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

Background: The incidence of arterial aneurysms associated with moyamoya angiopathy (AA-MMA) is five times higher than in general population. The risk of AA-MMA rupture can reach 90%. AA-MMA clipping is accompanied by postoperative complications in 25% of cases, and endovascular treatment leads to a forced change of surgical tactic in 26% of cases. In this regard, it is relevant to discuss the features of surgery for AA-MMA and effective treatment algorithm.

Objective: To present rare clinical cases of AA-MMA and surgical treatment options.

Material and methods: The authors present two patients with ruptured AA-MMA. In the first case, there was a distal aneurysm of the right lenticulostriate artery associated with MMA (Suzuki III). The patient underwent aneurysm embolization followed by combined revascularization three months later. In the second case, aneurysm of ACA-AcomA complex was associated with contralateral MMA. The patient underwent microsurgical clipping of aneurysm and combined revascularization 1.5 months later.

Results: These clinical cases demonstrate successful endovascular embolization and microsurgical treatment combined with delayed revascularization for the treatment of AA-MMA. In both cases, aneurysms were successfully removed. Perfusion improved after revascularization in both cases. There were no recurrent strokes throughout 2 years in the first case and 9 years in the second case.

Conclusion: AA-MMA is a complex pathology requiring special attention. Standard methods of surgical treatment are often associated with high risk of postoperative complications. Preoperative planning and consideration of pathogenic features of MMA are important.

Moyamoya disease is a rare cerebrovascular disorder, and appropriate studies focus primarily on techniques and outcomes of anterior revascularization (MCA and ACA). However, posterior cerebral arteries are also affected in some cases. The authors presented a patient who has suffered from Moyamoya disease since 7-year-old age with 10-year progression of disease and involvement of anterior circulation, as well as posterior circulation after 5 years. There were surgical interventions. PCA revascularization using augmented reality technology is the first such case presented In Russian literature.

Aptamers can increase human glioblastoma cell death rate after exposure to radiotherapy. Cell cultures derived from human glioblastomas allow for selection of effective combined therapy.

Objective: To analyze viability of human glioblastoma cell cultures exposed to EGFR-specific aptamers U31, GR20, and GR200 compared to combination of these aptamers and radiotherapy (20 Gy).

Methodology: G22 and SusfP2 cell cultures were harvested from tumor tissue. They were exposed to aptamers (10 μM, 72 hours) and irradiated once with 20 Gy. We analyzed viability using flow cytometry.

Results: In G22 cell culture, aptamer U31 reduces apoptosis by 45.8%, but increases necrosis by 67.5%, while GR20 and GR200 increase two types of death (apoptosis and necrosis). In SusfP2 culture, all three aptamers significantly increased apoptosis while proportion of necrosis decreased. The most significant decrease in the number of necrotic cells was observed for aptamer U31 (by 77.7%). Radiotherapy combined with aptamers was followed by the following effects for G22 cell culture: U31 and GR200 enhance apoptosis (by 59.4%) and necrosis (by 57.7%), aptamer GR20 increases necrosis by 28.3%. In SusfP2 culture, U31 aptamer enhances apoptosis by 132.9% and necrosis by 52.9%, GR20 - 125.4% and 17.7%, GR200 - 27.4% and 30.6%, respectively.

Conclusion: Aptamers have different effects on glioblastoma cell cultures. For SusfP2, a combination of radiotherapy with GR20 aptamer is optimal. Either a single application of U31 aptamer or combination of radiotherapy and GR200 aptamer is optimal for G22 cell culture. This result demonstrates the importance of combined therapy and preliminary studies in cell cultures for individualized approach to each CNS tumor.

Brain injury is accompanied not only by primary neurological disorders, but also secondary complications, including organ dysfunction, immunosuppression with infections and disorders of homeostasis. One way or another, all of them are associated with cerebral dysfunction.

Objective: To determine the risk factors of adverse outcomes in patients with severe traumatic brain injury.

Material and methods: We performed post hoc analysis of a randomized controlled trial at the Sklifosovsky Research Institute for Emergency Care. Patients with severe traumatic brain injury underwent intensive therapy aimed at normalizing intracranial pressure. In the main group, sevoflurane (AnaConDa) was used for sedation. Sevoflurane can dose-dependently increase cerebral blood flow. However, parallel decrease in brain metabolism leads to cerebral vasoconstriction and decrease in intracranial pressure. Propofol was used in the control group. This drug reduces intracranial blood filling through suppression of metabolism. Manifestation of pneumonia and 30-day mortality were studied. Predictors: drug for sedation, age, gender, body mass index, fact of aspiration, transfusions, acute renal failure, acute respiratory distress syndrome (ARDS), seizures, meningitis. We performed ROC analysis of the SOFA (Sequential Organ Failure Assessment), APACHE II (Acute Physiology and Chronic Health Evaluation), VIS (Vasoactive Inotropic Score), and GCS (Glasgow Coma Scale) scales, as well as oxygen extraction ratio (OER) and age.

