[Pathological tortuosity of intracranial arteries (pure arterial malformation) - diagnosis and management tactics]. / Patologicheskaya izvitost' intrakranial'nykh arterii (arterial'naya mal'formatsiya) ­ diagnostika i taktika vedeniya.

BACKGROUND: Tortuosity of intracranial arteries is rare and usually mistaken for arteriovenous malformations. In the world literature, the term «pure arterial malformations¼ is used to refer to this disease. OBJECTIVE: To summarize the experience of the Burdenko Neurosurgery Center on diagnosis of intracranial artery tortuosity, management and treatment of these patients, as well as to review appropriate literature data. MATERIAL AND METHODS: Tortuosity of intracranial arteries was detected in 11 patients (8 women and 3 men) aged 7-48 years who underwent outpatient or inpatient examination and treatment at the Burdenko Neurosurgery Center between 2009 and 2022. We analyzed angiographic, clinical and follow-up data of these patients, as well as appropriate literature data. RESULTS: According to angiography data, all patients had moderate dilatation, elongation and tortuosity of intracranial arteries without signs of arteriovenous shunting. The most common finding was tortuosity of several segments of internal carotid artery (5 cases). Lesion of PCA, PComA, MCA and ACA was less common. In 7 cases, the walls of the deformed vessels had calcified zones. In two cases, there were saccular aneurysms in the walls of the tortuous vessels. In one case, tortuosity was combined with kinking of the left subclavian artery, in another one - tortuosity of C1 segment of the right ICA. No patient had specific clinical manifestations. The follow-up period was 1-10 years in 7 patients. There were no changes in structure of tortuosity or appearance of new aneurysms. CONCLUSION: Tortuosity of intracranial arteries is an extremely rare disease with the highest incidence in young women. This abnormality has no specific clinical manifestations and does not require surgical or conservative treatment. Tortuosity of intracranial arteries should be differentiated from arterial dolichoectasia, fusiform aneurysms and AVMs.

[Spinal CSF-venous fistula: case report and literature review]. / Spinal'naya likvoro-venoznaya fistula kak prichina sindroma spontannoi vnutricherepnoi gipotenzii: sluchai iz praktiki i obzor literatury.

Syndrome of spontaneous intracranial hypotension is increasingly described in the literature as a multifactorial disease with impairment of the quality of life and risk of mortality. CSF-venous fistula as a cause of intracranial hypotension syndrome is extremely rare and requires complex diagnosis and timely surgical treatment. OBJECTIVE: We present a 55-year-old patient with acute spontaneous intracranial hypotension and spinal CSF-venous fistula. Literature data are also analyzed. RESULTS: Algorithm for diagnosis and efficacy of microsurgical resection of CSF-venous fistula is demonstrated. CONCLUSION: Intracranial hypotension following spinal fistula requires careful examination. Accurate understanding of pathophysiological and anatomical features of this disease is necessary to select an effective treatment method.

[Middle meningeal artery embolization for chronic subdural haematoma. Case series and literature review]. / Embolizatsiya srednei obolochechnoi arterii kak metod lecheniya khronicheskikh subdural'nykh gematom. Seriya klinicheskikh sluchaev i obzor literatury.

Middle meningeal artery embolization as primary method for treatment of chronic subdural hematomas became more popular in past decade. There are few large case series (>150 patients) and literature reviews characterizing advantages and drawbacks of endovascular treatment and technical features of surgeries. In this manuscript, the authors report 11 patients with chronic subdural hematoma scheduled for middle meningeal artery embolization and review the literature data on this issue.

[Intracisternal administration of verapamil for the prevention and treatment of vasospasm in patients after microsurgical treatment of cerebral aneurysms in the acute period of hemorrhage]. / Intratsisternal'noe vvedenie verapamila dlia profilaktiki i lecheniia vazospazma u bol'nykh posle mikrokhirurgicheskogo lecheniia anevrizm sosudov golovnogo mozga v ostrom periode krovoizliianiia.

