Management of giant internal carotid aneurysm by extracranial-intracranial bypass and flow diverter stent.

Flow diverter stents have become the standard approach to managing intracranial aneurysms; however, in some cases of complex, wide-necked aneurysms, poor outcomes due to stent occlusion have been reported. We report the case of a giant internal carotid artery aneurysm treated by high-flow extracranial-intracranial (EC-IC) bypass with flow diverter deployment. Seven months post-operatively, radiographic imaging demonstrated occlusion of the stent and parent artery, with further ischemic events prevented by collateral flow from the high flow bypass. This case demonstrates the continued utility of EC-IC bypass in the endovascular era, especially as a rescue tool in cases of delayed stent occlusion.

An Uncommon Case of Moyamoya Syndrome Is Accompanied by an Arteriovenous Malformation with the Involvement of Dural Arteries.

(1) Background: This report describes the surgical management of a case of concurrent AVM with the involvement of dural arteries and moyamoya syndrome. Given the infrequency of this combination, there is currently no established management strategy available. (2) Case Description: A 49-year-old male patient with multiple symptoms including headaches, tinnitus, and visual impairment diagnosed with the coexistence of an arteriovenous malformation with the involvement of dural arteries and moyamoya syndrome was admitted to the national tertiary hospital. The patient underwent surgical management through embolization of the AVM from the afferents of the dural arteries, which has resulted in positive clinical outcomes. However, this approach may not be suitable for all cases, and a multidisciplinary team approach may be required to develop an individualized treatment strategy. (3) Conclusion: The contradictory nature of the treatment approaches in cases of combined AVM with the involvement of dural arteries and MMD highlights the complex nature of this condition and the need for further research to identify the most effective treatment strategies.

Risk factors for aneurysm rupture among Kazakhs: findings from a national tertiary.

BACKGROUND: Rupture of intracranial aneurysms (RIA) leads to subarachnoid hemorrhage (SAH) with severe consequences. Although risks for RIA are established, the results vary between ethnic groups and were never studied in Kazakhstan. This study aimed to establish the risk factors of RIA in the Kazakh population.  METHODS: Retrospective analysis of 762 patients with single IAs, who attended the neurosurgical center from 2008 until 2018, was conducted. Demographic characteristics, such as age, sex, smoking status, and hypertension were considered. Descriptive and bivariate analyses were performed. A multivariable logistic regression model was built to identify factors correlated with RIA. RESULTS: The mean age of participants was 48.49 ± 0.44 years old. The majority (68.37%) of IAs have ruptured. Of the ruptured aneurysms, 43.76% were < 6 mm, and 38.39% were located on the anterior cerebral and anterior communicating arteries (ACA). Logistic regression model indicates younger age group (16-40 years), smoking, having stage 3 hypertension, smaller IA size and its location on ACA increase the odds of rupture. CONCLUSIONS: This study has revealed that younger, smoking patients with stage 3 arterial hypertension are at higher risk for RIA. Small aneurysms (< 6 mm) and location on ACA had increased odds of rupture, while larger aneurysms on internal carotid arteries had lower odds.

Reaching the horizon and looking beyond: neurosurgery education in Kazakhstan.

Neurosurgery education in Kazakhstan has 55 years of history. The first neurosurgery department was established in 1964 in the city of Almaty, South Kazakhstan (the former capital of Kazakhstan). The department was headed by the pioneer of Kazakhstani neurosurgeons, Prof. Yevgeniya Azarova. A new neurosurgery education system was adopted after a while. To date, 4 medical universities and 1 neurosurgical center in Kazakhstan have a neurosurgery department that prepares around 10 neurosurgeons annually. The country's populations are currently served by more than 300 neurosurgeons. However, isolated regions lack neurosurgical services and a specialized medical workforce. Urbanization results in inequality of receiving medical care among rural and regional inhabitants.To develop and strengthen the neurosurgery services, the National Center for Neurosurgery was opened in the heart of the country. The center has placed great importance on the development of neurosurgery and neurosurgical education in Kazakhstan. The World Federation of Neurosurgical Societies, European Association of Neurosurgical Societies, Asian Congress of Neurosurgeons, and International Society for Pediatric Neurosurgery have held many international meaningful events on neurosurgery at the center. Opened in 2008, the neurosurgery center has prepared 41 neurosurgeons in the residency program. This article seeks to provide readers with an understanding of the state of neurosurgery education in Kazakhstan and its development history.

