Introduction. The patients suffered from multiple aneurysms with at least one of large or giant size put together 19,6% among all patients admitted into Scientific Research Institute of Neurosurgery n.a. N.N. Burdenko requiring accurate preoperative estimation and individual treatment strategy. Material and methods. We conducted the analysis of treatment outcomes at 22 patients with multiple bilateral aneurysms of internal carotid artery (ICA), one of which had large or giant size/ All these patients underwent step-by-step or combined surgical treatment. The total amount of aneurysms located on various ICA segments was 61. The average patients’ age was 45,6±5,9 years old, men : women - 6 : 16. The mass effect of aneurysm was seen at 7 patients, 15 patients suffered from subarachnoid hemorrhage (among them 4 were operated on in acute period of hemorrhage). Results. The radicality of surgical treatment of intracranial ICA aneurysms was 89,1% (46 aneurysms). The single-step treatment was performed at 8 patients, two-step - at 12 patients, 3- and 4-step surgery - one and one clinical case. The good functional outcomes (GOS = 4 - 5) after step-by-step surgical treatment were achieved at 15 (68,2%) patients at discharge and at 14 (87,5%) patients with known follow-up. This article demonstrates the current possibilities of microsurgical and endovascular methods using clinical cases as well as discusses the treatment outcomes and choice of treatment strategy. Conclusion. The combination of microsurgical and endovascular treatment methods allows achieving favorable treatment outcomes at patients with multiple ICA aneurysms. The choice of treatment strategy should be based on clinical condition of patient as well as on anatomical features of aneurysms and treatment opportunities of certain hospital.

Objective. To study the frequency of intraoperative arterial thrombosis (IAT) during microsurgical treatment of large and giant partially thrombosed aneurysms of middle cerebral arteries (MCA) and to assess various options to treat this complication. Materials. The consecutive series of 53 patients operated on for partially thrombosed MCA aneurysms in Burdenko Neurosurgical Institute from January 2005 to September 2014 were analyzed. The large aneurysms (15-25 mm) were seen at 32 patients, giant (> 25 mm) aneurysms - at 21 patients. Results. The aneurysm clipping was performed at 47 patients, trapping - at 3, wrapping with surgical gauze - at 3. IAT was diagnosed at 10 (18.9%) patients. The injection of modified human recombinant prourokinase (mr-proUK) in the thrombosed artery was performed at 7 patients, among them 5 (71.4%) patients were discharged without any changes in the neurological status, one (14.3%) patient - with moderate deterioration (MRS 2) and one (14.3%) patient - with severe deterioration (MRS 4). Among patients without injection of mr-proUK (3 persons) two patients suffered from severe (MRS 3 and 4) and one - from moderate deterioration (MRS 2). Conclusion. The main risk factor for thrombosis of MCA branches is thrombectomy under condition of temporary trapping. The injection of fibrinolytic drugs in thrombosed MCA branch is an effective method to treat IAT. The revascularization operation (bypass) should be considered in the case of fibrinolytic agent fails to solve the problem.

Objective. To estimate the endovascular treatment outcomes in the surgery of asymptomatic unruptured intradural aneurysms of anterior circulation of the circle of Willis. Material and methods. Retrospective analysis of 92 patients with unruptured aneurysms of the anterior part of the circle of Willis treated at Burdenko Institute of Neurosurgery in the period from 2000 to 2011 was performed; patients’ age varied from 12 to 73 years. Multiple aneurysms were discovered at 11 patients. Endovascular embolization by coils was performed at all cases, 35 patients also underwent stent and balloon assistance. Results and discussion. The following clinical outcomes have been observed: absence of neurological deficits in 86 (93.5%), permanent neurological deficits in 5 (5.4%) cases; intraoperative ruptures were seen in 3 patients, thromboembolism - 3 patients. Mortality was 1,1%. Complete occlusion was achieved in 70 (76.05%) cases, subtotal in 19 (20,65%) and partial occlusion in 3 (3.3%) cases. During follow up period (from 1 till 11 years) including 52 patients the complete aneurysm occlusion was maintained in 95% of cases. None of the treated patients with subtotal and partial occlusions suffered from intracranial hemorrhage during the follow-up period. Conclusion. The endovascular treatment by skilled surgeons could be the treatment choice for random intradural aneurysms of the anterior circle of Willis.

