Objective: to estimate the surgical treatment outcomes in patients suffered from various types of pharmacoresistant epilepsy. Material and methods: 43 patients suffered from various types of pharmacoresistant epilepsy were examined and treated under condition of neurosurgical department of Scientific Research Institute of Emergency Care n.a. N.V. Sklifosovkiy from 01 Jan 2014 till 31 Dec 2015. Results: the received data of our study confirmed the safety and efficacy of surgery for symptomatic pharmacoresistant epilepsy treatment. The seizure control was achieved in 69,5% of operated patients (follow-up and check point in 12 months). Conclusion: The presented data confirmed the safety and efficacy of surgery for various types of pharmacoresistant epilepsy treatment as well as the necessity of full adequate examination of all patients suffered from pharmacoresistant epilepsy for making the decision concerning the possible surgical treatment.

Objective. to present the preliminary experience of differentiated strategy for the usage of various keyhole approaches for the treatment of anterior circulation aneurysms. Material and methods. Authors operated 90 patients with 95 aneurysms of anterior circlulation from 2014 to March 2016. The majority of patients had unruptured aneurysms (62 patients). Subarachnoid hemorrhage (SAH) was observed in 28 patients, among them 18 patients were operated on in the acute period of SAH. The severity of state of all patients with SAH was assessed as I and II stage according to Hunt-Hess scale and intensity of SAH was 1-2 by Fisher scale. The choice of surgical approach was determined after accurate assessment of intracranial structures and aneurysms anatomy. Results: All aneurysms were completely excluded from the cerebral blood flow. No serious complications or deaths were observed in examined group. Conclusion. The progress of minimally invasive procedures and adequate selection of patients for operation allow significantly lowering the surgical trauma, the number of associated complications and incidence of adverse cosmetic effects. The fast recovery of patients and shortening the in-hospital stay period alongside with the social adaptation after neurosurgical procedures is the priority direction nowadays.

Objective. to present the clinical case of transciliary supraorbital craniotomy for the clipping of unruptured aneurysm of the posterior communicating artery. Material and methods. The indications and contraindications for minimally invasive surgery of aneurysms as well as surgical technique are discussed. Results. The supraorbital keyhole approach to anterior circulation aneurysms under condition of adequate patients’ selection has confirmed its high efficacy and safety in the hand of experienced neurosurgical team. Conclusion. The supraorbital craniotomy allows adequately visualizing the necessary intracranial structures despite its small dimensions.

Objective: to evaluate the changes of visual function and to analyze the causes of visual impairment in patients suffered from paraclinoid aneurysms of internal carotid artery as well as from aneurysms of anterior cerebral and anterior communicating arteries after aneurysms clipping. Materials and methods: the risk of postoperative visual disturbances was estimated as high in 70 patients with paraclinoid aneurysms of internal carotid artery as well as with aneurysms of anterior cerebral and anterior communicating arteries. All these patients underwent comprehensive assessment of visual functions using standard examination methods before and after surgery. Results: early postoperative complications in form of acute optic neuropathy were observed in 7 patients (10%) with paraclinoid aneurysms, among them 4 patients had improvement of visual functions during the treatment in the early postoperative period, 2 patients had improvement of visual functions within 3-6 postoperative months, and 2 patients had no any improvement. There were no postoperative visual disturbances in patients with aneurysms of anterior cerebral and anterior communicating arteries Conclusion: satisfactory visual functions in the preoperative period in patients with paraclinoid aneurysms of internal carotid artery do not always mean the preservation of optic nerve. The patients suffered from ophthalmic aneurysms with upward dome position have the worst prognosis for visual functions preservation in postoperative period.

