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

Background: Growing skull fracture (GSF) of the orbital roof is a rare complication of head injury in infancy and early childhood. Analysis of the Medline database between 1983 and 2023 identified 17 articles describing 63 children after surgical treatment of GSF of the orbital roof.

Material and methods: We present a 2-year-old child with moderate traumatic brain injury (TBI) complicated by GSF of the orbital roof. Neuroimaging and literature data are described.

Results: Severe ophthalmological symptoms in acute period of TBI subsequently partially regressed with persistent swelling of the upper eyelid and hypophthalmos. CT and MRI revealed a linear fracture of the frontal bone extending to superior orbital wall and intraorbital collection of cerebrospinal fluid (pseudomeningocele) mixed with blood. MR signs of GSF of the orbital roof with pseudomeningocele shrinkage were found in 5 weeks after injury. After 6 months, CT and MRI revealed signs of more severe GSF. Surgical treatment implied craniotomy, excision of scars, arachnoid membrane and abnormal brain matter, resection of deformed fracture edges, dura mater sealing and orbital roof reconstruction with bone autograft. Ophthalmological symptoms regressed after 6 months. The follow-up period was 6 years. There were no signs of fracture recurrence.

Conclusion: In this case, acute intraorbital pseudomeningocele led to GSF of the orbital roof in 5 weeks after injury. Incomplete regression of ophthalmological symptoms, their aggravation or delayed appearance in children with orbital roof fracture requires a thorough examination including high-resolution CT and MRI, and orbital roof GSF should be considered in the differential diagnosis.

Melanoma is a malignant neuroectodermal tumor arising from skin pigment cells (melanocytes). Distant metastases and damage to the nervous system occur mainly at the later stages of disease. However, primary tumor may not be verified despite distant metastases in some cases. We present a patient with metastatic melanoma to the left median nerve and brachial plexus without clear primary lesion. This case describes surgical treatment of melanoma metastasis followed by median neuropathy.

Introduction: Cortical blindness occurs with bilateral damage to the visual cortex. It can be caused by various reasons, including the posterior cerebral arteries stroke due to the tentorial herniation.

Material and methods: A case of a 40-year-old patient with a large right-sided sphenoidal meningioma. A systematic review on the problem of cortical blindness after tentorial herniation according to the PRISMA guideline.

Results: Subtotal removal of dense meningioma. At night after the operation, there was an acute headache, then a coma. Immediately dehydration therapy, tracheal intubation, mechanical ventilation. CT scan showed a small hemorrhage in the tumor bed and subarachnoid space, brain edema and dislocation. After 53 minutes, ventricular drainage was installed, intracranial pressure was normal and ranged from 6 to 14 mmHg. After sedation withdrawal, cortical blindness was detected, which did not regress for 1.5 years. There are no other neurological symptoms, the patient walks, serves herself. Radiation therapy in a total of 54 Gy for the remainder of the grade 1 meningioma ensured tumor control.

Discussion: The time window for restoration of the cerebral blood flow, according to the European Stroke Organization guidelines, is 4.5 hours. In this case, compression of the posterior cerebral arteries lasted less than 53 minutes, however, irreversible ischemia developed in their territory; the outcome on the modified Rankine scale was 4 points. Similar cases are not described in the literature.

Conclusion: Patients should be warned about even the non-obvious risks of neurosurgical intervention, since even timely measures taken do not always avoid complications.

Primary central nervous system vasculitis is still a challenge due to rarity of disease, unspecific clinical and neurological presentation, as well as low specificity of MRI and laboratory tests.

Objective: To present the potential of hybrid neuroimaging in diagnosis of primary central nervous system vasculitis.

Material and methods: The results of MRI, PET/CT with 11C-methionine, histological and immunochemical data in a 23-year-old patient with first-time epileptic seizure are demonstrated.

Results: MRI revealed multifocal lesion of the left frontal lobe with contrast accumulation, edema and mass effect. The largest lesion demonstrated high 11C-methionine uptake that was typical for tumor. Stereotactic biopsy of this lesion was performed. Morphological examination revealed lymphocytic vasculitis.

