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

Background: Craniosynostosis (CS) is a group of skull malformations manifested by congenital absence or premature closure of cranial sutures. Reconstructive surgery in the second half of life is traditional approach for CS. The issues of surgical stress response after reconstructive surgery for CS in children are still unclear.

Objective: To evaluate clinical and laboratory parameters in children undergoing traumatic reconstructive surgery for CS.

Material and methods: Inclusion criteria were CS, reconstructive surgery, age <24 months, no comorbidities and available laboratory diagnostic protocol including complete blood count, biochemical blood test with analysis of C-reactive protein, procalcitonin, ferritin and presepsin. The study included 32 patients (24 (75%) boys and 8 (25%) girls) aged 10.29±4.99 months after surgery between October 2021 and June 2022. Non-syndromic and syndromic forms of CS were observed in 25 (78.1%) and 7 (21.9%) cases, respectively.

Results: There were no infectious complications. We analyzed postoperative clinical data, fever, clinical and biochemical markers of inflammation.

Conclusion: Early postoperative period after reconstructive surgery for CS in children is accompanied by significant increase of inflammatory markers (C-reactive protein, procalcitonin, ferritin). However, these findings do not indicate infectious complications. This is a manifestation of nonspecific systemic reaction. Severity of systemic inflammatory response syndrome with increase in acute phase proteins indicates highly traumatic reconstructive surgery for CS in children. Analysis of serum presepsin allows for differential diagnosis between infectious complication and uncomplicated course of early postoperative period.

Theranostics combines diagnostics and therapeutic exposure. Regarding glioblastomas, theranostics solves the problem of detecting and destroying tumor stem cells resistant to irradiation and chemotherapy and causing tumor recurrence. Transmembrane surface antigen CD133 is considered as a potential marker of tumor stem cells.

Objective: To detect CD133 in patient-derived glioblastoma continuous cell cultures using fluorescence microscopy and modified aptamers (molecular recognition elements) anti-CD133.

Material and methods: To detect CD133, we used mousey fluorescence monoclonal antibodies anti-CD133 MA1-219, FAM-modified DNA aptamers anti-CD133 AP-1-M and Cs5. Non-aptamer DNA oligonucleotide NADO was used as a negative control. Detection was performed for three samples of patient-derived glioblastoma continuous cell cultures coded as 1548, 1721 and 1793.

Results: MA1-219 antibodies brightly stained cell culture 1548, to a lesser extent - 1721. There was diffuse staining of cell culture 1793. Cs5-FAM aptamer stained cells in a similar way, but much weaker. AP-1-M-FAM aptamer interacted with cells even weaker and diffusely stained only cell culture 1793. Non-aptamer NADO did not stain cell culture 1548 and very weakly diffusely stained cell culture 1793.

Conclusion: For both molecular recognition elements (MA1-219 antibody and Cs5 aptamer), 3 cell culture samples can be arranged in the following order possibly reflecting CD133 status decrease: strong signal for cell culture 1548, much weaker for 1721, even weaker for 1793. Only cell culture 1548 can be considered CD133 positive with combination of Cs5+ and NADO signals. Cell culture 1793 is CD133 false positive with combination of Cs5+ and NADO+ signals.

There is a problem of bacterial contamination of autologous blood despite long-term experience of intraoperative blood salvage and reinfusion.

Objective: To analyze safety of blood reinfusion with white blood cell filtration and X-ray irradiation for blood decontamination in neurosurgery.

Material and methods: The study included 57 patients with various neurosurgical diseases. We used intraoperative blood reinfusion in all patients considering high predictable risk of major blood loss due to neurosurgical diseases, features of neoplasm topography, anamnesis and examination data. Microbiological examination of autologous blood was carried out at different stages before reinfusion.

Results: Bacterial contamination of autologous blood samples was observed in 42% of patients. Enlargement of surgical access to paranasal sinuses in patients with craniofacial lesions poses a potential risk of bacterial contamination of autologous blood. Additional methods of decontamination including white blood cell filtration and X-ray irradiation reduced bacterial load. The above-mentioned methods were less effective for decontamination of microflora not typical for human skin compared to saprophytic ones. There were no postoperative infectious complications.

