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

Introduction: The concept of «complex» aneurysm is now widely used in the planning of neurosurgical interventions. It is obvious that the definition and objectification of this concept should be separate for microsurgical and endovascular treatment.

Objective: Is to objectify the «complex aneurysm» concept with regard to endovascular treatment.

Material and methods: A total of 739 patients, who underwent endovascular treatment of the unruptured aneurysm in the NMRC of Neurosurgery named after Academician N. N Burdenko in the period from 01.01.2018 to 01.02.2022, were analyzed. We evaluated 8 anatomical and morphological characteristics (AMCs) of the aneurysm and presence of 2 pathologies of brachiocephalic arteries (BCAs). Statistical analysis of the treatment results, determination of the statistical significance of differences in complications incidence depending on the presence of studied AMCs of the aneurysm and BCAs pathology were performed. On the basis of this analysis, an index of the complexity of endovascular treatment of unruptured aneurysms (ICAe) was created and the significance of differences in the incidence of complications according to the value of ICAe was evaluated. Web application for ICAe calculation - www.isae.rf - was created.

Results: The proportion of patients with pronounced neurological deficit on the day of discharge amounted to 0.8%, the incidence of death - 0.1% (1 patient). New neurological deficit after the surgery occurred in 4.6% of cases, moderate and severe complications - in 3.2% of cases. Non-radical aneurysm exclusion after 12 months was observed in 22.1% of cases.

At ICAe=0, the incidence of complications was lower in the general group by 0.9 - 10.9%. The ICAe value of 1 score was intermediate (part of complications occurred more often, part less). The incidence of adverse outcomes and complications was increased by 1.8-18.5% for ICAe=2, by 0.8-27.9% for ICAe=3 and by 6.5-28.7% for ICAe=4-5.

Conclusion: The created ICAe allows to objectively distinguish a group of aneurysms complex for endovascular treatment, stratify aneurysm complexity and incidence of adverse outcomes and complications.

Aneurysms with ICAe³2 can be classified as «complex» for endovascular treatment.

Surgical treatment of cancer patients with severe neurological symptoms is a complex multidisciplinary problem that often does not lead to a positive disease's outcome. It is also not always possible to perform operative treatment in a short time frame after paraparesis debut.

Objective: To evaluate the impact of the timeframe from the onset of neurological disorders to surgical decompression in patients with plegia, caused by the neural structures compression by the spinal tumor, on the disease's outcome.

Material and methods: An observation of 34 patients who underwent surgery for epidural tumor compression of the spinal neural structures from 2005 to 2021 was presented. Functional deficit was evaluated by the Karnofsky, ASIA AIS scales. All patients had paraplegia and sensitivity impairment (ASIA AIS A, B) before the operation. Primary sources were the mammary gland (7.7%), prostate (15%), kidney (27%), multiple myeloma (3.8%), lungs, liver and plasmocytoma (by 7.7% each), stomach, colon and chondrosarcoma (3.8%), other tumors (15.8%).

Results: Surgical treatment demonstrates a satisfactory result in the form of partial or complete restoration of the neurological deficit in a quarter of cases (23.5%) with no significant impact on life expectancy. Each day of persistent compression of the neural structures reduces the probability of neurological deficit regression by 4%.

Conclusion: Performance of surgery in patients with severe neurological disorders 27 days or more after the debut has an extremely low probability of restoring the ability to move independently. Diagnostic awareness in the detection of spinal tumors and timely surgical treatment of patients with the threat of developing epidural compression of the neural structures allow to reduce the risk of disability and improve the quality of life of patients.

Background: Metastatic brain lesions following Ewing sarcoma of bones and soft tissues in children are extremely rare and have unfavorable prognosis. There are few publications devoted to this issue. Survival rates after craniotomy are extremely low.

The authors describe a patient with metastatic form of Ewing sarcoma and two intracerebral (supra- and infratentorial) metastases. Total resection with subsequent radio- and chemotherapy were followed by stable remission for 23 months.

Background: High-risk cerebral AVMs (Spetzler-Martin grade IV-V) are characterized by higher cumulative risk of hemorrhage during life, as well as higher mortality and disability rates in case of rupture compared to low-risk AVMs. Nevertheless, there are currently no clear indications for surgical intervention for high-risk AVMs, and most patients with this disease are followed-up. However, available data on less favorable course of high-risk AVMs requires active surgical tactics to reduce long-term disability and mortality.

Currently, the following strategies are preferable for high-risk AVMs: combination of preoperative embolization with microsurgical resection and combination of partial endovascular embolization with subsequent radiosurgery.

Objective: To analyze the most common treatment combinations for high-risk AVMs regarding resection quality, functional outcomes and complications.