Results: Risk factors of 30-day mortality: older age (p=0.011), pneumonia (p=0.038), ARDS (p=0.011), decreased OER, negative dynamics according to the MACCE (incidence of major adverse cardiovascular events), VIS, SOFA, APACHE II, GCS scales. The risk of pneumonia is associated with propofol (p=0.028), ARDS (p=0.001), high MACCE score (p=0.038), APACHE II (p=0.040), and GCS (p=0.012) scores, blood transfusion.

Conclusion: Early detection of predictors of unfavorable outcomes is valuable to optimize therapy and increase the effectiveness of treatment.

Background: Ionizing radiation and radiotherapy/radiosurgery are widely used in modern medicine. Stereotactic approach and new irradiation techniques have enabled radiosurgical treatment with high precision and conformity. This significantly expanded the indications for radiotherapy in neurosurgical patients.

Objective: To present more than 42 000 patients were treated at the first Russian center for stereotactic radiotherapy and radiosurgery at the Burdenko Neurosurgical Center over the past 20 years.

Material and methods: Over 20 years, we have used linear accelerators and GammaKnife system for various CNS diseases.

Results and conclusion: Stereotactic radiotherapy and radiosurgery have been shown to be highly effective treatments with minimal complications and adverse reactions for meningiomas, neurinomas, glomus tumors, hemangioblastomas, pituitary adenomas, craniopharyngiomas, pilocytic astrocytomas, recurrent high-grade gliomas, secondary metastatic tumors and melanoma; AVM and dural fistula; trigeminal neuralgia, and other diseases with high socioeconomic impacts. These results indicate the role of stereotactic irradiation in the treatment of neurosurgical patients today and allow for revision of existing neurosurgical treatment standards.

According to the order of April 15, 1935, the opening of the Department of Neurosurgery, the first head of which was Nikolai N. Burdenko, laid the foundation for the development of neurosurgical activity and training of neurosurgical personnel in the USSR within the walls of the Russian Medical Academy of Medical Sciences (TsIUV). N.N. Burdenko was an outstanding Soviet surgeon, one of the founders of neurosurgery, academician of the Academy of Sciences of the USSR (1939) and the Academy of Medical Sciences of the USSR (1944-1946), Hero of Socialist Labor, honorary member of the British Royal Society of Surgeons and the Paris Academy of Surgery, Colonel General of Medical Service.

Despite the progress in understanding the pathogenesis of diffuse brainstem tumors, treatment of these neoplasms is usually empirical and conducted without morphological and molecular verification. Liquid biopsy is a minimally invasive technique providing data on tumor biology without standard biopsy. This method is based on analysis of cell-free nucleic acids (predominantly, extracellular DNA) in biological fluids with detection of specific mutations. Despite wide implementation in diagnosis and disease monitoring in extracranial malignancies, it is infrequently applied in neuro-oncology.

Objective: To estimate diagnostic value of liquid biopsy in detecting H3K27 and BRAF V600E mutations in patients with diffuse brainstem tumors.

Material and methods: Lumbar puncture with cerebrospinal fluid sampling was performed in 16 patients (5 children and 11 adults) with diffuse brainstem tumors verified by neuroimaging data. Cell-free DNA (cfDNA) was used in digital droplet PCR for determination of H3F3A K28M and BRAF V600E oncogenic missense variants. In 14 patients, investigation of cfDNA was performed in parallel with analysis of correspondent mutations in DNA derived from tumor tissue.

Results: None patient had BRAF V600E mutation. H3F3A K28M variant was detected in 5 CSF samples and 6 tumor specimens from patients who underwent surgical biopsy. Thus, overall sensitivity of the method in determination of H3F3A K28M variant was 92.9% (13/14).

Conclusion: Liquid biopsy is highly informative for identifying the specific mutation H3F3A K28M and often verifies diffuse brainstem glioma without standard biopsy.

Sellar tumors are predominantly benign neoplasms accounting for approximately 14-18% of all brain tumors. For many decades, there have been a few clinical cases confirming possible simultaneous coexistence of two nosological groups in one area. We present 2 rare cases of sellar collision tumors (a 61-year-old male with pituitary adenoma and craniopharyngioma; a 68-year-old female with pituitary adenoma and meningioma of tubercle), clinical features, anamnesis, preoperative neuroimaging, intraoperative picture and postoperative outcomes. Combination of pituitary adenoma and craniopharyngioma/ meningioma as a type of collision tumors requires caution at all stages of treatment due to impossible preoperative analysis of tumor density and, accordingly, correct choice of surgical access. Transsphenoidal endoscopic access reduces mortality rate according to literature data. Preoperative MR elastometry needs to be studied in depth including patients with sellar collision tumors.