Conclusion: Radiological and metabolic semiotics of primary central nervous system vasculitis can mimic cerebral tumor. High ¹¹C-methionine uptake in active inflammation focus is valuable to choose the target for biopsy.

To date, the optimal therapeutic and diagnostic strategy in patients with simultaneous clinical manifestations of degenerative cervical spine disease and upper-extremity nerve compression is still unclear.

Objective: To analyze the results of simultaneous surgical interventions in patients with cervical radiculopathy combined with distal peripheral compression-induced ischemic neuropathy.

Material and methods: We retrospectively studied postoperative outcomes in 23 patients with two-level degenerative cervical spine disease with radiculopathy and peripheral nerve compression (cubital canal, Guyon's canal or carpal tunnel syndromes). Two surgical teams performed interventions. Technical features of interventions, postoperative characteristics, clinical parameters (VAS scores of pain, NDI, SF-36 and DASH scores) and complications according to the Dindo-Clavien classification were studied.

Results: Mean surgery time was 104 min, blood loss - 75 ml, length of hospital-stay - 4 days. In long-term period, cervical pain score decreased from 73 (57;88) to 6 (3;11) mm (p=0.006), pain in upper extremities from 85 (74;95) to 3 (2; 5) mm (p=0.001), NDI from 74 (60; 86) to 6 (6;10) (p=0.001) points. Physical component of health increased from 26.12 (19.37; 35.51) to 52.26 (50.68; 56.42) (p=0.007) scores, psychological component - from 32.68 (18.57;40.52) to 54.92 (50.73;56.92) scores (p =0.003). DASH score of upper limb function improved from 74 (62;80) to 8 (6;10) points. There were 3 (13%) minor complications Dindo-Clavien grade I, II and IIIA after cervical spine surgery and 2 (8.7%) events after peripheral nerve repair. Only 1 (4.3%) serious complication (Grade IIIB, IV and V) was identified after cervical spine surgery.

Conclusion: Simultaneous surgery for cervical radiculopathy combined with peripheral nerve compression is safe and effective for appropriate patients.

Preserving the function of the facial nerve is extremely important in surgery for vestibular schwannomas. Two methods of arachnoid dissection are described for resection of vestibular schwannoma via retrosigmoid approach (from the brain stem and internal auditory canal).

Objective: To evaluate the results of arachnoid dissection of the facial nerve from internal auditory canal when resecting the vestibular schwannoma.

Material and methods: We analyzed 61 patients with vestibular schwannomas. Patients were divided into 2 groups depending on surgical technique. We estimated facial nerve function before and after surgery, preoperative dimension of vestibular schwannoma and extent of resection. The influence of various factors on extent of resection and postoperative facial nerve function was studied.

Results: Vestibular schwannoma resection from the brain stem was performed in 30 patients, arachnoid dissection - in 31 patients. There was no significant between-group difference. Gross total resection was performed in 78.7% of cases. Both techniques demonstrated similar results regarding extent of resection. Arachnoid dissection showed the advantage regarding facial nerve function immediately after surgery (p=0.012) and 6 months later (p<0.001). Normal facial nerve function in 6 months after arachnoid dissection was observed in 80.7% of patients. Preoperative dimension of tumor influenced facial nerve function in addition to technique of resection (p=0.001).

Conclusion: We identified the factors influencing facial nerve function after resection of vestibular schwannoma. Surgical technique was the most significant factor. These data expand and popularize arachnoid dissection in surgery of vestibular schwannomas.

Cerebral persistent primitive arteries are uncommon and associated with cerebrovascular diseases, like cerebral aneurysms. They can cause vertebrobasilar ischemia and neuropathy of the cranial nerves. The authors present a patient with trigeminal artery associated with giant partially thrombosed cavernous internal cerebral artery aneurysm.

Background: Tortuosity of intracranial arteries is rare and usually mistaken for arteriovenous malformations. In the world literature, the term «pure arterial malformations» is used to refer to this disease.

Objective: To summarize the experience of the Burdenko Neurosurgery Center on diagnosis of intracranial artery tortuosity, management and treatment of these patients, as well as to review appropriate literature data.