Early and midterm results of treatment of giant internal carotid artery paraclinoid aneurysms with trapping and flow diverters.

BACKGROUND: Flow diverter devices (FDD) carry risks of postoperative complications when treating aneurysms with wide necks, stenosis, and severe tortuosity of the parent vessel. In this study, we evaluated early and midterm results for the treatment of giant paraclinoid aneurysms managed by trapping and endovascular deployment of FDD. METHODS: Medical records were analyzed for patients with giant paraclinoid aneurysms treated between July 2008 and December 2017 at National Centre for Neurosurgery with either a flow diverter or by trapping the aneurysm with or without extracranial-intracranial (EC-IC) bypass surgery. We recorded age, sex, clinical presentation, treatment modality, morbidity, and mortality. Clinical outcomes were assessed using a modified Rankin scale (mRS). RESULTS: Among 29 consecutive patients, 13 were treated with FDD, and 16 patients were managed by trapping the aneurysm, where 7/16 cases had preliminary EC-IC bypass. Of 16 trapping patients, six were trapped endovascularly and ten were trapped surgically. During the follow-up period (mean 33 months, range 6-96), total exclusion of the aneurysm from the circulation was observed 100% of aneurysms in the trapping group and 84.6% in the FDD group (P = 0.192). Early postoperative morbidity was observed in three (23%) cases in the FDD group, and four (25%) in trapping group (P = 0.525). The FDD group had one (7.7%) fatal complication due to stent occlusion and severe ischemic stroke after three months postoperatively, despite appropriate antiplatelet therapy. There were no mortalities in the trapping group (P = 0.149). The rate of mRS 0-2 did not differ significantly across groups at discharge (81.3% vs. 69.2%; P = 0.667), and all patients had mRS 0-2 at follow-up (P = 1.000). CONCLUSIONS: FDD deployment for giant paraclinoid aneurysms results in comparable angiographic and clinical outcomes to aneurysm trapping. Despite implementation of modern endovascular treatment methods, aneurysm trapping remains a valuable treatment option in carefully selected patients with giant paraclinoid aneurysms.

The outcomes of microvascular decompression for primary trigeminal neuralgia: insights from a single-center experience and technical advancements.

Background: Microvascular decompression (MVD) remains the primary surgical treatment for trigeminal neuralgia due to its positive postoperative results. This study aims to evaluate the outcomes of patients with primary trigeminal neuralgia who underwent MVD. Additionally, the paper offers a detailed explanation of the surgical methodology of MVD employed at the neurosurgical hospital in Kazakhstan. Methods: The study involved 165 medical records of patients with trigeminal neuralgia who underwent MVD between 2018 and 2020. Out of these 165 patients, 90 (54.55%) were included in the final analysis and were further evaluated using the Barrow Neurological Institute pain intensity score. Various variables were analyzed, including age, sex, affected side, dermatomes, offending vessel, and surgical intervention type. Moreover, the surgical technique employed at the hospital was described. Results: The average follow-up period after the MVD procedure was 32.78 ± 9.91 months. The results indicated that out of the 90 patients, 80 (88.89%) achieved a good outcome as evidenced by BNI scores I and II. It was observed that patients with affected maxillary dermatomas and those with affected ophthalmic + maxillary dermatomas were more likely to experience fair + poor postsurgery BNI scores. On the other hand, patients with neurovascular conflicts involving the maxillary + mandibular dermatomas demonstrated good BNI scores (p = 0.01). Conclusions: The outcomes of MVD in patients with primary trigeminal neuralgia showed good BNI scores within this study population. The outcome depended on the affected dermatome of the trigeminal nerve with the vessel. Additionally, patient positioning, intraoperative management including small skin incisions, minimal craniotomy, and precise closure of the dura, as well as intraoperative neurolysis, may contribute to achieving good clinical and satisfactory post-surgery aesthetic outcomes.