Conclusion: Combination of white blood cell filtration and X-ray irradiation reduces bacterial contamination and increases safety of reinfusion although these methods do not completely free autologous blood from opportunistic microorganisms. Decontamination quality significantly depended on microflora and surgical approach.

Prognosis of IDH (IDHwt) wild-type gliomas is worse compared to IDH-mutant tumors regardless of histological criteria for glioblastoma. However, there is still uncertainty regarding favorable course of disease and predictors of long-term survival in IDHwt gliomas.

Objective: To study the metabolic characteristics of IDH1wt diffuse astrocytomas using ¹¹C-methionine PET/CT and prognostic significance of PET-associated parameters for disease-free survival.

Material and methods: We analyzed 79 adults with IDH1wt diffuse gliomas. Quantitative analysis consisted of ¹¹C-methionine accumulation index and metabolic tumor volume. Kaplan-Meier and Cox analyses were used to determine prognostic significance of histological findings and PET parameters.

Results: Glioblastoma and astrocytoma grade 2 or 3 were diagnosed in 41% and 59% of patients, respectively. Accumulation index significantly differed between astrocytomas grade 2 and 3 (p=0.03). Significant predictors of disease-free survival were age, histological type of astrocytoma and tumor grade, contrast enhancement, PET-associated biomarkers (accumulation index and metabolic tumor volume) and compliance of metabolic pattern with glioblastoma syndrome (p<0.05). Disease-free survival >24 months was established for age <41 years, maximum accumulation index <1.64, tumor accumulation index <1.39 and metabolic tumor volume <13.44 cm³. In multivariate Cox analysis, independent predictors of disease-free survival were age and PET syndrome of glioblastoma.

Conclusion: Diffuse IDH1wt gliomas are a heterogeneous group differing in metabolic characteristics and prognosis. PET/CT with ¹¹C-methionine may be effective for stratifying patients into groups with unfavorable and favorable prognosis, as well as assessment of advisability of in-depth searching for IDH1/IDH2 mutation.

Cerebral aneurysms are diagnosed in 1-5% of people and cause 80-85% of subarachnoid hemorrhages (SAH). Aneurysmal hemorrhages are more common in people aged 30-50 years causing high socio-economic significance of this disease. Therefore, the outcomes of microsurgical clipping are an urgent problem in these patients.

Objective: To evaluate the immediate and long-term results after microsurgical treatment of cerebral aneurysms in acute period of hemorrhage; to analyze functional results and long-term outcomes, including higher mental functions and return to previous work.

Material and methods: The study included 517 patients in acute period of subarachnoid hemorrhage between 2019 and 2022. Severity of hemorrhage was assessed using the Hunt-Hess scale while the Fisher scale was valuable to estimate dimensions of hemorrhage and predictions for vasospasm. All patients underwent microsurgical clipping of aneurysms. We assessed clinical status and outcomes immediately after microsurgical clipping, within 2 weeks, 1, 3, 6 and 12 months after surgery. The Modified Glasgow Outcome Scale, Modified Rankin Scale (mRS), EQ-5D-3L Quality of Life Questionnaire, Mini-Mental State Examination MMSE and Hamilton Anxiety Rating Scale were used.

Results: After 1 month, mRS score 0 was observed in 22% of patients, score 1 - 17%, score 2 - 19.4%, score 3 - 6.2%, score 4 - 2.6%, score 5 - 1% of patients. Mortality rate was 6.4%. After 12 months, mRS score 0, 1, 2, 3 and 4 was observed in 67%, 15%, 8%, 3% and 0.4% of patients, respectively. After 12 months, 39 (8.3%) patients did not return to previous work. Among 427 (91.7%) patients who returned to previous work, 20% returned to work after 3 months, 65% after 6 months and 15% after 9 months.

Conclusion: Short-term and long-term functional outcomes vary significantly. There were significantly better mRS scores in long-term period compared to early period. Analysis of immediate and long-term results after hemorrhage will allow us to determine the most important predictors of adverse functional outcomes, assess the prevalence, characteristics, modifiable risk factors and consequences of hemorrhage.