Objective. To estimate the methods of surgical treatment at patients with combined tortuosity of common and internal carotid arteries and their atherosclerotic lesions as well as to define the frequency of such combined pathology. Material and methods: we operated 18 patients with combined tortuosity of common (CCA) and internal carotid arteries (ICA). All patients had symptomatic lesions of brachiocephalic arteries (BCA). Patients were divided into 3 groups: 1st group (n=4) and 2d group (n=4) - combination of CCA and ICA tortuosity without their atherosclerotic lesions while the patients of 3d group (n =10) had associated atherosclerotic stenosis of BCA. Results: The following operations were performed in 1st and 2d groups of patients: 7 cases - CCA resection with bringing down of its bifurcation and the following «end-to-end» anastomosis, this method was accompanied by external carotid artery (ECA) ligation. The following operations were performed in3d group of patients: 3 patients underwent eversion endarterectomy from ICA with forming of its anastomosis in the region of its “old” orifice in CCA; 5 patients - eversion endarterectomy from CCA bifurcation with its «end-to-end» anastomosis, 3 patients also underwent ECA ligation. We estimated the level of CCA bifurcation intraoperatively. There were no lethal outcomes. The transient ischemic attack was seen at 3 (16,7%) patients, hypoglossal nerve paresis - at 3 patients (16,7%). Conclusion: The choice of reconstruction method depends on the length of ECA trunk, presence of associated atherosclerotic stenosis as well as excessive length of ICA and structural features of arterial wall in the case of ICA pathological tortuosity.

Objective. To determine the angular parameters of operative wound and observation directions of difficult accessible segments of circle of Willis via orbitozygomatic approach. Material and methods. The orbitozygomatic approach was simulated on 30 anatomical specimens during our study. The angular parameters of operative wound and accessibility of basal observation of А1 segment of anterior cerebral and anterior communicating arteries, clinoid segment of internal carotid artery and bifurcation of middle cerebral artery as well as basilar tip and orifice of anterior inferior cerebellar artery were estimated. The assessment of operative wound parameters consisted of measurement of projection, vertical and horizontal angles and depth of wound. All approaches were performed on anatomical specimens using operative microscope MBS-10, routine set of neurosurgical instruments and high speed neurosurgical bone drill. Results. The orbitozygomatic approach decreases the projection angles for difficult accessible segments of circle of Willis. The vertical operative angles increased by 2 times for А1 segment of anterior cerebral and anterior communicating arteries, by 2-4 times for clinoid segment of internal carotid artery, by 1,5 times for bifurcation of middle cerebral artery and by 3-8 times for basilar tip comparing with pterional approach. The vertical angles increases by 3-4 times for orifice of anterior inferior cerebellar artery while using orbitozygomatic transcavernous approach comparing with retrosigmoid approach and by 1,5 times comparing with orbitozygomatic approach. Conclusions. The orbitozygomatic approach is the general for achieving of aneurysms located on difficult accessible segments of circle of Willis as well as for aneurysm dissection and clipping as well as for various variants of transcavernous approaches and extended approaches via floor of middle cerebral fossa (anterior petrosectomy) as well as for temporopolar extradural, preauricular infratemporal and combined postauricular transpetrosal apprpaches with transposition (or without) of internal carotid artery, VII nerve and sigmoid sinus.

The main reason for low back pain in 15-30% of clinical cases is the pathology of sacroiliac joint (SIJ) instead of degenerative vertebral diseases. The majority of neurosurgeons deeply involved in the treatment of spinal and vertebral pathology are quite unfamiliar with this pathology. This literature review enlights the diagnostics, signs and principles of treatment for SIJ lesions. The main accent is made on clinical usage of radiofrequency denervation of SIJ, because this technique is hardly used in Russian Federation.