Associations of Brain Arteriovenous Malformation-Related Factors with Epileptic Seizure Presentations.

BACKGROUND: Arteriovenous malformations (AVMs) are abnormal tangles of arteries and veins that connect directly without an intervening capillary bed. Epileptic seizures are the second most common symptom in patients with brain AVMs, occurring in 30 to 50% of cases. However, the exact mechanism of epileptic seizure development in AVMs remains unclear. In this study, we aimed to investigate the factors associated with epileptic seizures in patients with brain arteriovenous malformation (AVMs) in Kazakhstan. METHODS: A case-control study was conducted, which included 163 patients diagnosed with brain AVMs. Demographic and clinical data were collected and analyzed, and multivariate logistic regression was built to assess the factors associated with seizures in brain AVMs. RESULTS: from this rupture of vessels OR = 0.36 95% CI (0.14-0.91, a medium-to-high Spetzler-Martin score (III-V) OR = 6.16 (2.14-17.69) and OR = 3.05 (1.08-8.68), respectively), location in brain cortex (frontal lobe OR = 6.16 (2.04-18.54), parietal lobe OR = 9.37 (3.26-26.91), temporal lobe OR = 4.57 (1.56-13.36), occipital lobe OR = 0.27 (0.08-0.91), and the presence of hemiparesis OR = 0.12 (0.02-0.66) in adverse outcomes were statistically significantly associated with the presence of epileptic seizures in brain arteriovenous malformations patients. CONCLUSIONS: To conclude, this contributed to model factors associated with brain arteriovenous malformations that are linked to epileptic seizures.

Safety and efficacy of flow diverter stents in the treatment of bifurcation cerebral aneurysms: single-center experience.

PURPOSE: The use of flow diverter (FD) stents is continually expanding. Aneurysms on arterial bifurcation typically have an undesirable anatomical form, are frequently wide-necked, and include one or more side-branch arteries. In recent years, the off-label use of flow diversion in treating intracranial aneurysms beyond the internal carotid artery has become increasingly popular. This study reports our center's initial experience treating bifurcation aneurysms with FD devices, documenting occlusion outcomes using the O'Kelly-Marotta and modified Cekirge-Saatci scales, as well as the safety of FD usage in bifurcation locations. METHODS: This retrospective, single-center study analyzed a prospectively maintained database of patients with cerebral aneurysms treated endovascularly. The study identified bifurcation aneurysms that were treated between January 2019 and May 2022 by placing an FD device covering the neck of the aneurysm. RESULTS: Our short series suggests that flow diversion is a viable therapeutic option for bifurcation aneurysms with favorable angiographic outcomes. CONCLUSION: In highly selective cases, flow diversion may be considered for treating bifurcation aneurysms in patients who will undergo follow-up examinations in the future. CLINICAL SIGNIFICANCE: Flow diversion has emerged as a valuable technique in the management of bifurcation aneurysms, offering the potential for satisfactory occlusion and long-term outcomes.

A case report of multi-step management of extracranial carotid artery aneurysm and carotid-cavernous fistula combination in patients.

Extracranial carotid artery aneurysms (ECAA) and carotid-cavernous fistulas (CCF) are rare arterial pathologies with severe complications and increased risk of mortality. The optimal treatment approach for this combined condition is a topic of debate among neurosurgeons and neuroradiologists, and a standardized treatment protocol has yet to be established. The aim of this case report was to demonstrate the management of a rare combination of ECAA and CCF in patients. The treatment strategy included a two-step procedure of endovascular embolization of CCF followed by dual antiplatelet therapy and endovascular stenting of an aneurysm. Control angiograms showed the exclusion of an aneurysm from the blood circulation and CCF symptoms were resolved.