Background: Botulinum toxin A (BTA) injections are effective for facial neuropathy. However, there is insufficient number of studies devoted to long-term management of these patients.

Objective: To evaluate the effectiveness and safety of BTA therapy in patients with facial neuropathy after neurosurgical interventions.

Material and methods: The study included 86 patients with facial neuropathy after surgical treatment of posterior cranial fossa and cerebellopontine angle tumors. All ones were divided into 2 groups: group I (main) - 57 patients with BTA prescribed early after facial nerve injury, group II (control) - 29 people undergoing exercise therapy, as well as special exercises and acupressure of painful muscle cords. The Sunnybrook Facial Grading Scale (SFGS) was used to assess facial symmetry and synkinesis, the Facial Disability Index (FDI scale) - to assess the quality of life. Overall duration of the study was 5 years (control points: 6 months, 1, 2, 3 and 5 years).

Results: The SFGS scores after 1, 2, 3 and 5 years were significantly better in the main group (resting symmetry p<0.01, voluntary movement symmetry p<0.01, synkinesis p<0.01, general condition of facial muscles p<0.01). Scores of physical and social functioning were significantly higher in the main group after 1 (p<0.01), 2 (p<0.01), 3 (p<0.01) and 5 years (p<0.01) after surgery. There was no need to change BTA dosage over 5 years. Thus, this form of BTA may be the most effective for synkinesis of facial muscles.

Conclusion: Correction of synkinesis caused by facial neuropathy requires long-term follow-up and long-term treatment. BTA is effective and may be recommended for long-term treatment of these patients.

Craniopharyngiomas (CP) are benign chiasmatic-sellar tumors in children and adults. Surgical resection is currently the main method for CP and largely depends on topographic and anatomical location of tumor.

Objective: To analyze topographic and anatomical classifications of CP available in the world literature.

Material and methods: Searching for literature data on classifications of CPs was performed in the PubMed, eLibrary and CyberLeninka databases between 1960 and 2023. We used the following keywords: «craniopharyngioma», «third ventricle», «endoscopic transnasal surgery for craniopharyngiomas».

Results: We found 21 eligible manuscripts. The vast majority of studies are devoted to topographic and anatomical location of CPs in their own series: baseline growth along hypothalamic-pituitary axis (4 classifications), relation to the third ventricle (5 classifications), pituitary stalk (2 classifications), optic nerves (2 classifications) and meninges (3 classifications), classification of papillomatous CPs (1 report) and adamantinomatous CPs (1 report), functional classifications of hypothalamic lesions (3 reports).

Conclusion: Topographic classifications of CPs characterize their relation to the most important basal brain structures: pituitary gland, hypothalamus, optic pathways and circle of Willis. There are also single topographic and anatomical classifications with emphasis on morphological component of CP. Exact anatomical and topographic variant of CP is often of decisive importance for choosing the optimal surgical approach, possibility and expediency of total resection. Further clarification of relationship of CP to diencephalic structures is associated with improvement of diagnostic methods, in particular, high-resolution MRI (7.0 T) and MR tractography.

Despite slow growth of most pituitary tumors and high rates of total resection and/or effective therapy, pituitary neoplasms are characterized by aggressive behavior with high growth rate, frequent relapses and resistance to standard treatments in 10% of cases. In modern WHO classifications of tumors of the central nervous system, endocrine and neuroendocrine tumors, the authors propose the definition «pituitary neuroendocrine tumor» instead of previous «pituitary adenoma» and «metastasizing pituitary neuroendocrine tumor» instead of «pituitary carcinoma». Currently, there are no effective prognostic markers of aggressive tumors. This complicates early diagnosis. It is proposed to apply a five-stage prognostic classification based on proliferation rate (including mitotic count, Ki-67 index and p53 immunoexpression) and morphometric markers of invasiveness for all resected pituitary neoplasms. This approach would be valuable for earlier detection of aggressive tumors and pituitary carcinomas. Compression of visual pathways, third ventricle and brain stem due to rapid growth of aggressive tumors usually requires redo surgeries with subsequent radiotherapy. Hormonally active tumors require therapy with somatostatin analogues and dopamine agonists in maximum possible doses. Chemotherapy with temozolomide as first-line option is recommended if standard treatment is ineffective. Alternative treatment includes peptide receptor radionuclide therapy (PRRT), molecular targeted therapy (bevacizumab, tyrosine kinase inhibitors, everolimus and cyclin-dependent kinase inhibitors) and immunotherapy (checkpoint inhibitors). Considering the need for combined treatment, these cases should always be discussed by a multidisciplinary team (neurosurgeon, endocrinologist, radiotherapist, oncologist, pathologist) with necessary qualifications and experience in treating these patients. Treatment of aggressive tumors and pituitary carcinomas is becoming an active and rapidly developing direction in neurosurgery, endocrinology and oncology.