Material and methods: The study was carried out in accordance with international recommendations for systematic reviews and meta-analyses (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Searching was conducted in the Pubmed/Medline and eLibrary databases using the keywords «High grade», «Arteriovenous Malformations», «Management», «IV-V» and «AVM» for English-language search engines, "high-grade arteriovenous malformations." for Russian-language systems. Available full-text English- and Russian-language articles were selected between 1981 and 2024.

Results: Among 371 articles, 6 studies met the inclusion criteria. There were 478 patients who underwent two most common strategies for combined treatment of high-risk AVMs.

Conclusion: At present, there is no consensus on the advantage of certain combined method. There are data on less favorable course of high-grade AVMs and unsatisfactory outcomes after monomodal treatment. Thus, combined methods may be valuable for such AVMs.

Unlike widespread and well-studied atherosclerosis of supra-aortic arteries, non-atherosclerotic vascular diseases are less common. Of these, one of the most unusual is extravasal compression by additional structures between scalene muscles. Close topographic and anatomical connections of scalene muscles, vertebral and subclavian arteries, brachial plexus and stellate ganglion can lead to complex syndrome including impaired blood supply to the arm, brachial plexus compression and vertebrobasilar circulatory disorders. The main treatment method for supraclavicular compression syndromes is surgery. However, differential diagnosis, indications for surgical treatment and optimal technique are still discussable due to small incidence of disease. The key factor in determining treatment strategy is the cause of compression (congenital or acquired scalene muscle hypertrophy, age-related ptosis of the shoulder girdle; neck injuries; cervical spine degeneration). One of the rarest causes of compression is rudimentary additional cervical rib («cervical rib syndrome») and vessels. Combination of these factors is a casuistic etiology. The authors present a 25-year-old patient with stellate ganglion schwannoma whose mass effect caused dislocation and compression of subclavian artery by rudimentary additional cervical rib and scalene muscle. Surgical treatment including resection of tumor, release of the artery and scalenotomy restored arterial patency and eliminated clinical symptoms.

Background: Surgical treatment of skull base and craniovertebral junction chordomas remains a challenging task in modern neurosurgery. Currently, various anterior and posterior approaches are used to remove such lesions.

Objective: To present a 14-year-old patient with giant chordoma at the level of intact clivus and C1-C3 vertebrae. Surgery implied combination of approaches without disturbing stability of craniovertebral junction.

Results. t: Umor in lateral parts of spinal canal was removed via posterior median access, and ventral fragment was excised through transoral access. Resection of lower sections of clivus (5 mm) and upper edge of anterior C1 semicircle (2 mm) expanded the angle of surgical action from 7 to 11⁰ and accessibility zone necessary for maximum tumor removal and decompression of brainstem and upper cervical spinal cord without compromising stability of craniovertebral junction.

Conclusion: Patients with giant neoplasms of craniovertebral junction require a personalized approach. Total resection of craniovertebral junction chordoma is often accompanied by unreasonably high risk of impaired quality of life. In our opinion, maximum possible resection safe for quality of life with brainstem decompression and subsequent radiotherapy is advisable.

Differentiation of high-grade gliomas (WHO grades III and IV) is still a pressing issue despite advances of molecular biology in tumor stratification. Even with a comprehensive approach to differential diagnosis, uncertainty sometimes arises in classifying a glioma into a particular grade. This can complicate prognosis and selection of appropriate treatment.

Objective: To develop an effective method for differentiating high-grade gliomas based on marker gene expression analysis.

Material and methods: We analyzed expression of 31 marker genes in high-grade glioma samples (Grade III and IV) diagnosed with isocitrate dehydrogenase (IDH)-mutated oligodendroglioma, IDH-mutated astrocytoma and IDH-wildtype glioblastoma. Real-time polymerase chain reaction was used. Spearman rank correlation method was applied to select genes whose expression was most closely related to glioma grade. Gene expression and their ratios were compared in groups of Grade III and IV malignant gliomas using the Mann-Whitney test.

Results: Expression ratios of three genes (CD44, CIRBP, and SOX2) were selected to assess malignancy grade. Expression ratios for these genes distinguishes IDH wild-type glioblastomas from IDH-mutated astrocytomas and oligodendrogliomas. They also have a stronger correlation with glioma grade than expression of each individual marker gene.

Conclusion: Original method based on marker gene expression ratios does not replace standard diagnostic protocols, but may be an additional tool for optimized diagnostic process. This approach will be valuable to minimize errors and personalize therapeutic strategies. The last one is critical for prognosis.

Primary hypophysitis is a rare disease that is usually diagnosed retrospectively after surgery for suspected tumors of the sellar region (pituitary adenomas, craniopharyngiomas, etc.). The most common variant of the primary forms is lymphocytic hypophysitis, characterized by the presence of lymphocytes in the inflammatory infiltrate. Granulomatous hypophysitis is the second most common variant of the disease, the cause of which remains unknown.

