The study objective is to analyze the results of using adenosine-induced cardioplegia during cerebral aneurysms clipping.

Materials and methods. The study included 15 patients who underwent microsurgical aneurysm clipping during period from 2016 to 2017.

 Results. In all cases it was possible to completely isolate the aneurysm from the circulation. No complications associated with the administration of adenosine were observed. It was shown that adenosine-induced cardioplegia can be used when temporary clipping is impossible because of changing in the parent vessel. Also, the using of adenosine is useful for “simple” aneurysms, which leads to a softening of the sack without additional injuries.

Conclusion. The combination of adenosine-induced cardioplegia and temporary clipping allows to provide better control over possible intraoperative bleeding and more comfortable positioning of the permanent clip on the aneurysm neck.

The study objective is to analyze the effectiveness of the use of minimal invasive polyetheretherketone (PEEK) rod systems in the treatment of lumbar spine degenerative diseases.

Materials and methods. The minimal invasive semi-rigid stabilization using PEEK rod systems was performed in 24 patients (4 (17 %) male and 20 (83 %) female) patients (mean age 46.3 ± 8.4, ranging from 32 to 63). The average follow-up duration was 15 months. Inclusion criteria: mechanical low back pain, White–Panjabi instability: 5 points, degenerative changes of the disc by C. Pfirrmann scale: II–IV grade. Follow-up at the 6 and 12 months postoperatively.

Results. In the postoperative period, the majority of patients had a complete or significant regression of pain (on average, from 6.3 to 1.8 points on the visual analog scale). The Oswestry disability index decreased from 64/66 [64; 68] to 33/34 [32; 36] in 6 months (p <0.001) and 18/17 [16; 18] in 12 months (p <0.001). Before surgery, the height of the operated disk was 0.96 cm, after 1 year decreased to 0.91 cm. Range of rotary motion in the operated segment in all cases did not exceed 6°.

Conclusion. The PEEK rod fixation in patients with mechanical low back pain provides good and excellent clinical results on the I. Macnab scale in 83.4 % of cases. Within 12 months, the minimal volume of movements on the operated segment remains, without signs of continued degeneration of adjacent intervertebral discs.

The study objective is to analyze the results of surgical treatment of patients with endocrine ophthalmopathy using minimally invasive transorbital approaches and intraoperative frameless neuronavigation.

Materials and methods. The study was based on the results of examination and surgical treatment of 9 patients with endocrine ophthalmopathy (17 orbits) in the period from 2015 to 2017. At the first stage the preoperative computed tomography images of the orbits was imported into the navigation software program, and then the area of the proposed resection of the orbit walls was marked. Further, in the operating room, the patient head position was registered in the navigation system. To perform bone decompression of the orbit and lipectomy, we used preseptal, transcaruncular and lateral retrocanthal approaches. These approaches are transconjunctival and do not leave postoperative scars. Upon completion of the orbitotomy, its accuracy and dimensions were determined by the intraoperative pointer of the neuronavigation system.

Results. The postoperative period was uneventful. In all patients, according to clinical examination and computed tomography, good cosmetic and functional results were achieved. Only 1 patient developed a simblypharon after transconjunctival access, which required additional intervention to reconstruct the lower eyelid. There were no other complications of surgical treatment. The minimum degree of regression of exophthalmos was 3 mm, the maximum 7 mm. Diplopia completely regressed in 2 patients. The observation period was 6 months.

Conclusion. Minimally invasive transorbital approaches allow the transconjunctival view of all orbital walls to perform decompression of the orbit and lipectomy without cutaneous incisions, to achieve good cosmetic and functional results. The intraoperative use of the neuronavigation system ensures the bone decompression of the orbit in full.

The study objective is to indicate conditions of various operative neurosurgical interventions in patients with tuberculosis / HIV co-infection. 

Materials and methods. Studied microbiological, radiological and histological characteristics in 682 patients treated, 331 deaths and 12 operated patients with central nervous system tuberculosis combined with HIV infection. Produced 15 operations: ventriculoperitoneal shunting on 3 patients, stereotactic biopsy on 7 patients, removal of inflammatory foci with a capsule on 5 patients.

