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

Treatment and rehabilitation of patients with acute cerebral insufficiency necessitate critical objectives (assessment of brain damage severity and prediction of potential outcomes). Despite the role of this stage, current consciousness assessment methods often lack sufficient accuracy and objectivity. A promising approach is the Full Outline of UnResponsiveness scale (FOUR) providing objective patient evaluation compared to traditional Glasgow Coma scale.

Objective: To evaluate clinical significance of the FOUR scale for patients with cerebral insufficiency.

Material and methods: A prospective single-center study included 200 patients with acute cerebral insufficiency. Analysis employed ROC curves, logistic regression and correlation methods.

Results: The FOUR scale demonstrated high prognostic accuracy in comatose patients (AUC=0.944 vs. 0.742 for GCS, p< 0.001). Strong correlations were found between FOUR scores and GOS grades (rs=0.7546, p<0.0001), as well as prediction of mortality (OR=3.4, 95% CI 2.1-5.6). For patients with chronic consciousness disorders, the FOUR scale showed benefits (AUC=0.936 vs. 0.745 for GCS).

Conclusion: The FOUR scale represents an optimal monitoring tool for patients with cerebral insufficiency.

Objective: To create a prognostic scale for overall survival in grade 4 astrocytomas based on molecular biological data.

Material and methods: After morphological confirmation of WHO grade 4 astrocytoma (2021 WHO classification criteria), 175 patients were classified as GBM (grade 4) without IDH1 mutations; IDH1 mutation was detected in 25 patients (12.5%; G4 astrocytoma). Molecular biological analysis of IDH1 gene mutations and MGMT promoter methylation was performed in 194 (97%) patients.

Results: To study concomitant significance of IDH1 mutation and MGMT promoter methylation in grade 4 gliomas, we created the IDH1/MGMT index(0 - IDH1+/MGMT+; 1 - IDH1/MGMT (+/-); 2 - IDH1-/MGMT-). This predictor was digitized in 194 patients who underwent molecular analysis. The most informative classification matrix according to overall survival was as follows: IDH1/MGMT index (OR=1.712; p=0.0004), REP (OR=1.971; p=0.0001), functional status before microsurgery at the lowest possible level (OR=1.797; p=0.001). Simple summation of numerical indicators for factors 1-3 in each patient allowed us to identify 5 prognostic classes: class 1 (0-1 points), class 2 (2 points), class 3 (3 points), class 4 (4 points), class 5 (5 points). Log-rank criterion for Kaplan-Meier survival curves revealed significant differences between classes (χ²=55.780; p<0.001). The median survival rates were 71.5, 42.3, 23.6, 17.4 and 8.1 months, respectively. Significant differences in survival were noted between almost all neighboring classes: classes 1-2 (χ²=3.21; p=0.073), classes 2-3 (χ²=5.77; p=0.016), classes 3-4 (χ²=6.03; p=0.014), classes 4-5 (χ²=11.97; p=0.0005). In "classes 1-3" in prognostic scale, median overall survival was 44.98 months (n=53; 95% CI: 20.5-69.4) for 3 Gy fractionation regimen and only 23.23 months (n=78; 95% CI: 17.3-29.1; χ²=9.28; p=0.002) for 2 Gy regimen. There were other results for classes 4-5. Median overall survival for 3 and 2 Gy fractionation regimens was low: 17.41 (n=28; 95% Cl: 13.8-21.0) and 15.83 months (n=41; 95% Cl: 11.7-20.0; -2=0.59; p=0.442), respectively.

Conclusion: The new prognostic scale for overall survival, based on molecular data, allows not only to predict further course of disease, but also to recommend irradiation 3 Gy for patients in classes 1-3 as an alternative to radiotherapy.

Objective: To analyze the incidence of facial neuropathy after microsurgical resection of cerebellopontine angle (CPA) tumors using various intraoperative neurophysiological monitoring (IONM) scenarios.

Material and methods: We analyzed 792 articles from PubMed, Google Scholar, Web of Science, and e-library databases and selected 35 eligible studies. There were 4.657 patients including 1.173 ones with facial neuropathy after CPA tumor resection. Statistical analysis was performed using OpenMeta Analyst software. Differences were significant at p< 0.05.

Results: The pooled incidence of postoperative facial neuropathy after CPA tumor resection was 28.9% (95% CI: 23.3% - 34.6%). In case of multimodal IONM, this value decreased to 23.5% (95% CI: 17.9% - 29.2%). This demonstrates significant effectiveness of this approach compared to direct facial nerve stimulation and resting EMG monitoring.