Background: Preoperative examination of patients with focal drug-resistant epilepsy requires invasive diagnostic methods in 30-40% of cases. Stereo-EEG is one of them and often the most significant for verification of epileptogenic zone and its subsequent resection. The desire to minimize surgical trauma led to idea of local radiofrequency thermocoagulation through SEEG electrodes [1]. This allows destruction of epileptogenic zones during examination. Despite the safety of this method, appropriate studies are contradictory and require further analysis [2].

Objective: To clarify the role of radiofrequency thermocoagulation in diagnosis and treatment of patients with focal drug-resistant epilepsy.

Material and methods: A single-center retrospective study included 75 patients with focal drug-resistant epilepsy who underwent radiofrequency thermocoagulation between 2020 and 2023. The results were assessed 6 and 12 months after thermocoagulation.

Results: Six-month freedom from seizures was 35% (26 patients). Seizure rate decreased by more than 50% (McHugh I-II) in 39 (52%) patients. Most patients with the McHugh II outcome (10 out of 12) experienced less incidence and intensity of seizures. This made unnecessary subsequent surgery. MR-negative nature of epilepsy (p=0.015), right-sided localization of epileptogenic substrate (p=0.032) and bihemispheric distribution (p=0.05) were negative predictors of treatment outcomes. A relationship was found between localization of radiofrequency thermocoagulation in the frontal lobe and freedom from seizures. Mean volume of one thermocoagulation point was 0.98±0.3 cm³. The number of points did not significantly influence the outcomes either for the McHugh scale (p=0.654) or for the Engel scale (p=0.288). Total volume of thermocoagulation foci ranged from 0.52 to 13.5 cm³ (mean 3.85±2.9). Twenty-six (35%) patients underwent surgery for persistent and/or recurrent seizures after radiofrequency thermocoagulation (SEEG-guided resection of epileptogenic zones). After 12 months, freedom from seizures was 28% (21 patients), seizure rate decrease by more than 50% (McHugh I-II) was observed in 33 (44%) patients. McHugh class III outcome was observed in 12 patients (16%). MR-negative nature of epilepsy (p=0.009) and right-sided localization of epileptogenic substrate (p<0.001) were negative predictors regarding Engel I outcomes.

Conclusion: Stereo-EEG-guided radiofrequency thermocoagulation is a unique and safe technique significantly reducing the incidence and intensity of epileptic seizures in patients with focal drug-resistant epilepsy with minimal iatrogenic risk.

Rationale: Hydrocephalus as a consequence of intraventricular hemorrhage (IVH) in premature infants is a life-threatening complication of the neonatal period. The question remains as to which methods are best to be used for temporary drainage of cerebrospinal fluid until sufficient body mass for possible shunt implantation is achieved.

Objective: Is to compare four methods of temporary treatment of posthemorrhagic hydrocephalus in terms of their safety and effectiveness.

Material and methods: A multicenter (12 healthcare facilities of the Russian Federation) prospective study included 165 premature infants with IVH and signs of worsening enlargement of the ventricles. External ventricular drainage (EVD) was used in 43 observations, ventriculosubgaleal shunt (VSGS) in 93 observations, neuroendoscopic lavage (NEL) in 25 observations and Ommaya reservoir - in 4. Methods were compared by effectiveness and postoperative complications. The examination of patients in catamnesis was carried out at the age of 6, 12, 24 and 36 months.

Results: Differences regarding brain tissue defect in the access zone (the highest in the NEL group and the lowest in EVD group, p<0.001); multilocular hydrocephalus frequency (the highest in the EVD group - 33% and the lowest in the NEL group - 17%, p<0.05); proportion of patients in need of permanent shunting (the highest indicator in the VSGS group - 88.1% and the lowest in the NEL group - 57%, p<0.001); number of infectious complications (most of all in the EVD group - 12%, the lowest in the NEL group - 0%) have been revealed. The best indicators of children's motor development have been noted in the NEL group (2.25), the worst in the EVD group - 3.75. Long-term mortality in the distant period amounted to 7%.

Conclusion: The most effective method of temporary arresting of hydrocephalus is neuroendoscopic lavage. It has a minimal number of infectious and other complications, the best hydrocephalus stabilization, low percentage of complicated hydrocephalus (multilocular) and the best motor development indicators and does not require reinterventions.