[Combination of infraoptic anterior cerebral artery with an aneurysm of the ACA-AcomA complex. Case study and literature review]. / Sochetanie infraopticheskoi perednei mozgovoi arterii s anevrizmoi kompleksa PMA-PSA. Sluchai iz praktiki i obzor literatury.

The infraoptic anterior cerebral artery (ACA) is an abnormal vessel that usually is a bifurcation of the intradural part of the internal carotid artery (ICA) or near the site of discharge of the ophthalmic artery, which passes under the ipsilateral optic nerve and penetrates between the optic nerves into the prechiasm cistern, reaching the ACA-AcomA complex. The infra-optic ACA is an extremely rare anomaly, but it may be of great clinical significance in surgery of the arteries of the anterior sections of the Willis circle. The article describes the case of a combination of infra-optical ACA with an aneurysm of the ACA-AcomA complex. This observation is of interest both from the viewpoint of the rarity of the considered pathology and the associated increased risk of the formation of intracranial aneurysms.

[A cavernous malformation associated with an extensive acute subdural hematoma. A case report and literature review]. / Kavernoznaia mal'formatsiia, vyzvavshaia razvitie obshirnoi ostroi subdural'noi gematomy. Sluchai iz praktiki i obzor literatury.

The article presents a rare clinical case of a patient with multiple cavernous malformations who developed acute subdural hematoma associated with one of the cavernomas. We address the issue of diagnosing an origin of hemorrhage in subdural hematomas, in particular in the absence of traumatic brain injury (TBI) findings.

[Reasonability and efficacy of decompressive craniectomy in patients with subarachnoid hemorrhage after microsurgical aneurysm exclusion]. / Opredelenie opravdannosti i éffektivnosti dekompressivnoi trepanatsii cherepa u bol'nykh s subarakhnoidal'nym krovoizliianiem posle mikrokhirurgicheskogo vykliucheniia anevrizm.

In recent years, the so-called primary or preventive decompressive craniectomy (DC) has been increasingly used in patients with aneurysmal subarachnoid hemorrhage (SAH). The main goal of the technique is prevention of refractory intracranial hypertension (ICH) and its consequences. PURPOSE: The study purpose was to define the CT criteria for reasonability and efficacy of DC as well as clarification of the indications for preventive DC in patients with SAH after microsurgical aneurysm exclusion. MATERIAL AND METHODS: The study included 46 patients who underwent microsurgical clipping of aneurysms and DC in the period between 2010 and 2016. All patients underwent surgery in the period of 1 to 12 days after SAH. Preventive DC (imultaneously with clipping of aneurysms) was performed in 38 patients. Secondary (delayed) DC was performed in 8 patients. RESULTS: Mortality in a group of all patients with DC was 15.2%. Preventive DC was considered as 'reasonable' when the patient had signs of cerebral edema in the postoperative period. The X-ray criteria of reasonable DC included a more than 5 mm brain prolapse into the trephination defect or a lateral dislocation of more than 5 mm. If the patient had no prolapse and dislocation in the postoperative period, DC was considered 'unreasonable'. Among patients with ICH in the postoperative period, including 20 patients with reasonable preventive DC and 8 patients with delayed DC, mortality was 25%. The CT signs of efficient DC were found to be a more than 5 mm brain prolapse into the trephination defect in combination with a decrease in the lateral dislocation less than 5 mm. All seven patients with inefficient DC in our group died. To clarify the indications for preventive DC, we analyzed various preoperative factors in patients with reasonable and unreasonable DC. CONCLUSION: In most cases, preventive DC in microsurgical aneurysm exclusion is indicated for patients in an extremely grave condition (Hunt-Hess Grade V), a lateral displacement of the mline structures of more than 5 mm, an intracranial hematoma of over 30 mL, and symptoms of acute cerebral ischemia (pronounced cerebral vasospasm and emerging ischemic foci).

[Rupture of a giant aneurysm of the accessory middle cerebral artery: a case report and a literature review]. / Razryv gigantskoi chastichno trombirovannoi anevrizmy dobavochnoi srednei mozgovoi arterii: sluchai iz praktiki i obzor literatury.

The accessory middle cerebral artery is a rare congenital vascular abnormality. The international literature has reported cases of accessory MCA aneurysms. In this article, we describe a case of rupture of a giant partially thrombosed aneurysm of the accessory MCA. This case is of great interest due to rarity of the pathology and associated diagnostic errors.