Results. The indications for surgery in only 3 of 24 patients with hydrocephalus have all been a positive effect. The probability of detecting the pathogen of encephalitis biopsy is 71.4 %. All the radical operation for removal of the local formations of the сentral nervous system in conjunction with appropriate chemotherapy led to the recovery of patients.

Conclusions. When distributive of hydrocephalus in patients with combined pathology of conditions for the ventriculoperitoneal shunting are no reduction of hydrocephalus in the course of conservative treatment, the reduction of pleocytosis of cerebrospinal fluid under the effect of chemotherapy and positive result of the tap test. A biopsy of the brain in HIV infection are shown in order to clarify diagnosis and determine the range of drug susceptibility for the correction of chemotherapy. Conditions for radical removal of tuberculous formations of the brain in HIV infection are: the absence of a tendency to reduce the size of the formations under the influence of chemotherapy, prescribed within the spectrum of drug susceptibility of at least 2 months; the disappearance of the zone of perifocal edema around the lesion in the brain.

The study objective is to investigate immediate angiographic and clinical results of endovascular treatment of ischemic stroke in patients who had contraindications to the appointment of adjuvant thrombolytic therapy (TLT), and patients who underwent combined treatment (TLT + thrombolysis/thrombextraction).

Materials and methods. From 2016 to 2018, selective cerebral arteriography was performed in 48 patients with acute stroke within 4.5 hours from the onset of the disease to ascertain the possibility of endovascular treatment. The main indication was occlusion of a large intracranial vessel (internal carotid artery or middle cerebral artery at the level of M1–M2 segments) according to multislice computed tomography. In the absence of contraindications, TLT was prescribed and selective angiography and thrombaspiration/thrombextraction were performed. In 5 (10.4 %) patients with TLT no occlusion of the intracranial vessel was found, it was interpreted as evidence of effectiveness, these patients were excluded from further analysis.

Results. The group of combined treatment (TLT + endovascular procedure) included 18 patients, the group of endovascular treatment without TLT – 25. The severity of stroke in patients who were denied TLT was objectively heavier, which led to a statistically worse prognosis than in patients who were assigned TLT. However, after the endovascular procedure (which was more successful according to a number of indirect criteria), the clinical characteristics of both groups were similar. In patients undergoing endovascular intervention without TLT, thrombaspiration often proved to be an effective, rarely used expensive tools to thrombextraction, decreased the number of attempts of thrombextraction using a stent retriever and there were rare cases of embolization of the distal territory.

Conclusion. If it is possible to perform endovascular intervention without TLT and without additional time spent on transportation, it can be a method of choice, providing equal or possibly greater efficacy and safety of treatment in comparison with TLT. Further experience and further research is needed to clarify the value of both methods.

The study objective is to analyze the results of combined (direct and indirect) brain revascularization in adult patients with moyamoya disease. 

Materials and methods. From February 2015 to August 2016, 12 operations were performed on 12 hemispheres in 7 patients (2 men, 5 women) with moyamoya disease. Six patients had bilateral disease, 1 – unilateral. The age of patients ranged from 25 to 60 year old, the average – 41 year old. Multislice computed tomography (MSCT) perfusion imaging of the brain with a stress test was made in every patient, MSCT angiography of the extraand intracranial arteries was perfomed. Stages of the disease were determined according to the Suzuki–Takaku classification: stage III was revealed in 5 patients, stage IV – in 2. To evaluate the clinical course of the disease the Matsushima classification was used: type VI – in 2 cases, type III – in 2, type IV – in 1, type V – in 1. In 1 case, the pathological vascular network of 1 hemisphere was detected by accident. Extracranial-intracranial (EC–IC) bypass and encephaloduromyosynangiosis (EDMS) was used in 3 cases; a double-barreled EC–IC bypass and EDMS – in 3; a double-barreled EC–IC bypass and encephaloduroperiosteomyosynangiosis – in 1; EC–IC bypass and encephaloduroarteriomyosynangiosis (EDAMS) – in 3. In 1 case was perfomed EC–IC bypass and encephaloduroperiosteosynangiosis. Only indirect revascularization was performed in 1 case – EDAMS. We assessed the neurological status in the follow-up period (5–11 months); MSCT angiography and MSCT perfusion imaging of the brain were performed. 