The first results of intracisternal administration of verapamil for the prevention and treatment of cerebral vasospasm (CVS) in patients in the acute period of subarachnoid hemorrhage (SAH) after microsurgical clipping of cerebral aneurysms are presented. OBJECTIVE: Safety assessment of the method of prolonged intracisternal infusion (PII) of verapamil. MATERIAL AND METHODS: Over the period from May 2017 to December 2018, 42 patients were included in the study, who underwent clipping of aneurysm of the anterior segments of the Willis circle. Most patients (78.6%) were operated during the first 6 days after SAH. For each patient, a thin silicone catheter was installed, through which verapamil was infused. A prerequisite was the installation of external ventricular drainage and opening of the lamina terminalis. The daily dosage of verapamil varied from 25 to 50 mg of the drug diluted in 200-400 ml of isotonic sodium chloride solution. The indication for the use of the PII method was the presence of one of the following factors: a score on the Hunt-Hess scale from III to V, 3 or 4 points on the Fisher scale, confirmed angiographically by the CVS before the operation. RESULTS: The PII procedure was performed from 2 to 5 days. The average dose of verapamil was 143.5±41.2 mg additionally, in the presence of an angiographically confirmed CVS accompanied by clinical manifestations, 14 (33.4%) patients received intra-arterial injection of verapamil in several stages, with individual selection of the drug dose. The formation of new cerebral ischemic foci of vasospastic genesis was observed in only 1 (2.4%) patient. No infectious intracranial complications were noted. The average follow-up period was 297.6±156.1 days. Long-term treatment outcomes, assessed by a modified Rankin scale from 0 to 2 points, were observed in 83.3% of patients. There were no outcomes such as vegetative status and no deaths. The frequency of liquorodynamic disorders, as well as epileptic syndrome did not exceed that among patients with SAH according to the literature. CONCLUSION: The study has confirmed the safety of prolonged PII. The efficacy of the method, compared with other methods for CVS treatment requires further investigation. The first results look quite promising: the observation shows a low percentage of new foci of cerebral ischemia and the absence of deaths associated with it. In patients with severe CVS, the efficacy of the PII method is increased when combined with intra-arterial administration of verapamil.

[Endovascular surgery of spinal dural arteriovenous fistulas]. / Éndovaskuliarnaia khirurgiia dural'nykh arteriovenoznykh fistul spinnogo mozga.

The article summarizes the experience in the treatment of spinal dural arteriovenous fistulas (SDAVFs). OBJECTIVE: To evaluate the efficacy of endovascular treatment of SDAVFs, depending on the pathophysiological mechanisms of impact on the spinal cord. MATERIAL AND METHODS: For the last 5 years (2013-2017), 302 patients with SDAVFs were diagnosed and treated at the Neurosurgical Institute. The endovascular technique was used in 295 patients with this pathology. Males accounted for 82%; females accounted for 18%; the mean age was 51 years. Magnetic resonance imaging (MRI) was used to assess the degree of spinal cord involvement. All SDAVF patients underwent total selective spinal angiography in order to study angioarchitectonics and to choose an endovascular treatment option. RESULTS AND CONCLUSION: Endovascular embolization of fistulas was performed in 295 out of 302 patients; direct surgery was used in the remaining cases. Endovascular treatment provided total SDAVF occlusion in 78% of cases and partial SDAVF occlusion in 22% of cases. Long-term outcomes were followed-up in all patients in a period of 6 to 12 months. In 90% of cases, improvement or stabilization of neurological symptoms was observed. In 60% of cases, there was a marked improvement in the neurological status in the form of rapid (within a few days) recovery of lost motor functions. The remaining patients had stabilization of clinical symptoms.

[Treatment of postoperative vasospasm after insular tumor removal by intra-arterial administration of verapamil (analysis of two clinical cases and a literature review)]. / Lechenie posleoperatsionnogo vazospazma posle udaleniia opukholi ostrovkovoi doli s pomoshch'iu intraarterial'nogo vvedeniia verapamila (analiz dvukh klinicheskikh nabliudenii i obzor literatury).