[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.

[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.

[De novo cerebral aneurysms].

OBJECTIVE: To substantiate the reasonability and duration of angiographic follow-up of patients operated on for cerebral aneurysms to rule out de novo aneurysm formation. MATERIAL AND METHODS: The results of angiographic examination (cerebral angiography and SCT angiography) of 43 patients with cerebral aneurysms operated on at the Burdenko Neurosurgical Institute in 1995-2012 are analyzed. The follow-up duration varied from 1 to 14 years after surgery (mean duration, 5 years). Patients' age ranged from 14 to 56 years. RESULTS: Control angiographic examination showed that de novo aneurysms were formed in 7 (16.2%) patients. A total of 8 de novo aneurysms were detected (in one case there were two aneurysms formed). All aneurysms, both the previously operated and the de novo ones, were located in the anterior part of the circle of Willis. De novo aneurysms were clipped in 5 cases; the cavity of the de novo aneurysm was occluded with spirals in one case. One patient with a small aneurysm of the middle cerebral artery refused surgery. Neither lethal nor unfavorable outcomes were recorded. CONCLUSIONS: The patient groups with the high risk of de novo aneurysm formation are as follows: 1) young smokers with hypertension; 2) patients who developed clinical signs of the disease when being young; 3) patients subjected to proximal exclusion of the main artery; and 4) patients with multiple and familial forms of the pathology. Dynamic angiographic follow-up (SCT angiography or magnetic resonance angiography) for 1-3 years is recommended for these patients.

[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.

[Cognitive disturbances in patients with arteriovenous malformations, cerebellar cavernomas and hematomas].

A clinical-neuropsychological study using Luria's method has been conducted in 13 patients with arteriovenous malformations (AVM) and 12 patients with cerebellar cavernomas and hematomas. The syndromes were similar to lesions of the large hemisphere cortex, more often of premoter regions and less often of the cortex of posterior hemispheric regions. After a surgery on the right cerebellar hemisphere, some patients had perseverations and micrographia in writing. These syndromes were principal similar with findings described in the literature. However there were differences including the absence of marked cognitive disturbances even after the surgery. The disturbances of verbal memory were found in the lesion of both right and left cerebellar hemispheres that is the functional asymmetry of cerebellar hemispheres was not pronounced. The inactivity of speech and agrammatism in writing, even in patients with large duration of hemorrhage, were not observed. In some patients with the lesion of right cerebellar hemisphere, the disinhibition of speech, similar to that in patients with the lesion of right frontal lobe, was found. There were no marked mental disturbances. The most distinct cognitive disturbances were found after surgeries of the superior cerebellar artery. Possible mechanisms of the cerebellum's role in cognitive functions are discussed.

[Neuropsychological signs in patients with arteriovenous malformations, cavernomas and hematomas of cerebellum].

Neuropsychological assessment was performed in 13 patients with arteriovenous malformations and 12 with cavernomas and hematomas of cerebellum before and after surgery. In all patients we identified syndromes that were similar to the damage of different areas of neocortex (predominately frontal lobe). Apraxia and disturbance of verbal memory were the most frequent signs. Half of patients after AVM embolization and all patients after direct surgery developed deterioration of verbal memory. Some patients after manipulations on right cerebellar hemisphere had micrography and perseverations. There were no severe mental disorders neither before nor after surgery. That was controversial to other similar studies. The most severe cognitive disorders were found after surgery on superior cerebellar artery and its branches.

[Giant fusiform partially thrombosed aneurysm of fenestrated middle cerebral artery].

The authors describe a rare case of 15-year old patient with ruptured giant fusiform partially thrombosed aneurysm of fenestrated middle cerebral artery (MCA). The patient underwent surgical treatment: clipping of proximal and distal necks of aneurysm and thrombectomy. Intraoperative signs of MCA fenestration are described in details. The observation is instructive if a surgeon discovers 'double-necked' aneurysm for selection of adequate tactics of aneurysm occlusion.

[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.

[Arterial wide-section anastomoses: experimental study on animals].

