio= 139:163, age ranged 1 to 68 years, mean: 26.4. Multiple lesion were diagnosed in 27 (8.9%) patients, eloquent in 77 (24.9%) cases. Mean follow up was 55.2 months. Functional outcomes using modified Rankin scale and epilepsy outcomes using Engel scale were assessed. Data were statistically analyzed in respect to natural history, lesion type, location, size, extent of resection, use of anti-epileptic drugs, etc. Seizures suffered 74.8% of patients, generalized seizures--79.6% from those who have an epilepsy. In 34.5% of patients epileptic symptoms tended to worsen over time. Seizures improved in 78.2% patients post op, 62.3%--became seizure-free. Early surgery and less than 5 seizures in history were found a reliable predictors of better epilepsy outcome. Drug-resistant subgroup was associated with worse outcomes. Resection of gliosis and tailored ECoG-guided resection with respect to epilepsy outcome were not proved beneficial. Long-term disability was 9%, 3% in non-eloquent and 21% in eloquent and deep cavernomas group. One patient died (0.3%). Surgery remains an effective treatment for recurrent hemorrhage prevention and seizure control with acceptable morbidity. The benefits of surgery for eloquent and deep-seated cavernomas must be accurately weighted with higher risks. For symptomatic non-eloquent cavernomas surgical excision should be considered as soon as possible after disease onset.

[Microsurgical treatment of cerebral arteriovenous malformations in Burdenko Neurosurgical Institute (recent experience)].

Recently the number of AVM resections in Burdenko Neurosurgical Institute has been increased dramatically. Aim of this study was to assess the results of open surgery in our clinic in modern neurosurgical era. Consecutive series if 160 patients with AVM treated using microsurgical technique since 2009 till 2011 was analyzed. Spetzler-Martin score distribution was: grade I--29 (18.1%) cases, grade II--84 (52.5%), grade III--38 (23.8%), grade IV--9 (5.6%). Patients with grade V AVMs were not operated. Treatment options included: AVM resection in 143 (89.4%) cases, embolization followed by resection in 15 (9.3%) and clipping of afferents in 2 (1.3%). Glasgow outcome scale score distribution was the following: V (good recovery)--70 (43.7%), IV (moderate disability)--71 (44.4%), III (severe disability)--16 (10%), II (vegetative state)--1 (0.6%) and I (death)--2 (1.3%). Microsurgery remains the primary option for radical treatment of cerebral AVMs. Careful selection of patients and planning of surgery are crucial for good outcomes.

[Substantiation of differentiated management of patients with multiple cerebral aneurysms].

The study was performed to substantiate optimal tactics of management of patients with multiple cerebral aneurysms based on analysis of surgical results. This study included 233 (20%) patients with multiple cerebral aneurysms who were treated in Burdenko Neurosurgical Institute since 1995 till 2007. We analyzed results of single-stage (microsurgical technique) and multistage (microsurgical technique and step-by-step application of endovascular and microsurgical techniques) approaches. The following factors were investigated: severity of subarachnoid hemorrhage (Hunt-Hess scale), localization of aneurysms in different arterial systems, quantity and size of aneurysms.. Postoperative mortality was 4.7%. Poor outcomes were observed in 37 (16%) patients. In multi-stage surgical treatment the number of totally occluded aneurysms was significantly higher (92% vs. 79%, p < 0.05) as the number of palliative operations and untreated aneurysms was lower (5.8% vs. 16%, p < 0.05). The best technical and clinical results were obtained in the group of patients who were treated using step-by-step application of endovascular and microsurgical techniques. Despite coexistence of aneurysms of both carotid systems with vertebrobasilar aneurysms in 15% of this group, poor outcomes were not observed and total occlusion of aneurysms was performed in 91.4% of cases. Obtained technical and clinical results of treatment of multiple aneurysms prove that multi-stage surgical management is the therapy of choice in surgery of multiple aneurysms. Our data demonstrate high effectiveness of multimodal approach with integration of endovascular and microsurgical methods. Combination of both techniques is preferential in coexistence of aneurysms of carotid and vertebrobasilar systems.

[The role of susceptibility-weighted MRI in detection of ruptured aneurysm in multiple aneurysms].