Long-Term Outcomes of Endovascular Embolization in a Vein of Galen Aneurysmal Malformation: A Single-Center Experience.

BACKGROUND: A vein of Galen aneurysmal malformation (VGAM) is a rare congenital cerebral vascular condition with a high mortality rate if left untreated. This study describes the long-term outcomes of patients with VGAM, who were treated with endovascular embolization. METHODS: This retrospective analysis focused on VGAM patients who underwent one or more endovascular embolization sessions between January 2008 and December 2022. The study included newborns and children under 18 years. Data encompassed clinical and demographic characteristics, types of endovascular embolization, treatment complications, mortality rates, and long-term outcomes. RESULTS: Out of 22 VGAM cases, the majority were boys (86.36%), and the average age of the participants was 38 months, ranging from 25 days to 17 years. Endovascular embolization using liquid embolizing agents was the most common intervention (50%), and around 73% of patients underwent multiple sessions. Some patients underwent ventriculoperitoneal shunting (VPS) due to persistent hydrocephalus. In long-term outcomes, four patients (18.2%) showed developmental delays, and 16 patients (72.7%) had a positive outcome. CONCLUSIONS: Combining endovascular therapy with a comprehensive management strategy significantly reduces mortality rates and improves the possibility of normal neurological development in patients.

Challenges in Neurosurgery During the COVID-19 Pandemic: The Experience of Kazakhstan.

BACKGROUND: The practice of neurosurgery has been profoundly affected by the coronavirus disease 2019 (COVID-19) pandemic in Kazakhstan. Many elective surgeries were postponed or canceled, which resulted in difficulties in hospitalization. In the present study, we aimed to describe the effects of COVID-19 on neurosurgical practice and to determine whether a discrepancy was present in the effects between metropolises and regional cities in Kazakhstan. METHODS: We performed an electronic internet-based survey among Kazakhstan's neurosurgeons using the virtual snowball sampling method. The invitation link to complete the questionnaire was sent to neurosurgeons through personal and corporate electronic mail and social networks. The data were analyzed using Excel and Stata. RESULTS: A total of 43 neurosurgeons completed the survey. The distribution of regional and urban respondents was almost equal. The male neurosurgeons outnumbered the female neurosurgeons (93.02% vs. 6.98%). A decrease in consultations (65.34% ± 28.24%) and surgeries (56.55% ± 26.34%) had been observed by all neurosurgeons, regardless of city type. However, the proportion of neurosurgeons who had attended online educational courses during the pandemic was significantly higher (P = 0.001) for the surgeons from major cities (68.18%) compared with the surgeons from smaller cities (19.05%). The regional neurosurgeons tended to perform urgent surgeries on COVID-19-positive patients 3 times more often than had the metropolitan neurosurgeons (P < 0.001). CONCLUSIONS: The true effect of the pandemic remains unknown for Kazakhstan. A discrepancy between the metropolitan and regional cities was found in the present study. Efforts are required and relevant guidelines must be developed to ensure that the neurosurgical treatment of various conditions continues to be available during health emergencies and that the disparities are addressed.

Whole-Exome Sequencing Reveals Pathogenic SIRT1 Variant in Brain Arteriovenous Malformation: A Case Report.