Objective: to determine the influence of perioperative analgesia methods on the incidence of « failed back surgery syndrome» after intervertebral discal hernia removal. Material and methods: This prospective study was conducted from 2010 till 2013 and included 129 patients who underwent lumbar discectomy regarding intervertebral discal hernia. Patients of group GA+R (n=20) were operated on under general anesthesia (GA) and received «analgesia at request» (R) in postoperative period. Group SA+PMA included patients (n=23) who were operated under spinal anesthesia (SA) with the following usage of preventive multimodal analgesia (PMA) based on ketoprofen, paracetamol and nalbuphine. General anesthesia and PMA was used in GA+PMA (n=21) group; the additional wound infiltration by bupivacaine solution (I) was used in GA+PMA+I (n=21) group; application of corticosteroids (A) in the area of damaged spinal root - in GA+PMA+A (n=20) group; combination of wound infiltration by bupivacaine solution and application of corticosteroids - in GA+PMA+IA (n=24) group. The intensity of acute postoperative pain was assessed within 7 postoperative days. The phone interview was conducted in 6 months after operation with examination of long-term outcomes of surgical treatment. Results: The analgesia was inadequate in all patients of GA+R group within 4 postoperative days comparing with adequate analgesia in patients of GA+PMA group during whole period of observation. The pain syndrome within first 4 postoperative days had significantly lower intensity among patients of GA+PMA group comparing with GA+R group. Patients of SA+PMA group reported that pain intensity was significantly lower only during first 2 hours after operation comparing with GA+PMA group. Patients of GA+PMA+I and GA+PMA+IA groups had lower intensity pain within 2 postoperative days comparing with GA+PMA group. Studying the long-term outcomes of surgical treatment it was revealed that 60% of patients had back and/or lower extremity pain, among them 30% - lower extremity pain in 6 months after operation. The mean pain intensity was assessed as 2,85 (2; 3) according to numeric rating scale, 24% of patients suffered from chronic pain reported about sleep disturbances, 23% - significant reduction in the life quality, 25% of patients were были unable to work. There were no statistically significant differences between examined groups concerning incidence of chronic back and/or lower extremity pain as well as lower extremity pain (p=0,459 и p=0,903 consequently, x² test) and mean pain intensity (p=0,112, Kruskal-Wallis test ANOVA) in 6 months after operation. Conclusion: The usage of preventive multimodal analgesic schemes provides the adequate pain control within 7 postoperative days while the usage of analgesia at request does not allow solving this challenge within first 4 postoperative days after intervertebral discal hernia removal. The spontaneous release of pain intensity is seen after 4th postoperative day. The SA usage in patients with discal hernia provides the pain release only during first several hours after operations (within time of residual subarachnoid block) comparing with patients underwent surgery under GA. The usage of wound infiltration by bupivacaine solution allows achieving the lowering of pain intensity during first 2 postoperative days comparing with patie nts without wound infiltration. The 60% of patients suffered from back and/or lower extremity pain and 30% of patients - from lower extremity pain in 6 months after operation/ More over the chronic severe pain syndrome is observed in 23-25% of patients, accompanied by sleep disturbances, inability to work and significant reduction in the life quality The incidence of failed back surgery syndrome occurrence after intervertebral discal hernia removal is independent of perioperative analgesia schemes.

Objective: To analyze the treatment effectiveness in patients with secondary facial pain and to study the pain evolution depending on the relationship of posterior fossa tumor and trigeminal nerve, histological type and size of tumors and extent of surgery. Materials and methods: 27 patients (23 women, 4 men) with benign skull base tumors and affected by secondary facial pain underwent open surgery from 2013 till 2016. The Visual Analog Scale (VAS), BNI Pain Scale and BPI-Facial were used for estimation of pain intensity. The surgical outcomes in relation to facial pain regress were assessed using scale by J. Miller (2009). Results: Secondary facial pain was obderved in 13.2% of pontocerebellar angle tumors (51.9% in meningiomas and 48.1% in schwannomas). The clinical manifestation was mimicking the trigeminal neuralgia type 1 in 85.2% and type 2 - in 14.8%. The tumor leaded to displacement of trigeminal nerve in the the majority of patients (71.4%) Neurovascular conflict with the intracranial vessel due to tumor displacement was observed in 14.3% and manifested as typical attacks of trigeminal neuralgia. The persistence of facial pain or pain relapses were identified in 17.8% of patients during postoperative period. Conclusion: High-density tumor more often caused various sensitivity disorder, neuropathy and resistance to antiepileptic drugs. The most significant value for the development of secondary trigeminal neuralgia plays the tumor localization near the trigeminal nerve root instead of tumor size. The development of facial pain can be caused even by military mass lesions of cerebellopontine angle region. The adequate and complete revision of the trigeminal nerve root is recommended to perform for well-time neurovascular conflict detection. The risk of pain relapses is higher in patients with partially removed tumor.

Despite the progress of endovascular treatment of cerebral aneurysms (CA) (stent-assisted and balloon-assisted aneurysm coiling, usage of flow diverting stents, development of new microcatheters, types of coils and stenting techniques («jailed-catheter technique» and «trans-cell technique» for aneurismal wall reconstruction, «Y-stent&waffle-cone technique» and «X-stent technique» for stenting of bifurcation aneurysms)) and the usage of new technical endovascular development which allows remodeling the blood flow in aneurysm (WEB-device, PED - Pipeline Embolization Device), the outcomes of secure CA occlusion by endovascular methods according to Raymond-Roy scale remain unsatisfactory with the large amount of Raymond II (residual neck) and Raymond III (residual aneurysms) results as well as high aneurysm recanalization rates and repeated operations (CLARITY (2011), ATENA (2009), АНА (2015), ISAT (2009), CARAT (2008), BRAT (2012), BRAT-3 (2014)). Microsurgical treatment of CA provides more radical exclusion of CA from blood flow (Raymond I) comparing with endovascular treatment. However the usage of routine approaches to aneurysms of basilar artery (BA) is limited because of high mortality and disability of patients. Objective: to enlight the modern cranial base approaches for microsurgical treatment of aneurysms of basilar artery. This article presents the most popular skull base approaches to basilar bifurcation as described by their authors. Results. The accurate technique of skull base approach performance, manipulations on skull base in surgically allowed areas and the extension of routine surgically routes with combination of various traction methods of basal brain regions turn the skull base approaches into unreplaceable manipulations.. Conclusion. The described skull base approaches allowed safely and securely eliminating basilar aneurysms from blood flow with good and excellent treatment outcome estimated by Glasgow Outcome Scale and Rankin scale.