Background. Although the concepts of «complex aneurysm» and «technically complex aneurysm» are widely used at present, there is no generally accepted definition. Moreover, the criteria are often subjective. Depending on the parameters included, complex aneurysms comprise 5-9.7% of all patients with cerebral aneurysms [1, 2]. Complex aneurysms have higher risk of complications, whose accurate assessment is difficult. In case of unruptured aneurysms, analysis of this risk is of particular importance.

Objective: To develop the microsurgical complexity index in the treatment of unruptured aneurysms for objective assessment of complexity of microsurgical treatment and prediction of complications.

Material and methods: The study included 850 patients with a single unruptured aneurysm who underwent microsurgical treatment. Postoperative outcomes and incidence of various complications were analyzed depending on anatomical and morphological characteristics of aneurysm.

Results: We developed the microsurgical complexity index for the treatment of unruptured aneurysms and appropriate web application (www.isam.rf). Patients with severe neurological disorders at discharge comprised 2.5%, and mortality rate was 0.47%. New neurological deficit after surgery occurred in 9.3% of cases. Moderate and severe in-hospital complications occurred in 8.6% of cases. Non-radical exclusion of aneurysm was observed in 4.1% of cases. In case of complexity index «0», the incidence of various complications was lower compared to the group as a whole by 1.8-5.7%, index «1» - by 0.1-2.7%, index «2». The incidence of in-hospital complications Clavien-Dindo grade III-V was lower by 0.3%. The incidence of functional status mRS score 4-6 did not differ from the group as a whole, and the incidence of other complications was higher by 0.9-3.6%. In case of complexity index «3», the incidence of all complications was higher by 0.6-12.8%, index «4» - by 10.8-22.6%, index «5-6» - by 3.9-22.7%.

Conclusion: Original index may be valuable for more objective assessment of the risks of microsurgical treatment of aneurysms depending on anatomical and morphological characteristics and stratification of aneurysms according to their complexity. Aneurysms with index ≥3 may be classified as a group of complex aneurysms.

Despite modern advances in neurosurgery, treatment of intramedullary spinal cord tumors is still associated with postoperative neurological impairment and high incidence of adverse outcomes. Intraoperative neurophysiological monitoring allows real-time functional assessment of spinal cord conduction pathways and accurate tumor resection. Currently, concomitant monitoring of somatosensory and motor evoked potentials, as well as D-wave is the most common. This excludes damage to both sensory and motor pathways. In modern literature, there are some differences in methods of intraoperative neurophysiological monitoring, such as sensitivity and specificity of the method, criteria of «alarm» during surgical treatment of intramedullary tumors and correlation of neurophysiological monitoring parameters with postoperative neurological status of patients.

Objective: To study the structure, incidence and risk factors of perioperative complications in children with craniosynostosis (CS).

Material and methods: A systematic searching of data was performed for analysis of perioperative complications and adverse events following surgical correction of CS in patients younger 24 months.

Results. a: Systematic review included 33 manuscripts. The overall incidence of complications and adverse events was 9.8%. In patients after endoscopic surgeries, this rate was 7.2%, whereas open reconstructive surgeries were followed by 13.5% morbidity.

Conclusion: The most common surgical complications in pediatric craniosynostosis surgery were intraoperative blood loss requiring transfusion (35.7%), dural tears (3.8%), cerebrospinal fluid leaks (0.7%), hematomas (1.6%), and surgical site infections (1.6%). Non-surgical complications included non-surgical infections (1.1%), respiratory (1.2%) and neurological disturbances (0.5%). Fever (3.4%) is an undesirable phenomenon and can aggravate postoperative period after surgery for CS.

Objective: To study the dynamics of permeability of the blood-brain barrier (BBB) after focused ultrasound (FUS) thalamotomy in patients with tremor of different origin through visualization phenomena, assessment of the tendency of contrast accumulation level change at MRI in coagulation necrosis focus over different time intervals.

Material and methods: The study included 10 patients (8 - with Parkinson's disease, 2 - with essential tremor). MRI of the brain was performed before the procedure, MRI of the brain with contrast enhancement («Gadobutrol») was carried out after 2 and 24 hours, 1, 3, 6 and 12 months from FUS thalamotomy. The volume and nature of contrast accumulation in the impact area were evaluated.