Material and methods: Tortuosity of intracranial arteries was detected in 11 patients (8 women and 3 men) aged 7-48 years who underwent outpatient or inpatient examination and treatment at the Burdenko Neurosurgery Center between 2009 and 2022. We analyzed angiographic, clinical and follow-up data of these patients, as well as appropriate literature data.

Results: According to angiography data, all patients had moderate dilatation, elongation and tortuosity of intracranial arteries without signs of arteriovenous shunting. The most common finding was tortuosity of several segments of internal carotid artery (5 cases). Lesion of PCA, PComA, MCA and ACA was less common. In 7 cases, the walls of the deformed vessels had calcified zones. In two cases, there were saccular aneurysms in the walls of the tortuous vessels. In one case, tortuosity was combined with kinking of the left subclavian artery, in another one - tortuosity of C1 segment of the right ICA. No patient had specific clinical manifestations. The follow-up period was 1-10 years in 7 patients. There were no changes in structure of tortuosity or appearance of new aneurysms.

Conclusion: Tortuosity of intracranial arteries is an extremely rare disease with the highest incidence in young women. This abnormality has no specific clinical manifestations and does not require surgical or conservative treatment. Tortuosity of intracranial arteries should be differentiated from arterial dolichoectasia, fusiform aneurysms and AVMs.

Objective: To assess the main performance indicators of neurosurgical departments in surgical treatment of cerebral aneurysms in the Russian Federation.

Material and methods: We analyzed 22 neurosurgical departments (19 regional and 3 federal hospitals) in 2017 and 2021. The study enrolled 6.135 patients including 3.160 ones in 2017 and 2.975 ones in 2021. We studied the features of surgical treatment of cerebral aneurysms in different volume hospitals and factors influencing postoperative outcomes.

Results: The number of surgeries for cerebral aneurysms decreased from 2.950 in 2017 to 2.711 in 2021. Postoperative mortality rate was 6.3% and 5.6%, respectively. The number of microsurgical interventions decreased from 60% in 2017 to 48% in 2021. The share of endovascular interventions increased from 40% to 52%, respectively. Endovascular embolization was accompanied by stenting in 55% of cases. Simultaneous revascularization was carried out in 2% of cases. In 2021, the number of patients undergoing surgery in acute period of hemorrhage increased to 70% (in 2017 - 61%). The number of hospitals performing more than 50 surgical interventions for cerebral aneurysms annually increased from 14 in 2017 to 17 in 2021.

Conclusion: Certain changes in neurosurgical service occurred in 2021 compared to 2017. Lower number of surgical interventions for cerebral aneurysms, most likely caused by the COVID-19 pandemic, is accompanied by lower postoperative mortality. Endovascular interventions and revascularization techniques became more common. The number of surgeries in acute period after aneurysm rupture and hospitals performing more than 50 surgical interventions for cerebral aneurysms annually increased.

An urgent problem in modern neurosurgery is resection of brain tumors adjacent to corticospinal tract (CST) due to high risk of its damage and subsequent disability. The main methods for prevention of intraoperative damage to CST are preoperative MR tractography and intraoperative electrophysiological monitoring. Both methods are used in pediatric neurosurgery. We reviewed the PubMed database since 2000 using the following keywords: «tumors of the hemispheres in children», «corticospinal tract», «MR tractography», «intraoperative electrophysiological monitoring». We present available literature data on preoperative MR tractography and intraoperative electrophysiological monitoring in children with supratentorial tumors near CST. Algorithm of intraoperative electrophysiological monitoring is often missing or insufficiently described. MR tractography is usually presented in case reports. Researchers do not compare the effectiveness of MR tractography and intraoperative electrophysiological monitoring. In case of MR tractography, a limitation is impossible CST reconstruction in children 2-3 years old. This may be due to unformed pyramidal system in these children.

Conclusion: Preoperative MR tractography and intraoperative electrophysiological monitoring are valid methods for assessment of CST. Optimal research parameters in children require careful study that will allow objective planning of each stage of preoperative management and increase resection quality for gliomas near CST in children without neurological deterioration.