Objective: to analyze the literature data concerning various types of surgical complications after transnasal transsphenoid operations. Material and methods: The analysis of 38 trials published from 1997 till 2015 and reflected various complications after transnasal transsphenoid surgery of pituitary adenomas is conducted. The published papers contain data concerning postoperative period in patients (from 50 patients in case of single center experience to 5527 patients in multi-center analysis) during multi-year follow-up. Results: Nowadays the endoscopic surgery of pituitary adenomas is the treatment of choice. However the surgical treatment of chiasmosellar mass lesions may be accompanied by various complications, among them nasal liquorrhea, secondary meningitis and hemorrhage within the tumor bed are the most frequently observed. The injury of cavernous part of internal carotid artery is rare but more dreadful complication. Such delayed postoperative complications as sinusitis, synechiae of nasal cavity or nasal septum perforation are considered as separate group. Conclusions: Despite the relatively high amount of postoperative complications after transnasal removal of pituitary adenomas, the most of them are successfully responded to treatment. The literature data justify that the number of intraoperative and postoperative complications is consequently decreased under increasing the number of conducted operations.

The subject of study: degenerative lumbar spinal stenosis in elderly and senile patients Objective: To examine the state of the problem of lumbar spinal stenosis surgery in elderly and senile patients. Material and methods: the analysis of literature data as well as discussion of various differentiated surgical treatment strategies for elderly and senile patients suffered from lumbar spinal stenosis and the review of unsatisfactory results causes as well as influence of comorbidity on treatment outcomes. Results. The basic classification, clinical manifestation and methods of diagnosis as well as differential surgical treatment and causes of unsatisfactory results of lumbar spinal stenosis surgery in elderly patients were discussed. Conclusions: the routine treatment strategy for spinal stenosis surgery is not applicable for the older age patients

Objective: to conduct the systematic review of published papers concerning syringomyelia associated with Chiari malformation type I as well as to examine and to assess the efficacy of various treatment strategies in patients with such pathology based of worldwide literature data. Material and methods: the source concerning «syringomyelia and Chiari malformation type I» against the accessible Internet databases including PubMed revealed 586 published papers with maximal numbers of clinical cases within the last 20 years. The analysis of these publications was performed. Conclusions: the systemic assessment was conducted and the efficacy of various treatment strategies for syringomyelia associated with Chiari malformation type I was examined based on analyzed literature data. The optimal treatment strategy for such patients was determined. This strategy includes well-timed decompression of posterior cranial fossa performed adequately upon indications and focused on improving of life quality and prevention of patients’ disability.

Objective: to present the current strategies for treatment of cerebral arteriovenous malformations (AVMs) with associated aneurysms (AA). Materials and methods: this article describes two patients with AVM and AA. These patients underwent successful treatment of AVM (microsurgical excision) as a primary source of intracranial hemorrhage but suffered from aneurysm rupture in postoperative period. Results: This article presents the detailed review of clinical cases and treatment strategy in both patients as well as the literature review dedicated to this problem. Despite the conventional thinking about primary surgery of the intracranial hemorrhage source, authors’ experience indicates that this strategy is not always justified. Conclusion: The accurate diagnostics as well as careful preparation for surgery is obligatory for patients suffered from AVM with hemodynamic AA require careful diagnostics and operation prepare. Hemodynamic AA should be treated simultaneously with AVM resection or as the first stage of surgical treatment regardless of source of primary hemorrhage.

Objective. To justify the «step by step» recommendations for practitioners concerning treatment decision for conservative therapy or surgery selection in patients suffered from brain injuries. Material and method. Analysis of published data devoted to mechanisms of formation and evolution of the brain injuries lesions; own material including data of 108 patients with traumatic brain injury (TBI), representing different variants of clinical and volume dynamic of traumatic brain lesions. Results. The basic mechanisms of brain injury lesions formation, getting involved with the course of time from the trauma, which is necessary to take into account along with routinely accepted clinical signs and neurovisualization criteria for treatment decision in patients with TBI are presented in this article. Conclusion. The adaptableness of decision making concerning conservative or surgical treatment of TBI lesions is justified. The suggested algorithm is based on current clinical signs and neurovisualization data as well as time from trauma and predictors of volume progression of TBI lesions.

Objective. To analyze the current challenges in neurosurgical education of residents and their solutions. Material and methods. The search against the database PubMed revealed 57 foreign publications devoted to the practical training of neurosurgeons in residency. The analysis of the valid Russian legislation concerning training in neurosurgical residency was conducted. Results. The analysis of the literature data allowed determing the ways to solve the named challenges in practical training of neurosurgical residents in Europe and United States and making the proposals for the reorganization of the practical training system in neurosurgical residency in Russian Federation. Conclusions. The active implementation of training simulation technologies and apprenticeship in hospitals are the main two ways for solving the challenges in neurosurgical education of residents.