A mechanical device for making arterial wide-section anastomoses was tested on a series of 15 laboratory rabbits. End-to-side anastomoses were made using a vein graft and they functioned in 93.1% of cases, as evidenced by intraoperative Doppler studies. When an anastomosis is made, the mean duration of temporary blood flow arrest in the rabbit aorta averaged 2 min. According to outcomes, the survived animals were divided into 3 groups: Group 1 comprised 2 (13.3%) rabbits that died within 10-12 hours after surgery and had significant symptoms of anastomotic dysfunction. Group 2 included 8 (53.3%) animals that died 2-3 days after surgery. They moved 5-6 hours following surgery without assistance, which was indicating of anastomotic functioning. Group 3 consisted of 3 (20%) rabbits that survived 2 weeks. Autoptic studies revealed no anastomic thrombosis in Group 2 animals. Group 3 animals were noted to have signs of allograft thrombosis and rejection. Thus, it is expedient to continue studies to make arterial wide-section anastomoses, by using the above device, in order to introduce this procedure into clinical practice.

[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.

[Intraoperative contact Doppler ultrasonography in the surgery of cerebral aneurysm].

Vascular occlusion leading to the development of an ischemic focus or incomplete aneurysm closure is one of the main causes that deteriorate the total results of surgical treatment in patients with cerebral aneurysms. The study covering 50 patients with 54 aneurysms who were evaluated for vascular patency by contact Doppler ultrasonography (CDUS) assessed the role and reliability of this technique. In the study group, the ratio of males to females was 30:24, their mean age was 44 years (23-67 years); the ratio of patients with acute subarachnoidal hemorrhage (SAH) to those without SAH was 24:30. The functional outcomes were assessed by a modified Rankin scale and compared with those in the control group. The clip site was inspected by the results of CDUS in 19 (31.7%) cases; clip reposition was made in 16 (26.7%) cases due to vascular stenosis; an additional clip was use to exclude the aneurysmal functioning part in 1 (1.7%) case. Vascular stenosis was detected in 2 (3.3%) cases; however, the position of clips remained unchanged since aneurysm was excluded under the conditions of its rupture. According to the modified Rankin scale, good results were slightly more in the study group of "acute" patients than in the control group: 96.7% versus 90%; the similar results were obtained in non-SAH patients: 66.7% versus 62.5%; lambda < 1.36). CDUS is a noninvasive, simple, reliable, and inexpensive technique for blood flow evaluation.

[Intensive care using hypervolemic hypertensive hemodilution in the acute period of subarachnoidal hemorrhages in patients with arterial aneurysms].

Cerebral vasospasm and its associated ischemia are one of the main causes of death in 23% of patients with prior aneurysmal subarachnoidal hemorrhage (SAH). At present, a diversity of approaches to treating vasospasm has been developed, among them hypertensive hypervolemic hemodilution (deriving its abbreviated name 3H-therapy) offers certain advantages. At the same time a number of aspects of application of this approach remain unclear. Fifty-four patients with significant cerebral arterial spasm (elevated linear systolic blood flow velocity > or = 200 cm/s) who had been operated on in the acute period of aneurysmal SAH were selected. Of them, 18 patients had undergone hypervolemic hypertensive hemodilution (3H-therapy) under guidance of systemic hemodynamics, by using a Swan-Ganz catheter (these patients formed a study group). Thirty-six patients who had not undergone 3H-therapy under invasive monitoring of systemic hemodynamics constituted a control group. Hypervolemic hypertensive hemodilution was performed by means of continuous intravenous infusion of a combination of colloid-crystalloid solutions. The therapy was considered to be adequate by meeting the following requirements: maintenance of cardiac index not less 3.5 l/min/m2, pulmonary capillary wedge pressure below 14-16 mm Hg or central venous pressure under to 8-10 mm Hg, packed cell volume below 28-32%, and systolic blood pressure under 200 mm Hg. Hypervolemic hypertensive hemodilution (3H-therapy) applied to patients operated on in the acute period of aneurysmal SAH was effective in increasing cardiac output, central venous pressure, systemic arterial pressure and hence cerebral perfusion with the minimum number of complications unassociated with the use of this technique. This permitted a reduction in mortality rates in patients with baseline Hunt-Hess grade I-III SAH. At the same time, it should be emphasized that 3H-therapy may be used in neurosurgical patients, by thoroughly monitoring the parameters of central hemodynamics, blood coagulation system, cerebral circulation and, desirably, intracranial pressure.

[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.