PURPOSE: We describe our experience of using intra-arterial administration of Verapamil to resolve vasospasm in two patients who underwent surgery for insular glial tumors. MATERIAL AND METHODS: Severe vasospasm (an increased systolic LBFV in the M1 MCA, more than 250 cm/s, and a Lindegaard index of 4.1) was observed in 2 (3.2%) of 62 patients in the early postoperative period after removal of intracerebral insular tumors. In both cases, vasospasm was confirmed by angiography, was clinically significant, and manifested by the development of pyramidal hemisyndrome. RESULTS: Intra-arterial administration of Verapamil led to relief of angiospasm, which was confirmed by angiographic data, and complete regression of neurological symptoms. CONCLUSION: Vasospasm symptoms in patients after removal of insular tumors largely resemble those after aneurysm hemorrhage. An increase in the LBFV in the MCA and related neurological symptoms develop lately and persists for up to 2 weeks after surgery. LBFV values are similar to those in patients after SAH and reach 250-300 cm/s. Among the causes of focal symptoms developed after removal of insular tumors, injury to the inner capsule structures, injury to arteries of the MCA territory (especially perforators), and angiospasm should be differentiated.

[The brain after ischemic stroke: a clinical/histological study]. / Golovnoi mozg posle ishemicheskogo insul'ta: kliniko-gistologicheskoe issledovanie.

AIM: To analyze the histological features of changes in the brain tissue after ischemic stroke. MATERIAL AND METHODS: Brain tissue samples obtained in autopsy from 9 people died as a result of a left middle cerebral artery ischemic stroke from 3 to 7 days after admission were studied. Tissue samples were taken from 3 areas of the brain: 1) contiguous to the tissue necrotic damage site zone, 2) 5-10 cm distant from the previous one, 3) the contralateral hemisphere zone symmetrical to damage site. Samples were Nissl and hematoxylin-eosin stained. Detection of p53 protein, NSE, GFAP was performed by indirect immunoperoxidase immunohistochemistry. RESULTS: A decrease in the total number of neurons and glial elements, their spatial redistribution, change in cell structure and their functional activity was found. The changes of the artery wall and impaired regional blood flow were detected. The more intense NSE reactivity; p53-positive neurons, reduced neuron-astrocytes distance were identified in zones 2 and 3. CONCLUSION: Ischemic stroke is accompanied by severe histological changes. These changes with varying degrees of severity occur both in the areas adjacent to necrotic core, and in remote areas, and it is a substrate for neuroplasticity.

Structure changes of human brain gray matter neurons and astrocytes in acute local ischemic injury.

The purpose to identify key morphological features of the Astrocytes and Neurons in the acute local cerebral ischemia human cortex. Subjects and Methods: Left middle cerebral artery ischemic stroke died persons (n = 9) brain tissue samples from 3 zones: 1st - contiguous to the tissue necrotic damage site zone, 2nd - 5-10 cm distant from the previous one, 3rd - the damage site symmetrical zone of the contralateral hemisphere. For GFAP, MAP-2, NSE, p53 detection indirect immunoperoxidase immunohistochemical staining method has been used. Also, the samples were Nissl and Hematoxylin-Eosin stained. Results: The most pronounced changes in the quantity and morphological structure of astrocytes and neurons are found in directly adjacent to the necrotic core region of theleft middle cerebral artery ischemic stroke brain. This indicates the prevalence of the inflammation processes around the area of nerve tissueischemic destruction. Morphological changes of neurons and astrocytes, apoptosis, enhanced neuron-astrocyte interaction found in the area bordering on necrotic core (5-10 cm from it), as well as ischemic hearth symmetrical sites of the contralateral hemisphere. This interaction is essential for the neuroplasticityrealization in the local ischemic brain injury. Conclusion: The results obtained were shown the nerve tissue morphological characteristics changes occur in local cerebral cortex ischemic injury not only in the lesion, but also in the contralateral hemisphere. These changes are probably related to the implementation of neuroplasticity.

[Combined treatment of cerebral arteriovenous malformations. Experience of the Burdenko Neurosurgical Institute].

