Zhurnal voprosy neirokhirurgii imeni N. N. Burdenko最新文献

There was the 180^th anniversary of Ilya Yefimovich Repin on August 5, 2024. He is the greatest Russian realist artist of the XIX century, a master of historical and genre painting, as well as outstanding portraitist. Repin's biography is unique. He was a professor and then academician of the Imperial Academy of Arts, teacher, author of memoirs and essays on fine art. After the age of 40, the artist developed a disease with impaired function of the right hand. Therefore, he retrained to write with his left hand. Accurate lifetime and post-mortem diagnosis was not established. The appearance of the artist's right hand represented by posthumous plaster cast indicates neuropathy of the right ulnar nerve.

Background: Intramedullary spinal cord tumors are a rare group of central nervous system tumors with special treatment approaches. The main problems are related to optimal time of surgery, invasiveness and recurrence of tumor.

Objective: To review available literature data on the treatment of intramedullary spinal cord tumors, to summarize the main achievements and changes in treatment strategy over the past 5 years.

Material and methods: We reviewed Russian- and English-language literature on the treatment of intramedullary spinal cord tumors over the past five years. The studies were selected in accordance with PRISMA recommendations.

Results: We analyzed literature data in the PubMed, eLibrary, Cochrane and Medline databases over the last 5 years. The studies were selected taking into account the relevance and quality of researches.

Conclusion: Large-scale studies are rare due to rarity of intramedullary spinal cord tumors. The main changes in surgery for intramedullary spinal cord tumors in recent years have occurred due to changes in surgical tactics (emphasis on functional status rather total resection), improvement of equipment for adjustment of surgical approach (MRI, intraoperative monitoring, intraoperative ultrasound), more accurate and effective adjuvant therapy contributing to preoperative shrinkage of tumor and preservation of functionally important areas.

Augmented reality (AR) is a promising area in microsurgical treatment of cerebrovascular pathologies that can significantly facilitate preoperative planning and intraoperative understanding of anatomy.

Objective: To describe AR-assisted neuronavigation in microsurgical treatment of intracranial aneurysms, arteriovenous malformations and cavernomas; to evaluate accuracy and applicability of AR-assisted neuronavigation.

Material and methods: The study involved 22 patients with cerebral aneurysms, arteriovenous and cavernous malformations. Microsoft Hololens 2 HMD glasses and «Medgital» software for AR navigation were used. Accuracy of registration (TRE and FRE) and time for preoperative preparation were evaluated.

Results. mean: TRE when using QR code was 0.6±0.2 cm, when combining through craniometric points - 1.4±0.6 cm. Time for preoperative image processing was 24.7±5.1 minutes, application setup in the operating theatre - 1.6±0.2 minutes. Combination using QR code provided higher accuracy of registration compared to craniometric points. AR-assisted navigation improved visualization and planning of surgeries for aneurysms, arteriovenous malformations, microvascular anastomoses and cavernous angiomas.

Conclusion: AR-assisted navigation is an innovative method with specific advantages that can potentially improve microsurgical treatment of cerebrovascular diseases. Further research is needed to confirm these findings and develop AR technology in neurosurgery.

Background: The primary objective of neurosurgical intervention for central nervous system tumors is a balance between optimal tumor resection and minimal postoperative neurological impairment. Intraoperative neurophysiological monitoring is essential in safeguarding somatosensory tracts during surgery. Virtually the only tool for continuous monitoring of sensory pathways is registration of peripheral somatosensory evoked potentials (SSEPs). However, this method has some limitations.

Objective: To increase the quality of intraoperative SSEP monitoring in surgical treatment of brainstem and spinal cord tumors.

Material and methods: To ensure continuous monitoring of sensory pathway function in brainstem and spinal cord surgery, we modified the method for monitoring of SSEPs. Unlike standard technique, we placed two-contact electrode for stimulation either in the area of the bottom of the fourth ventricle or on posterior surface of the spinal cord along the midline. This allows us to stimulate pontine tegmentum or posterior columns of spinal cord.

Results: We demonstrated the feasibility of this method in 2 cases.

Conclusion: The advantage of this method is possible brainstem or spinal cord stimulation reducing the chain of somatosensory tract that is valuable to neutralize the effect of anesthesia on significance of neurophysiological data.