Objective: To study the frequency and nature of clinical manifestations, the features of MRI of the brain, as well as the results of neurosurgical treatment of patients with a confirmed histological diagnosis of hypophysitis.

Material and methods: A retrospective analysis of the case reports of 14 patients with histologically confirmed diagnosis of lymphocytic (13 cases) and granulomatous (1 case) hypophysitis operated at the Burdenko Neurosurgical Center.

Results: In none of the cases before the operation, according to the MRI data, the diagnosis of "hypophysitis" was made. Clinical symptoms were manifested by headaches in 12 patients, decreased acuity and/or visual field impairment in 9 patients, oculomotor impairments in 2 patients. Hypopituitarism was detected in 12 cases, and diabetes insipidus in 8 cases.

After surgery, 7 patients had a regression of headache and improved vision, in 5 cases there was no dynamics, in 1 case vision deteriorated. In all 8 patients with diabetes insipidus, it persisted after surgery. There were no new cases of diabetes insipidus. Panhypopituitarism was noted in all patients.

Conclusion: Given the difficulty of diagnosing hypophysitis without morphological verification, as well as the rarity of these cases, prospective multicenter studies are needed to study the pathognomonic signs of hypophysitis and improve their neuroimaging methods.

Background: Hemorrhagic stroke is associated with high risk of adverse outcome and follows intake of anticoagulants and antiplatelet agents in 25% of cases. The latest clinical guidelines of the Neurocritical Care Society for correction (reversal) of the effect of anticoagulants and antiplatelet agents in hemorrhagic stroke were published in 2016.

Material and methods: In accordance with PRISMA recommendations, we reviewed the PubMed, eLibrary and UpToDate databases to a depth of 5 years and selected 48 articles.

Results and discussion: Direct oral anticoagulants are currently common. To reverse their effect, one can use specific antidotes (idarucizumab is recommended for dabigatran, andexanet alfa (not yet registered In Russia) for factor Xa inhibitors (rivaroxaban, apixaban)) and combination of prothrombin complex concentrate and tranexamic acid. Protamine sulfate is antidote for unfractionated and low molecular weight heparins. Protamine sulfate completely inactivates unfractionated heparin, but it is less effective against low molecular weight heparin. It is characterized by high probability of anaphylactic reactions, especially after repeated administrations. The effectiveness of andexanet alpha and activated factor VII for reversing the effect of low molecular weight heparin is being studied. Fondaparinux sodium is used for heparin-induced thrombocytopenia. Protamine sulfate is ineffective for reversing the effect of fondaparinux. One can use prothrombin complex concentrate and andexanet alpha, but their effectiveness is unclear. Ciraparantag is being studied in clinical trials. Apparently, ciraparantag is highly effective as an antidote for various anticoagulants.

Conclusion: Early hemostatic therapy and reversal of anticoagulant effects in patients with hemorrhagic stroke significantly reduce the risk of adverse outcomes. This problem is being studied. Regular literature review with creation of updated clinical guidelines is needed.

Background: To date, 16 cases of en plaque hyperostotic meningioma of the convexity have been described. There are no clinical guidelines for the treatment of such patients.

Objective: To study the factors influencing the results of surgical treatment of en plaque convexity hyperostotic meningioma, to formulate the appropriate decision-making algorithm.

Material and methods: A retrospective total group of 69 patients with en plaque convexity hyperostotic meningioma who underwent surgery at Burdenko Neurosurgical Center between 2014 and 2023. We analyzed clinical manifestations, tactics and results of surgery and radiotherapy using statistical methods.

Results and discussion: Total resection of small local non-infiltrative hyperostotic meningioma not involving the superior sagittal sinus did not cause neurological deterioration. In case of spread infiltrative hyperostotic meningiomas, the best results (including regression of intracranial hypertension in all cases) were obtained after non-radical surgeries (resection of hyperostosis without wide excision of the dura or even without dura opening). Extent of resection of involved dura and intracranial tumor did not affect relapse-free survival. Additional morbidity at discharge from the clinic was 35%, after ≥6 months - 16%. The most common (27.5%) complication was pseudomeningocele. Redo surgery rate for pseudomeningocele - 7%, hematomas - 7%, wound infection - 6%. There were no mortality in the series. Radiotherapy increased relapse-free survival without statistical confirmation.

Conclusion: Total resection provides optimal results in patients with small convexity hyperostotic meningioma and no brain invasion. Resection of hyperostosis and expansive cranioplasty are preferable for large and giant convexity hyperostotic meningioma involving venous sinuses and / or the brain.