OBJECTIVE: Despite the achievements of recent years, cerebral AVMs continue to pose a challenge to treatment. The objective of this work was the development of recommendations for combined treatment of AVMs based on analysis of the available material and published data. MATERIAL AND METHODS: The study included 93 patients hospitalized at the Neurosurgical Institute for combined treatment of cerebral AVMs in 2010-2014. A group of combined surgery (removal of an AVM with preoperative embolization) consisted of 40 patients, and a group of combined radiotherapy (radiation after partial embolization or partial removal of an AVM) included 53 patients. 36 patients underwent radiosurgery, and 17 patients received stereotactic radiation therapy. Both groups were analyzed in terms of outcomes, complications, and follow-up results. RESULTS: In the group of combined surgery, according to the Glasgow outcome scale, good results (grade 4-5) were achieved in 35 (87.5%) patients at discharge and in 27 (90%) patients during follow-up. Treatment outcomes, surgery duration, and the amount of blood loss were not significantly different from those in the control group. Complete AVM obliteration was achieved in 29 (80.6%) patients 3 years after radiosurgery and in 8 (47%) patients after stereotactic radiotherapy. In discussion, these findings are compared to the published data, and recommendations for AVM treatment are suggested. CONCLUSION: The combined treatment of AVMs is effective management for patients with complex AVMs (Spetzler-Martin grade III-IV AVMs). Successful treatment of AVMs requires careful planning and teamwork of vascular and endovascular neurosurgeons, radiologists, and neurologists.

[The successful treatment of a patient with Lhermitte--Duclos disease (A case report and literature rewiew)].

INTRODUCTION: Lhermitte--Duclos disease is a rare autosomal dominant inherited disorder characterized by the loss of the normal cerebellar cortex architecture and hamartoma formation in the cerebellar hemispheres. Most commonly, this disease manifests in the third and fourth decades of life. Approximately 220 cases of Lhermitte--Duclos disease have been reported in medical literature to date. MATERIAL AND METHODS: The authors describe successful two-stage surgical treatment of a young female patient with Lhermitte--Ducos disease. CONCLUSION: This case report familiarizes practitioners with the clinical manifestations and neuroimaging features of Lhermitte--Duclos disease that facilitates timely diagnosis and proper treatment of the condition.

[The outcomes of stereotactic radiotherapy in patients with cerebral arteriovenous malformations].

INTRODUCTION: Cerebral arteriovenous malformations (AVMs) are the congenital anomalies of development of cerebral vessels during the embryonic period. The conventional therapy for AVMs currently includes endovascular management, microneurosurgical resection, and stereotactic irradiation. MATERIAL AND METHODS: A total of 315 patients with brain AVMs were subjected to stereotactic radiotherapy in 2005-2011. 238 (76%) patients had previous subarachnoid hemorrhage (SAH) within different time (6 months to 5 years) before the therapy; 214 (68%) patients had headaches; 113 (36%) patients had focal neurological symptoms caused by localization; and 82 (26%) patients had seizures. Twenty-three patients were subjected to surgical resection of an intracerebral hematoma prior to radiotherapy and 119 (36%) patients received endovascular treatment including partial embolization of the stroma of AVM. 267 patients received single-fraction radiosurgical irradiation. In patients with large AVMs, we used the hypofractionation technique consisting in target irradiation with several (usually 2-7) fractions; the radiation dose per fraction exceeds 2 Gy. Forty-six patients were irradiated in the hypofractionation mode; two patients had a course of stereotactic radiotherapy in the standard fractionation mode. The marginal dose of radiosurgical irradiation was 13-30 Gy (the average dose was 24 Gy). The main group of patients (38 individuals) with large AVMs was treated using hypofractionation of 35 Gy per 5 fractions. RESULTS: Control angiography was carried out in 225 patients who had been followed up for at least 2 years after therapy showed that complete obliteration was achieved in 83% of cases. The rate of symptomatic radiation reactions was less than 10%. The higher risk of developing obliteration was observed for AVMs less than 2 cm3 in size at marginal doses more than 24 Gy. In the hypofractionation group consisting of 27 patients with complete follow-up data, obliteration was observed in 10 (37%) patients. The rate of symptomatic reactions was less than 35%. CONCLUSIONS: The radiosurgical method is a minimally invasive choice of treatment for patients with brain AVM, which allows one to achieve sufficiently high degree of obliteration with the minimum complication rate. The hypofractionation procedure is the method of choice for treating large AVMs. Stereotactic irradiation using the Novalis linear accelerator makes it possible to treat patients with AVMs of virtually any location and volume.

[Malignant B-сell lymphoma of the anterior visual pathway].

This work was aimed at studying the optimal diagnosis methods and features of clinical signs of malignant B-cell lymphoma of the anterior visual pathways and choosing the most reasonable treatment method. Six immunocompetent patients with lymphomas in the chiasm-sellar region were examined. The outcomes of high-dose methothrexate chemotherapy and radiotherapy in these patients are analyzed.

[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.

