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

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.

The main functional parts of the glymphatic system are perivascular spaces and surrounding astrocytes. Cerebrospinal fluid enters the brain parenchyma from subarachnoid cisterns through perivascular Virchow-Robin spaces and passes into the interstitium through aquaporin channels in astrocytes. Then, cerebrospinal fluid removes metabolic products and mixes with interstitial fluid. Outflow of cerebrospinal fluid with metabolic products from the brain parenchyma occurs in three ways. The first route is periarterial through intermuscular spaces in the middle layer of cerebral arteries. The second route is perivenous. The third route is lymphatic through meningeal or sinus-associated lymphatic vessels. They provide drainage of macromolecules and immunocompetent cells from the brain to the cervical lymph nodes. Gliomas are accompanied by inhibition of normal cerebrospinal fluid outflow pathways, mainly due to additional intracranial tissue, and compensatory cerebrospinal fluid outflow along the spinal cord. Reduced cerebrospinal fluid release with impaired outflow contribute to accumulation of toxic metabolic products, proinflammatory cytokines and chemokines. Transport of antigens to lymph nodes is inhibited that disrupts antitumor immunity. Impaired cerebrospinal fluid circulation also reduces the effectiveness of intracranial drug delivery. One of the mechanisms of pathogenesis of glioma metastasis is based on migration of tumor cells along classical and meningeal lymphatic pathways. Damage to the latter contributes to metastasis.

Review of the book by A.A. Skoromets, A.V. Amelin, E.R. Barantsevich, I.A. Voznyuk, A.P. Skoromets, T.A. Skoromets, V.A. Sorokoumov, N.V. Shuleshova Cerebral Angioneurology, ed. by Academician of the Russian Academy of Sciences Yu.A. Shcherbuk: in 2 vols. St. Petersburg: Polytechnic; 2024.

Background: The probability of meningiomas metastasizing is 0.18%, and the causes are unclear. The most common localizations of extracranial metastases are lung (37.2%), bones (16.5%) and liver (9.2%). There are no effective treatment algorithms for metastatic meningiomas. Treatment tactics consists of symptomatic surgery and radiotherapy.

Material and methods: We present 3 patients including a 75-year-old woman with grade 1 meningioma and metastasis to occipital lymph node, a 59-year-old man with meningioma grade 2 and lung metastasis, a 45-year-old woman with grade 2 meningioma with extracranial component and lung metastasis.

Results and discussion: A female patient with grade 1 meningioma and occipital lymph node metastasis showed clinical stabilization after surgical treatment. The follow-up was 14 months. Treatment with nitrosourea was ineffective for metastatic lung lesions in a patient with grade II meningioma. Combination of bevacizumab and everolimus in a patient with G2 meningioma within craniovertebral junction and metastatic lung lesion achieved stabilization in all foci. The follow-up was 6 months.

Conclusion: It is necessary to continue accumulation of clinical experience due to rarity of meningioma metastasizing. Treatment of such patients remains individual.

Glioblastoma is the most common primary malignant tumor of nervous system and one of the most incurable human tumors. The median of overall survival is 16-17 months after comprehensive treatment. Among various difficulties for new therapeutic approaches, we should emphasize the blood-brain barrier complicating delivery of anti-cancer drugs to neoplasm and perifocal area. A promising approach is aptamer molecules as synthetic amino acid analogs capable of interacting and regulating activity of target proteins based on their spatial structural interactions. Aptamers possess high specificity and affinity to various receptors on cell surface and inside its structures if they penetrate cell membrane. In this review, we present various approaches to development of aptamer-based drugs against glioblastoma. Kopylov A.M. et al. synthesized a series of aptamers targeting EGFR and capable for delivery of toxic agents to tumor cells. Important clinical successes include the results of NOX-A12 drug and data on combined drugs based on trastuzumab in patients with metastatic breast cancer. NOX-A12 is an aptamer blocking CXCL-12 gene and reducing resistance to irradiation of glioblastoma cells. Furthermore, very high control of breast cancer brain metastases in HER-2 positive cases was demonstrated for trastuzumab-emtansine and trastuzumab-deruxtecan. The last finding indicates the perspective for aptamer targeting glioblastoma tumor cells in conjugation with emtansine or deruxtecan.

Basilar artery aneurysm is a rare and difficult pathology that can require combination of various surgical methods. The authors present successful combined endovascular and microsurgical treatment of fusiform aneurysm of proximal basilar artery and confluence of vertebral arteries with high origin of the left posterior inferior cerebellar artery from aneurysm dome. The choice of preliminary revascularization of functionally significant artery involved in aneurysm and subsequent endovascular occlusion of aneurysm are considered.

Objective: To describe the first experience of internal thoracic artery for high-flow extra-intracranial bypass.

Material and methods: Internal thoracic artery was used for high-flow extra-intracranial bypass in a patient with giant aneurysm of internal carotid artery. Internal thoracic artery harvesting technique is presented. A systematic review is devoted to the role of internal thoracic artery in neurosurgery. The main advantages and disadvantages of internal thoracic artery are described.

Results: High-flow extra-intracranial bypass through internal thoracic artery allowed safe ICA occlusion. CT- angiography confirmed graft patency.

Conclusion: We present the first experience of internal thoracic artery for high-flow bypass. The advantages and disadvantages are described. A final decision in favor of one or another graft requires further research.

Objective: To test the possibility of creating a non-invasive system for differential diagnosis and molecular-genetic characterization of tumor lesions of the CNS based on the determination of mutations of promoter of telomerase (TERTp) C228T and C250T catalyst subunit through the example of glioblastoma.

Material and methods: The collection of blood plasma samples and tissues of freshly frozen tumor samples was obtained in pairwise correspondence from 52 patients, who were treated in NMRC of Neurosurgery named after Academician N.N. Burdenko in 2022-2023. The digital droplet PCR (ddPCR) method using fluorescently labeled TaqMan probes was used for absolute quantification of C228T and C250T TERTp mutations in DNA samples extracted from the collection by commercial kits. The analysis of ddPCR data was performed with a baseline depending on the level of control reaction signal without adding a DNA matrix.

Results: Analysis of the sample of 52 patients' paired DNA (plasma-tissue) has shown the presence of C228T and C250T mutations in tumor samples: C228T was found in 33 cases (63.5%), and C250T in 14 cases (26.9%). In samples of cell-free DNA (CFDNA), 5 samples with C228T mutation and 3 samples with C250T mutation were found. C228T mutation was found in 15.1% and C250T mutation - in 21.4%.

Conclusion: TERTp mutations, specific for tumor DNA of glioblastomas, are determined by ddPCR in both the tumor sample and the CFDNA of the blood plasma, which indicates the transition of tumor DNA into the circulating (ctDNA) and that the ctDNA passes through the blood-brain barrier (BBB) of patients. The possibility of non-invasive molecular genetic characterization of tumor lesions of the CNS in blood plasma of patients with glioblastoma has been tested. The obtained results' analysis shows the need to optimize the extraction of CFDNA and modify the testing system to improve the method's effectiveness.