The discussions concerning methods and strategy treatment for brain metastatic lesions are still conducting in spite of high level of current evidence-based healthcare. The rapidly growing evidence database demonstrates that radiotherapy provides effective and predictive local control over tumor lesions as well as allows extanding the patient’s lifetime and decreasing the probability of new metastatic lesions development. The complex approach including combination of whole brain radiotherapy and various methods of local treatment has the most therapeutic capacity and allows achieving the best treatment outcomes.

This literature review presents the current data concerning the usage of interspinous vertebral fixation in the surgery of degenerative-distrophic diseases of lumbar spine. The biomechanical argumentation of such implants usage is presented. The results of the most important studies of clinical efficacy of interspinous vertebral fixation are described. The data of various studies comparing efficacy of interspinous vertebral fixation with other surgical methods for lumbar degenerative disease treatment are shown. The indications and contraindications for this technique usage are discussed.

The features of n. suralis endoscopic taking at children for reconstructive operations ion peripheral nerves are presented based on our own experience. The endoscopic taking of n. suralis for injured nerve plasty was performed at 4 patients at the age from 6 till 14 years old suffered from various pathologies of peripheral nerves. There were no addition skin incisions in all presented cases as well as no infectious complications in postoperative period. The 2-months follow up period revealed no complains about sensation disorders.

The usage of such current medical technologies as functional MRI, tractography, intraoperative sonography, neuronavigation, neurophysiological mapping of cortex and white matter of brain at patient in conscious lead to significant decrease of risk of postoperative neurological deficit development during removal of brain tumors located in the functionally significant brain areas. The usage of intraoperative neurophysiological mapping of cerebral cortex at patients in conscious using protocol “asleep-awake-asleep” allows increasing the radicality of removal of parenchymal tumors located in language significant areas with significant decrease risk of refractory postoperative neurological deficit development. However the performing of neurosurgical manipulations on brain under condition of “asleep-awake-asleep” protocol requires слаженной работы of a team including neurosurgeon, neurophysiologist, anesthesiologist, neuropsychologist and radiologist. This article presents the clinical case of successful surgical treatment of patient with left temporal and insular astrocytoma (grade II) with infiltration of language zones.

The tuberculosis of occipital condyles combined with tuberculous lesion of C1 and C2 vertebrae is described in literature as “suboccipital tuberculosis”, which is the extremely rare pathology and is accounting to not more than 1,5% among all tuberculous spondilytis. The neurological complications achieves 80- 89% among patients with this pathology and the lethality is 20% in the case of surgical treatment abandoning. These facts dictate the necessary of active surgical strategy which volume is determined by individual features of the process as well as surgeon’s experience. This article describes the clinical case of successful treatment of Приводим описание клинического наблюдения успешного лечения suboccipital tuberculous spondilytis, caused by mycobacteria with multiple drug resistance at patient with HIV-infection.

This clinical case describes the infectious complications after performing the multilevel puncture vertebroplasty (PVP) at the level of lumbar spine. The severe neurological disturbances (C type according to ASIA/ISIOP) were appeared in two weeks after PVP at female patient 65 years old suffered from postmenopausal osteoporosis and compressive L5 fracture because of purulent epiduritis and nonspecific spondylitis at the level of LIV and LV vertebrae. The nosocominal infection - Pseudomonos auriginosae - was discovered in postoperative material plating. The patient underwent staged surgical treatment which leaded to decline of inflammation process in lumbar spine and restoration of its support function with complete regress of neurological disturbances. The increase of number of postoperative complications is expected because of operative activity growth concerning spinal trauma and various spinal diseases. The only adherence of recommendations concerning accurate performance of surgical interventions as well as multicenter examination of surgical treatment outcomes under supervision of independent professional associations will allow investigating all causes for surgical complications development for their prevention.

The current problems of ethics in neurosurgery are enlightened. The factors of humanization and dehumanization of modern neurosurgery as well as the new contradictions of clinical neurosurgery generated by technologic progress are discussed. The solutions for neurosurgery humanization are presented.