[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.

[Structure of the oligosaccharide region (core) of the lipopolysaccharides of Shigella flexneri types 2a and 5b].

The full structure of the lipopolysaccharide core of bacteria Shigella flexneri types 2a and 5b, the causative agents of bacillary dysentery (shigellosis), was established by chemical methods, high-resolution electrospray ionization mass spectrometry, and two-dimensional NMR spectroscopy. The structure of the O-antigen repeating unit and the configuration and position of the linkage between the O-antigen and the core were determined in the lipopolysaccharide of S. flexneri type 2a.

Structural and serological characterisation of the O-antigenic polysaccharide of the lipopolysaccharide from Acinetobacter strain 96 (DNA group 11).

A polysaccharide containing D-Manp, L-Fucp (6-deoxygalactopyranose, fucose) and D-GlcpNAc was isolated by mild acid hydrolysis, followed by gel-permeation chromatography, from the lipopolysaccharide derived from Acinetobacter strain 96 (DNA group 11). The structure of the O-antigen was determined by compositional analysis and NMR spectroscopy of the polysaccharide as: [carbohydrate structure see text] A monoclonal antibody obtained after immunization of mice with heat-killed bacteria of Acinetobacter strain 96 was shown to bind to the O-antigen and did not cross-react with any Acinetobacter O-antigen of known structure.

Full structure of the O-specific polysaccharide of Proteus mirabilis O24 containing 3,4-O-[(S)-1-carboxyethylidene]-D-galactose.

The structure of a neutral polysaccharide isolated by degradation with dilute acetic acid of the lipopolysaccharide (LPS) of P. mirabilis O24 has been determined recently [E. Literacka et al., FEBS Lett., 456 (1999) 227-231]. Further studies of this LPS using alkaline degradation and hydrolysis at pH 4.5 showed that the polysaccharide chain includes an acetal-linked pyruvic acid residue, which is removed completely during delipidation with acetic acid. A revision using 1H and 13C NMR spectroscopy and methylation analysis resulted in determination of the following full structure of the repeating unit of the O-specific polysaccharide: carbohydrate sequence [see text] where D-Gal3,4(S-Pyr) is 3,4-O-[(S)-1-carboxyethylidene]-D-galactose.

Isolation using triflic acid solvolysis and identification of N(epsilon)-[(R)-1-carboxyethyl]-N(alpha)-(D-galacturonoyl)-L-lysine as a component of the O-specific polysaccharide of Proteus mirabilis O13.

An amino acid was released from the O-specific polysaccharide of Proteus mirabilis O13 by acid hydrolysis and identified as N(epsilon)-[(R)-1-carboxyethyl]-L-lysine by comparison with the authentic sample. An amide of this amino acid with D-galacturonic acid was isolated from the polysaccharide by solvolysis with anhydrous trifluoromethanesulfonic (triflic) acid and characterised by 1H and 13C NMR spectroscopy. These and published data enabled determination of the full structure of the repeating unit of the polysaccharide.

Structural and serological studies of the related O-specific polysaccharides of Proteus vulgaris O21 and Proteus mirabilis O48 having oligosaccharide-phosphate repeating units.

The O-specific polysaccharide chains (O-antigens) of the lipopolysaccharides (LPSs) of Proteus mirabilis O48 and Proteus vulgaris O21 were found to have tetrasaccharide and pentasaccharide repeating units, respectively, interlinked by a glycosidic phosphate. Polysaccharides and an oligosaccharide were derived from the LPSs by various degradation procedures and studied by 1H and 13C NMR spectroscopy, including 2D COSY, TOCSY, NOESY, H-detected 1H,13C and 1H,31P HMQC experiments. The following related structures of the repeating units of the O-antigens were established (top: Proteus mirabilis O48; bottom: Proteus vulgaris O21) The O-specific polysaccharide of P. vulgaris O21 has the same structure as that of Hafnia allvei 744 and PCM 1194 [Petersson C., Jachymek, W., Klonowska, A., Lugowski, C., Niedziela, T. & Kenne, L. (1997) Eur. J. Biochem., 245, 668-675], except that the GlcN residue carries the N-acetyl rather than the N-[(R)-3-hydroxybutyryl] group. Serological investigations confirmed the close relatedness of the Proteus and Hafnia O-antigens studied.