Higher effectiveness of cerebrospinal fluid shunting procedures is still an unresolved issue in the treatment of idiopathic normal pressure hydrocephalus. Thus, over 15% of patients do not experience symptom regression in postoperative period. In recent years, several MRI predictors have been actively investigated to forecast the outcomes of cerebrospinal fluid shunting procedures. We have previously introduced a prognostic model for comprehensive evaluation of MRI data facilitating identification of patients likely to benefit from surgical intervention.

Objective: To evaluate diagnostic properties of MRI data comprehensive assessment model compared to traditional invasive diagnostic method (spinal tap test) in prospective randomized trial.

Material and methods: MRI data and postoperative outcomes in patients diagnosed with idiopathic normal pressure hydrocephalus who underwent ventriculoperitoneal shunting between September 2022 and April 2024 were analyzed in prospective randomized study. In the study group, surgical decisions were based on MRI data, while the control group followed an algorithm incorporating invasive diagnostic method (spinal tap-test). Ventriculoperitoneal shunting with constant-pressure valve implantation was performed in all patients selected for surgery.

Results: The study included 54 patients (25 ones in the study group and 29 ones in the control group). Surgery was performed in 21 and 20 patients, respectively. We found no advantages of invasive diagnostic methods over comprehensive assessment of MRI data in predicting the effectiveness of surgical treatment.

Conclusion: Comprehensive assessment of MRI findings allows for avoiding invasive diagnostic procedures in decision-making on cerebrospinal fluid shunting surgery in some patients with idiopathic normal pressure hydrocephalus.

Primary brain metastases are common in oncology. Preoperative stereotactic radiosurgery followed by surgical resection is a perspective approach.

Objective: To evaluate own experience of preoperative radiosurgery followed by surgical resection (RS+S) of metastasis regarding local control, leptomeningeal progression, surgical and radiation-induced complications; to compare treatment outcomes with surgical resection and subsequent radiotherapy (S+SRT).

Material and methods. a: Retrospective study included 66 patients with solitary brain metastasis. Two groups of patients were distinguished: group 1 (n=34) - postoperative irradiation, group 2 (n=32) - preoperative irradiation. The median age was 49.5 years (range 36-75).

Results: Local 3-, 6- and 12-month control among patients with postoperative irradiation was 88.2%, 79.4% and 42.9%, in the group of preoperative irradiation - 100%, 93.3% and 66.7%, respectively (p=0.021). Leptomeningeal progression developed in 11 patients (8 and 3 ones, respectively). The one-year survival rate was 73.5% and 84.4%, respectively (p=0.33). Long-term surgical and radiation-induced complications occurred in 12 (18.2%) patients.

Conclusion: Preoperative radiosurgery with subsequent resection provides higher local control and lower incidence of leptomeningeal progression in patients with single brain metastases.

Objective: To investigate the effect of two fractionation regimens on survival in patients with Grade IV gliomas depending on rapid early progression (REP).

Material and methods: Fractionation with prescribed doses of 2 and 3 Gy was alternately used in 140 patients with morphologically confirmed Grade IV glioma using a pairwise modeling strategy.

Results: REP was diagnosed in 60 (42.9%) out of 140 patients with Grade IV gliomas and 55 (45.5%) out of 121 patients with glioblastomas. Fatal outcome was observed in 111 (79.3%) patients, 99 (70.7%) ones died from progression of glioma. In case of no REP, the median overall survival as of December 2023 was 32.20 (95% CI 25.7-38.7) months, with REP - only 16.03 (95% CI 13.5-18.6) months (p<0.0001). Median survival was slightly lower in patients with glioblastoma - 28.2 and 16.5 months, respectively (p<0.0001).

In patients with Grade IV gliomas and no REP, 3 Gy (n=40) fractionation regimen was followed by median overall survival 44.98 (95% Cl 15.3-74.6) months, 2 Gy (n=40) - 20.99 (95% CI 9.2-32.7) months (p=0.027). In case of glioblastoma, differences between fractionation regimes lose significance - medians 33.7 and 19.7 months, respectively (p=0.081). According to multivariate analysis, 3 Gy fractionation regimen is more effective than standard radiotherapy (p=0.009) in patients without REP, while significance of isoeffective doses <59.5Gy≥ is slightly lower (p=0.020). Radiotherapy on the background of temozolomide is equally important (p=0.007).