Results: Observations show that the performance of FUS thalamotomy leads to a temporary impairment of the BBB permeability. This is confirmed by the data of dynamic accumulation of contrast substance in MRI in the area of coagulation necrosis.

Conclusion: The analysis of the dynamic changes of volume and patterns of accumulation of contrast substance in MRI in the area of coagulation necrosis after FUS thalamotomy was performed during the study. The obtained data demonstrate almost complete absence of contrast enhancement 24 hours after intervention, that may indicate a partial restoration of the structural-functional integrity of BBB after its transient disruption in the early postoperative period.

Combat injuries to the spine and spinal cord refer to rare, but some of the most severe. Currently, there is a need to improve the treatment and rehabilitation of patients with injuries to the spine and spinal cord. However, the complicated course of the wound infection can become a critical factor influencing the treatment outcome.

Objective: To analyze the structure of complications in the early period and determine the factors that have the greatest influence on the incidence of their development in gunshot wounds and closed injuries to the spine and spinal cord under modern conditions.

Material and methods: The work analyzed the results of a prospective examination and treatment of 300 injured subjects, who received medical care at various stages of medical evacuation. A total of 65.6% of the injured had gunshot wounds, 34.4% - closed injuries to the spine. Mine blast injuries were the most common - 88%, and missile wounds - 12%. Age of the patients ranged from 18 to 59 years, median age was 34. Most observed patients (79.6%) had combined injuries.

Results: The incidence of surgical complications during the treatment in the Vishnevsky Central Military Clinical Hospital in the group of gunshot wounds amounted to 28%, in closed injuries - 7.8%, complications of the wound infection 42.4% and 17.6%, respectively. Liquorrhea has been observed only in the group with gunshot wounds in 5.2% of cases. The instability of surgical hardware has not been recorded in any case. The highest incidence of purulent-septic complications was recorded in the group with gunshot wounds and amounted to 26%, and in the group with closed injuries - 9%. Purulent meningitis has been developed in 3% of patients, all of them had gunshot wounds to the spine. Postoperative wound pyogenesis has been noted in 2.7%. Overall mortality was 6%.

Conclusion: The combination of the damage and severe nature of the injury are common for gunshot wounds and closed injury to the spine and spinal cord. The risk of surgical complications (purulent-septic, postoperative liquorrhea) for patients with gunshot wounds is higher. More frequent development of complications of wound disease, namely pulmonary, urological, infectious (pneumonia), is typical. Wound liquorrhea also statistically significantly increases the possibility of surgical complications.

Surgery of meningiomas of the craniocervical region is one of the most difficult parts of neurosurgery due to the closeness of the brainstem, caudal group of the cranial nerves (CNs) and vertebral artery. According to the literature, suffering of the caudal group of CNs is between 20 and 55% according to different authors. In their dysfunction, the recovery of CNs is long-term and requires joint efforts by both the medical team and the patient and his family.

Objective: To demonstrate the dynamics of the restoration of CNs functions (over 12 years) in patient after resection of the ventrolateral craniocervical meningioma.

Material and methods: The article describes a clinical case of patient with ventrolateral meningioma of the craniocervical region. The tumor was resected (Simpson II) from a posterolateral access with transcondylar extension.

Results: The dynamics of caudal CNs recovery over 12 years has been traced and presented. In this clinical case, the main restoration of caudal CNs function has been observed during the first 6 months after surgery and remained unchanged thereafter.

Conclusion: Based on the literature data and presented clinical observation, it appears that the resection of meningiomas from the lower third of the clivus is predictably associated with a high risk of caudal CNs dysfunction, that should be considered when planning an operation and a postoperative rehabilitation program.

Complexity of neurosurgery for intracerebral frontal lobe tumors is determined by adjacent cortical and subcortical functional zones and white matter fibers connecting these areas and responsible for various neurocognitive functions. When removing frontal lobe gliomas in dominant hemisphere, neurosurgeons are forced to interact with speech functional system. Recent studies have shown that neuroanatomical basis of speech is more complex, multicomponent and integrated system than previously thought. Postulates of classical model of speech analyzer organization do not coincide with results of modern researches in speech physiology and pathophysiology. According to modern neuroscience, cognitive functions of the brain are realized by distributed groups of connected and synchronized networks of neurons rather separate neural centers as previously assumed. To understand such a complex cognitive system as speech, it is necessary to recognize not only elementary components of this system, but also their interaction and appropriate new properties. This review systematizes modern ideas about organization of speech functional system from the perspective of neurosurgery for glial frontal lobe tumors.