Since 2008 till 2010 years 22 patients with multiple aneurysms were examined in Burdenko Neurosurgical Institute (Moscow, Russia). The series included 13 female and 9 male patients, age ranged from 28 to 62 years (mean 45 years). 68 aneurysms of different localization were discovered in these 22 patients. We also analyzed results of examination of 2 patients with solitary aneurysms in which SW-MRI was performed to confirm or exclude the fact of hemorrhage due to rupture of the aneurysm. All patients were operated microsurgically. SW-MRI is effective technique for identification of source of hemorrhage in patients with multiple aneurysms thus allowing selection of correct tactics of management. Information value of the method declines with increase of time after hemorrhage (over 2 years). SW-MRI enables verification of the fact of hemorrhage due to aneurysm in disputable cases (minimal non-specific clinical presentation, absence of hemorrhage verification).

[Structural features of cerebral arteriovenous malformations according to the data of optic microscopy and scanning electron microscopy of corrosion specimens].

The aim of this study was to investigate structure of cerebral arteriovenous malformations (AVM). We examined and treated 5 patients with AVMs of cerebral hemispheres. Treatment consisted of endovascular embolization with subsequent surgical resection of AVM. The series included 3 female and 2 male patients (age 19-44, mean - 28 years). Histoacryl (B. Braun, Germany) was used for embolization. Corrosion specimens were prepared according to standard technique and examined using optic and scanning electron microscopy. AVMs had similar structure. Casts were formed by distal segments of afferent arteries, fistulas, interjacent venous vessels, proximal segments of draining veins and vessels of angiomatous surrounding. The latter consisted of abnormal network of small arteries, veins, fistulas and dilated capillaries. The most variable length and formation of glomeruli was characteristic for interjacent venous vessels. AVMs extensively anastomosed with cerebral vessels. Big amount of aneurysms and aneurysmatic bulgings was present. Aneurysms of intranidal segment of afferent artery and angiomatous vessels are demonstrated.

[Aneurysm of posterior lateral choroid artery].

Rare clinical observation of a patient with spontaneous rupture of posterior lateral choroid artery aneurysm is described. The patient was surgically treated--clipping of aneurismal neck with preservation of arterial lumen was performed. The authors illustrated the paper with angiographic data and morphological view confirming genuine structure of aneurysm.

[Stage-by-stage treatment of multiple cerebral aneurysms using endovascular and microsurgical techniques].

Aim of the study was to substantiate effectiveness of stage-to-stage application of microsurgical and endovascular techniques in treatment of patients with multiple cerebral aneurysms (MA). 22 patients with MA were included in this study. 70 aneurysms of different location were found in this series. Aneurysms of MCA were the most frequent. Unilateral aneurysms were found in 6 patients, bilateral -- in 7, unilateral with aneurysm of vertebro-basilar system -- in 4, bilateral with aneurysm of vertebro-basilar system -- in 5. All 22 patients underwent surgical treatment with stage-to-stage application of endovascular and microsurgical techniques. 6 patients were operated in acute period of SAH. In 16 cases two-stage surgeries were made, in 5 -- three-stage. Totally 42 operations were performed. Intervals between stages varied from 1 day to 4 months. Total occlusion of aneurysms was achieved in 91.4% of cases. 40 aneurysms were clipped and 22 were coiled. In 2 cases aneurysms were occluded using coils and stent. Enforcement of aneurysmal walls by oxycellulose and different glue compositions was used in 4 cases. There was no mortality in the series. In 1 female patient with 6 aneurysms transient neurological deficit occurred after third stage of surgical treatment (stenting of basilar artery with coiling of aneurysm of this artery). We did not observe complications demanding wound revision. Obtained results of stage-to-stage surgical treatment of MA are the evidence of high effectiveness of multimodal approach with integration of endovascular and microsurgical techniques. This tactics allows to decrease mortality and disability in acute period of SAH as well in cold period. Described approach can be the treatment of choice in surgical management of MA.

[Microsurgical treatment of large and giant aneurysms of the internal carotid artery: analysis of application of intravascular blood aspiration technique and future perspectives].

The article discusses results of surgical treatment of 82 patients with large and giant cerebral aneurysms operated in Burdenko Neurosurgical Institute (Moscow, Russia) during the recent 14 years. Special attention was given to benefits of intravascular blood aspiration (IBA) technique. This technique was proven to be very effective, allowing to clip the aneurysm in 87.8% of cases with good recovery in 41.5% and with moderate disability in 39%. Postoperative mortality was 4.9% (4 patients). The authors suggested original surgical classification of large and giant aneurysms. IBA was ineffective in cases of giant partially thrombosed aneurysms with sclerotic walls and giant aneurysms with very wide neck. These aneurysms require other surgical procedures such as embolization of ICA followed by extraintracranial bypass or high-flow bypass.

[Arteriovenous malformation of septum pellucidum in combination with persistent trigeminal neuralgia].