In patients with grade 4 gliomas and REP, 3 Gy (n=30) fractionation regimen was followed by median overall survival 17.18 (95% CI 14.2-20.2) months, 2 Gy (n=30) - 12.88 (95% CI 5.4-20.3) months (p=0.849). In case of glioblastoma, Cox model classification matrix looks as follows: fractionation variant (p=0.423), isoeffective dose <59.5Gy≥ (p<0.0001), temozolomide during radiotherapy (p=0.701), functional status (p=0.485).

Conclusion: In patients with Grade IV gliomas and no REP, 3 Gy fractionation regimen has significant advantages over standard radiotherapy regarding overall survival. In case of more aggressive course of tumor (REP), higher single dose does not improve treatment outcomes. Isoeffective dose ≥59.5Gy is of great importance.

Objective: Assessing the diagnostic significance of MR morphometry in determining the localization of focal cortical dysplasias (FCD).

Material and methods: The study included 13 children after surgery for drug-resistant epilepsy caused by FCD type II and stable postoperative remission of seizures (Engel class IA, median follow-up 56 months). We analyzed the results of independent expert assessment of native MR data by three radiologists (HARNESS protocol) and MR morphometry data regarding accuracy of FCD localization. We considered 2 indicators, i.e. local cortical thickening and gray-white matter blurring.

Results: FCD detection rate was higher after MR morphometry compared to visual analysis of native MR data using the HARNESS protocol. MR morphometry also makes it possible to more often identify gray-white matter blurring as a sign often missed by radiologists (p<0.05).

Conclusion: MR morphometry is an additional non-invasive method for assessing the localization of FCD.

Background: Giant non-traumatic and non-iatrogenic cranial vault defects are poorly studied due to their rarity. Therefore, diagnosis and analysis of their causes are difficult. In available literature, we found only 4 cases of giant pericranial sinus accompanied by extensive cranial vault defects.

Objective: To present a rare and difficult diagnostic case of cranial vault lesion with non-traumatic and non-iatrogenic extensive bone defect, as well as to propose treatment of this pathology.

The patient presented with complaints of a «growing» parietal-occipital cranial vault defect in November 2022. This defect occurred in childhood. A comprehensive examination including CT angiography of cerebral vessels was followed by surgical treatment (bone resection along skull defect edge with biopsy (aponeurosis, periosteum, bone) and subsequent closure with titanium plate). Postoperative period was uneventful. CT of the skull and brain, including angiography and sinusography, were performed. The follow-up period was more than 10 months with favorable outcome.

Considering anamnesis, clinical and additional diagnostic data, we established giant dominant-type true pericranial sinus.

The main feature of idiopathic normal pressure hydrocephalus is reversible clinical manifestations after timely ventriculoperitoneal shunting. However, the effectiveness of such interventions does not exceed 85%. Invasive diagnostic methods are used to select candidates for surgery. At the same time, literature data indicate neuroimaging symptoms predicting postoperative outcomes without invasive examination.

Objective: To identify intrascopic predictors of favorable outcomes after ventriculoperitoneal shunting in Hakim-Adams syndrome; to present a model for evaluating MRI data and selecting candidates for surgery.

Material and methods: A single-center retrospective non-randomized study enrolled head MRI data in patients with idiopathic normal-pressure hydrocephalus who underwent ventriculoperitoneal shunting between September 2020 and March 2022. There were 34 patients including 15 ones in the main group (significant improvement after surgery) and 19 ones in the control group. We analyzed quantitative neuroimaging features: ventriculocranial indices, DESH syndrome (DESH score), angle of corpus callosum at the level of anterior and posterior commissures, dimensions of temporal horns of lateral ventricles, the number of lacunar infarcts in basal ganglia and white matter of hemispheres.

Results: We identified the most significant predictors of favorable outcomes after ventriculoperitoneal shunting: Evans index, indexed longitudinal size of lateral ventricles, angle of corpus callosum (at the level of anterior and posterior commissures) and DESH score. We created a classification model using discriminant analysis. This model allows us to predict the outcomes after ventriculoperitoneal shunting.

Conclusion: A comprehensive assessment of intrascopic symptoms allows us to predict the outcomes after ventriculoperitoneal shunting in patients with Hakim-Adams syndrome. In the future, we can avoid invasive diagnostic manipulations in some patients.