Arteriovenous malformations of the brain (bAVMs) are plexuses of pathological arteries and veins that lack a normal capillary system between them. Intracranial hemorrhage (hemorrhagic stroke) is the most frequent clinical manifestation of AVM, leading to lethal outcomes that are especially high among children and young people. Recently, high-throughput genome sequencing methods have made a notable contribution to the research progress in this subject. In particular, whole-exome sequencing (WES) methods allow the identification of novel mutations. However, the genetic mechanism causing AVM is still unclear. Therefore, the aim of this study was to investigate the potential genetic mechanism underlying AVM. We analyzed the WES data of blood and tissue samples of a 30-year-old Central Asian male diagnosed with AVM. We identified 54 polymorphisms in 43 genes. After in-silica overrepresentation enrichment analysis of the polymorphisms, the SIRT1 gene variant (g.67884831C>T) indicated a possible molecular mechanism of bAVM. Further studies are required to evaluate the functional impact of SIRT1 g.67884831C>T, which may warrant further replication and biological investigations related to sporadic bAVM.

Effect of Targeted Embolization on Seizure Outcomes in Patients with Brain Arteriovenous Malformations.

BACKGROUND: Seizures are one of the most debilitating manifestations of brain arteriovenous malformations (AVMs). This study aimed to evaluate the effect of curative embolization on brain AVM patients presenting with seizures. METHODS: The records of patients who underwent embolization for brain AVM from January 2012 to December 2020 were evaluated and patients presenting with seizures were interviewed. Patient responses were evaluated according to the International League Against Epilepsy (ILAE) and Engel classifications. Statistical analyses of factors associated with seizure outcomes and complications were performed using ANOVA and Fischer's exact tests. RESULTS: The mean age of the participants was 35.2 ± 10.7 years. More than 80% of the patients received no or suboptimal dosages of antiepileptic drugs (AEDs) prior to embolization. Positive seizure dynamics were observed in 50% of the patients post-procedure. A correlation was found between length of seizures in anamnesis and outcomes of both Engel and ILAE score, where shorter length was associated with better outcomes. Post-embolization hemorrhage was associated with initial presentation with hemorrhage. CONCLUSIONS: The embolization of brain AVMs had a positive effect on seizure presentation and a relatively low prevalence of complications. However, the results of the study are obscured by inadequate AED treatment received by the patients, which prompts prospective studies on the topic with careful patient selection.

Transforaminal Endoscopic Discectomy Under General and Local Anesthesia: A Single-Center Study.

Percutaneous spinal endoscopy is used for the treatment of disorders of the lumbar spine, as it has several advantages over traditional surgical methods. The performance of percutaneous spinal endoscopy is not possible without applying anesthesia methods. Two types (local and general) of anesthesia are used for percutaneous spinal endoscopy. Both, local and general anesthesia approaches contribute to safety in surgical procedures. Although it is believed that the method of local anesthesia has more benefits over general anesthesia, such as lowering the risk of postoperative neurological complications in a patient, the literature on the topic is inconclusive. The study aims to perform a comparative analysis of the two anesthesia methods using a prospective case-control design. Patients were divided into two groups: those who received local anesthesia (LA) (20 patients), and those who underwent general anesthesia (GA) (20 patients). As a result of the study, 40% of the patients experienced moderate pain and 5% of the patients experienced excruciating pain intraoperatively in the LA group. Although Visual Analog Scale and Oswestry Disability Index scores improved more rapidly in LA group, at the 12-month check-up point there was no significant difference between cases and controls. Nevertheless, there were postoperative complications such as nerve root injury in 10% of the patients; nausea, vomiting, dizziness, drowsiness in 15% of the patients in the GA group, and an insignificant or no such complications in patients of the LA group. The present study demonstrates that LA contributes to more positive short-term outcomes for patients as it facilitates nerve root damage prevention, and has no postoperative side effects on patients' well being.

Improvement of Neurological Function in Rats with Ischemic Stroke by Adipose-derived Pericytes.