A 16-year-old boy with arteriovenous malformation (AVM) of septum pellucidum in combination with left side persistent trigeminal artery (PTA) is described. Presentation of AVM included severe intracranial hemorrhage and the lesion was removed surgically. The case deserves interest for two reasons. 1) The observation demonstrates the possibility of increased pressure in the afferent arteries of AVM. It was illustrated by distinctive displacement of the zones of the hemodynamical balance around the circle of Willis. The raised pressure in conditions of shunting can be explained using principles of the constant shear stress in the vascular system. 2) The observation of the features of venous system that may be causative for PTA. These features included presence of the large anastomotic vein between petrosal and cavernous sinuses, enlargement of petrosal sinuses and shrinking of transverse sinus ipsilateral to PTA.

[Aneurysms of cerebral arteries in children and adolescents].

BACKGROUND: Intracranial aneurysms are rare lesions in children and adolescents and their epidemiology, clinical and anatomic features are poorly understood. Aim of the study was to reveal the specific features of cerebral aneurysms in children and adolescents and to develop guidelines for management of these patients. MATERIALS AND METHODS: The study was performed on consecutive series of 125 patients under 18 years of age harboring 145 aneurysms. All of them were treated in Burdenko Neurosurgical Institute (Moscow, Russia) from 1987 to 2007. RESULTS: Specific features of pediatric aneurysms include: high incidence on a background of connective tissue disorder (42%) and abnormalities of circle of Willis (20%), frequent localization in bifurcation of internal carotid artery (13.8%), its cavernous segment (17.9%), or in posterior part of circle of Willis (23.5%). In children giant aneurysms were observed in 31.7% of cases, fusiform in 19.3% and partially thrombosed in 33.8%. Complications of aneurysms in children with hemorrhagic type of course included recurrent hemorrhages (42.9%), hematomas (31%), hydrocephalus (16.7%) and seizures (33.3%). Generally, 107 pediatric patients (85.6%) with 118 aneurysm (81.4%) were operated. Microsurgical treatment was performed in 57% of patients and endovascular procedures in 43% In the series of 107 operated patients we observed excellent early postoperative results in 53 cases (49.5%), good in 45 (42.1%) and poor in 9 (8.4%). Postoperative mortality was 0.95% (1 patient). CONCLUSION: Considerable proportion of complex aneurysms in children and adolescents produces certain difficulties of treatment; however, due to good functional outcomes in this age group the range of causes of denial must be minimized.

[Microsurgical treatment of partially thrombosed giant cerebral aneurysms--technique of endoaneurysmal thrombectomy].

Surgical technique of endoaneurysmal thrombectomy in microsurgical treatment of giant partially thrombosed cerebral aneurysms is described. The suggested method implies removal of thrombotic masses using the same technique as in endarterectomy. The goal of this manipulation is clipping of aneurysm neck with reconstruction of affected artery during a shortened time. All stages are described and illustrated in details. Authors applied this technique in 9 patients with giant partially thrombosed aneurysm of different localization. Bloodflow cessation period varied from 4 to 12 minutes (mean--6 minutes), which was significantly shorter than in thrombectomy using CUSA. No mortality and ischemic complications were observed in our series.

[Spontaneous anterior meningeal arterial aneurysmal rupture].

The paper describes a rare case of a patient with spontaneous rupture of nontraumatic anterior meningeal arterial aneurysmal rupture. The patient underwent clipping of the neck of the aneurysm and its excision. A detailed account of intraoperative signs of this aneurysm is given. Angiographic and morphological data and the morphological pattern confirming the true pattern of the aneurysm are presented.

[Intraoperative rupture of cerebral aneurysm--incidence and risk factors].