Currently, there are no standards in surgical treatment of dumbbell-shaped tumors of lumbo-foraminal region.

Objective: To evaluate the effectiveness and long-term results of minimally invasive resection of dumbbell-shaped lumbar schwannomas Eden type 2 and 3 combined with transforaminal lumbar interbody fusion and transpedicular stabilization.

Material and methods: A retrospective study included 13 patients (8 men and 5 women) with lumbar dumbbell tumors Eden type 2 and 3 who underwent minimally invasive facetectomy through posterolateral anatomical corridor, microsurgical tumor resection and MI TLIF. We analyzed intraoperative parameters, neurological functions (ASIA scale), clinical characteristics (ODI, SF-36), and complications. Resection quality and area of the multifidus muscle were assessed according to MRI data. All patients were followed-up throughout at least 3-year.

Results: Surgery time was 147 min, blood loss - 118 ml, hospital-stay - 7 days. Clinical parameters significantly improved in the follow-up period: ODI score decreased from 72 to 12 (p=0.004), SF-36 PCS increased from 26.24 to 48.51 (p=0.006) and MCS score increased from 29.13 to 53.68 (p=0.002). According to MRI data, no tumor recurrences and severe muscle atrophy (>30%) were observed after 3 years in all cases. Superficial wound infection occurred in 1 (7.7%) case. There were normal neurological functions (ASIA type E) in all patients.

Conclusion: Minimally invasive facetectomy through posterolateral approach with MI TLIF technology can be used for safe and effective resection of dumbbell-shaped schwannomas Eden type 2 and 3.

Postherpetic neuralgia (PHN) is a rare complication of herpes zoster characterized by prolonged and excruciating pain. Traditional treatments for PHN, such as analgesics, anticonvulsants and antidepressants, do not always bring the desired result. One promising alternative that is attracting the attention of the scientific community is dorsal root ganglion stimulation (DRGS). This method focuses on targeted and precise targeting of the source of pain, providing a new level of effectiveness in the treatment of PHN.

Objective: A retrospective analysis of the technique and results of implantation of a permanent device for stimulating the spinal ganglia in patients with refractory PHN at the Burdenko Neurosurgical Center.

Material and methods: The study was conducted in 7 patients (5 men, 2 women) with refractory PHN in the period from 2018 to 2020. The age of the patients ranged from 57 to 84 years (average age 74±8.4). All patients were implanted with Boston systems (Precision or Spectra versions). Stimulation parameters: pulse width - 120-210 μs, frequency - 30-130 Hz, amplitude at the lower limit of the appearance of paresthesia with the possibility of increasing with increased pain up to 5 mA. The position of the electrode depended on the location of the pain. All systems were implanted under X-ray guidance.

Results: The duration of follow-up observation was more than 2.5 years. The average pain intensity one year after treatment was 3.42±2.45 points on the visual analogue scale (VAS) (a 62.3% decrease in intensity compared to baseline). In 3 (42.8%) patients, the result was characterized by us as «excellent» (intensity according to VAS decreased by 75% or more), in 1 (14.2%) - as «good» (intensity according to VAS decreased by 50-74%), in 1 (14.2%) - as «moderate» (VAS intensity decreased by 25-49% and in 2 (28.5%) as «unsatisfactory» (VAS intensity decreased by less than 25%, or postoperative complications occurred).

Conclusion: Given the complicated nature of PHN, the use of dorsal ganglion stimulation appears to be a promising and innovative treatment approach. Further research is needed to introduce this technique into clinical practice for the treatment of patients suffering from PHN.