Pericytes possess high multipotent features and cell plasticity, and produce angiogenic and neurotrophic factors that indicate their high regenerative potential. The aim of this study was to investigate whether transplantation of adipose-derived pericytes can improve functional recovery and neurovascular plasticity after ischemic stroke in rats. Rat adipose-derived pericytes were isolated from subcutaneous adipose tissue by fluorescence-activated cell sorting. Adult male Wistar rats were subjected to 90 min of middle cerebral artery occlusion followed by intravenous injection of rat adipose-derived pericytes 24 h later. Functional recovery evaluations were performed at 1, 7, 14, and 28 days after injection of rat adipose-derived pericytes. Angiogenesis and neurogenesis were examined in rat brains using immunohistochemistry. It was observed that intravenous injection of adipose-derived pericytes significantly improved recovery of neurological function in rats with stroke compared to phosphate-buffered saline-treated controls. Immunohistochemical analysis revealed that the number of blood capillaries was significantly increased along the ischemic boundary zone of the cortex and striatum in stroke rats treated with adipose-derived pericytes. In addition, treatment with adipose-derived pericytes increased the number of doublecortin positive neuroblasts. Our data suggest that transplantation of adipose-derived pericytes can significantly improve the neurologic status and contribute to neurovascular remodeling in rats after ischemic stroke. These data provide a new insight for future cell therapies that aim to treat ischemic stroke patients.

Genetic Risk Factors for Intracranial Aneurysm in the Kazakh Population.

An intracranial aneurysm (IA) is a weak or thin area on a blood vessel in the brain that balloons as it fills with blood. Genetic factors can influence the risk of developing an aneurism. The purpose of this study was to explore the relationship between single nucleotide polymorphisms (SNPs) and IA in Kazakh population. The patients were genotyped for 60 single nucleotide polymorphisms. Genotyping was performed on the QuantStudio 12K Flex (Life Technologies). A linear regression analysis found 13 SNPs' significant association with development and rupture of IA: the rs1800956 polymorphism of the ENG gene, rs1756 46 polymorphism of the JDP2 gene, variant rs1800255 of the COL3A1, rs4667622 of the UBR3, rs2374513 of the c12orf75, rs3742321 polymorphism of the StAR, the rs3782356 polymorphism of MLL2 gene, rs3932338 to 214 kilobases downstream of PRDM9, rs7550260 polymorphism of the ARHGEF, rs1504749 polymorphism of the SOX17, the rs173686 polymorphism of CSPG2 gene, rs6460071 located on LIMK1 gene, and the rs4934 polymorphism of SERPINA3. A total of 13 SNPs were identified as potential genetic markers for the development and risk of rupture of aneurysms in the Kazakh population. Similar results were obtained after adjusting for the confounding factors of arterial hypertension and age.

Microvascular Anastomosis Training in Neurosurgery: A Review.

Cerebrovascular diseases are among the most widespread diseases in the world, which largely determine the structure of morbidity and mortality rates. Microvascular anastomosis techniques are important for revascularization surgeries on brachiocephalic and carotid arteries and complex cerebral aneurysms and even during resection of brain tumors that obstruct major cerebral arteries. Training in microvascular surgery became even more difficult with less case exposure and growth of the use of endovascular techniques. In this text we will briefly discuss the history of microvascular surgery, review current literature on simulation models with the emphasis on their merits and shortcomings, and describe the views and opinions on the future of the microvascular training in neurosurgery. In "dry" microsurgical training, various models created from artificial materials that simulate biological tissues are used. The next stage in training more experienced surgeons is to work with nonliving tissue models. Microvascular training using live models is considered to be the most relevant due to presence of the blood flow. Training on laboratory animals has high indicators of face and constructive validity. One of the future directions in the development of microsurgical techniques is the use of robotic systems. Robotic systems may play a role in teaching future generations of microsurgeons. Modern technologies allow access to highly accurate learning environments that are extremely similar to real environment. Additionally, assessment of microsurgical skills should become a fundamental part of the current evaluation of competence within a microneurosurgical training program. Such an assessment tool could be utilized to ensure a constant level of surgical competence within the recertification process. It is important that this evaluation be based on validated models.