OBJECTIVE: To reveal and assess risk factors for intraoperative rupture (IOA) of aneurysms, which will reduce the incidence of this complication and improve the outcome of treatment. METHODS: Direct surgical interventions made in 610 cerebral aneurysms at the Vascular Department of N.N. Burdenko Research Institute of Neurosurgery, Russian Academy of Medical Sciences, in 2002 to 2005 were analyzed in 519 patients. Under study were the following factors: onset of IOA; site and anatomic and topographic features of aneurysms; time of an operation (acute or cold subarachnoidal hemorrhage), presence or absence of hemorrhage in the history, rate and severity of hemorrhage (according to the Hunt-Hess classification), temporary clipping of the nutrient arteries. RESULTS: The incidence of IOR was 11.7% of the operated aneurysms and 13.7% of the patients. Ruptures occurred during aneurysmal manipulations in 96% of cases. Moderate and significant hemorrhages requiring a surgeon to make additional measures to improve them more frequently occurred in IOR. The highest rate of IOR was recorded at surgery for aneurysms of the anterior cerebral artery--the anterior communicating artery. The incidence of ruptures increased with their greater sizes. There was a significant increase in the incidence of IOR in aneurysms with diverticula (p = 0.004) and with wide necks (p = 0.04). The level of IOR in the patients operated on within the first 3 weeks after SAK was 3 times higher than in those operated on in the cold period (p < 0.05). The incidence of IOR was rather low in the treatment of asymptomatic aneurysms (2.5%). The risk for IOR was higher in patients with recurring hemorrhage. Preventive temporary occlusion substantially lessens the risk of IOR. CONCLUSION: The low rate of IOA in the treatment of asymptomatic aneurysms is another argument in favor of the development of surgery for unruptured asymptomatic aneurysms. Timely temporary clipping of the nutrient artery at surgery substantially reduces the risk of IOR in all cases.

[Rupture of the dissecting vertebral arterial aneurysm].

The paper describes a rare case of a patient with dissecting vertebral arterial aneurysmal rupture. The patient was operated on--the aneurysmal wall was reinforced with surgical gauze. The intraoperative signs of the dissecting aneurysm are described in detail. The angiographic signs of dissecting aneurysms are given.

[The peculiarities of speech disturbance in patients with arteriovenous malformations of the caudate nucleus and the thalamus].

Clinical and neuropsychological study of 28 patients with arteriovenous malformations (AVM) of the caudate nucleus and 36 patients with AVM of the thalamus has been conducted. After surgical removal of the caudate nucleus, speech disturbances developed in 4 out of 8 patients with left-side AVM and in 1 patient, a converted left-hander, with right-side AVM. All 5 patients had mild speech disturbances, which differed by character in dependence of the AVM location. In case of AVM location in the head of the caudate nucleus, the speech disturbances were represented by perseverations and were similar to those caused by the lesion in the Broca area. In case of the caudate nucleus lesion, naming was mildly affected that resembled temporal aphasia. After surgical removal of AVM in the left thalamus in 9 patients, complex and rather stable speech disturbances developed in 7 cases. They were featured by the signs of frontal and temporal aphasias, i.e. there were perseverations and disturbances of naming, auditory and speech memory. The peculiarities of speech disturbances in lesions of the caudate nucleus and the thalamus were well explained by their anatomic and functional correlations with different regions of brain speech cortex. Speech disturbances in various subcortical lesions are reviewed. In the authors' opinion, subcortical aphasias do not have any particular character but include the same factors in different combinations as cortical ones that is determined by the presence of common functional systems for speech support which comprise cortical and subcortical patterns.

[Familial intracranial aneurysms].

The study included 38 patients with intracranial aneurysms, whose close relatives had experienced intracranial hemorrhages. The patients' relatives were divided into 2 groups according to the verification of the source of hemorrhage. The individuals at risk for aneurysmal disease in whom aneurysms should be sought before their rupture were examined. The patients with familial aneurysms were found to tend to rupture at younger age than those without familial aneurysms (the so-called sporadic aneurysms). The high rates of mortality due to intracranial bleeding were observed among the relatives of patients from the study group. Screening study of the first-order relatives of the patients with prior aneurysmal subarachnoidal hemorrhage is the method of choice in detecting unruptured cerebrovascular aneurysms. Early detection and switching-off of asymptomatic aneurysms may reduce mortality and disability rates in this group of patients.

[Surgical treatment for asymptomatic non-ruptured intracranial aneurysms]. / Khirurgicheskoe lechenie asimptomnykh nerazorvavshikhsia intrakranial'nykh anevrizm.

The study was undertaken to analyze the outcomes of treatment in 37 patients with 44 non-ruptured aneurysms (NRA) at different sites. The paper presents a detailed classification of NRA, identifies individuals at risk for aneurysmal disease in whom an active search for aneurysms until they rupture is recommended to prevent aneurysmal subarachnoidal hemorrhages and their sequels. Total aneurysmal exclusion was achieved in 93.2% of the cases; the aneurysmal walls were consolidated with surgical gauze in 7.2%. There were no fatal cases. Postoperative progression of focal neurological symptoms was noted in 4 patients. In 3 patients, these symptoms were entirely reversible. All NRAs should be operated on irrespective of their size particularly in young and middle-aged patients since this is technically possible and there are no concomitant diseases that make surgery contraindicated. It is expedient to perform computed or magnetic resonance imaging in combination with angiography in risk-group patients in order to reveal or exclude aneurysm.