Results. All patients in follow-up period demonstrated the increase of cerebrovascular reserve according to MSCT perfusion imaging of the brain with stress tests. Stroke, epilepsy, surgical complications were not detected in the postoperative period. In 1 case, the left-hand monoparesis regressed.

Conclusion. The combined (direct and indirect) revascularization may be effective in adult patients with moyamoya disease. To obtain more objective conclusions it is necessary to analyze the long-term results of interventions.

The study objective is to describe a case of ossified pseudomeningocele after spinal surgery and to develop an optimal treatment strategy for this disorder.

Materials and methods. We report a case of ossified pseudomeningocele developed after the removal of an intradural neurinoma in the lumbar spine in a female patient treated in the Clinic for Nervous Diseases, University Clinical Hospital No. 3 of the I.M. Sechenov First Moscow State Medical University in 2017. We also reviewed research literature describing this pathological condition.

Results. Upon admission, the patient was diagnosed with paresis of the left foot occurring in ankle joint dorsiflexion (score 4), absence of the Achilles reflex on the left side, and hypoesthesia of two first toes of the left foot. Magnetic resonance imaging revealed a postoperative cyst of irregular shape located in soft tissues at the level of L vertebral body and compressing the dural sac. The patients underwent surgery that included separation of the pseudomeningocele cavity from the dural sac and placement of an external lumbar drainage. In the postoperative period, we observed a complete regression of neurological symptoms.

Conclusion. Since ossified pseudomeningocele in the lumbar spine is extremely rare, an optimal treatment strategy has not been developed so far. We believe that maximum possible excision of the cyst wall and anastomotic sealing with a muscular or fat flap with biological glue followed by flap fixation from the extradural space is a simple and robust method of decompression and separation of the anastomosis. To eliminate the cavity in soft tissue of the paravertebral space, we recommend reconstruction of epidural fat with additional sealing using biological glue. To prevent anastomosis recurrence, we recommend placing an external lumbar drainage.

The study objective is to describe a rare case of putaminal intracerebral hemorrhage (PICH) results from a rupture of the distal lateral lenticulostriate artery (LSA) aneurysm and to summarize currently available information on its diagnosis and treatment.

Materials and methods. A 40-year-old female patient was admitted to the N.V. Sklifosovsky Research Institute of Emergency Medicine. Her arterial pressure was 200/110 mm Hg. Brain computed tomography (CT) revealed a 25 сm3 right-sided PICH with a minimal perifocal edema. CT angiography revealed a saccular aneurysm located in the right distal LSA with the dome of 5 mm and the neck of 2 mm. We performed right frontotemporoparietal osteoplastic craniotomy and used the transsylvian transinsular approach to PICH represented by ruptured while we were removing the blood clots. We performed aneurysm trapping and removed the hematoma.

Results. This clinical case demonstrates the possibility of successful microsurgical repair of the distal lateral LSA aneurysm rupture. Six months postoperatively, the patient had complete regression of left leg paresis and partial restoration of left hand functions.

Conclusion. This case report appears quite interesting since deep intracerebral hematomas of this etiology are extremely rare. An optimal treatment for LSA aneurysms remains a subject of debate due to the small number of patients with this disorder and limited data on it. Patients with fusiform aneurysms require conservative treatment and dynamic follow-up with periodic cerebral angiography. Patients with typical saccular aneurysms or PICH presenting mass effect should undergo surgical treatment.

The study objective is to describe currently available and optimal methods of central skull base reconstruction.

Material and methods. This article describes a 10-year experience of endoscopic surgery in reconstructing the defects after the removal of chiasmosellar tumors.

Results. We developed a strategy for assessing the risks for postoperative liquorrhea and choosing an optimal surgical technique. This strategy allows maintaining the incidence of postoperative liquorrhea of 4 %.

Conclusion. Autografts are the most widely used material for reconstructing skull base defects after the removal of chiasmosellar tumors. The multilayer reconstruction is more preferable due to the high risk of postoperative liquorrhea.

The study objective is analyze the modern ideas about the influence of time factor on the treatment outcome of patients with spinal cord injury. 

Results. Experimental studies clearly demonstrate the effectiveness of early decompression. According to the results of meta-analyses, in patients who underwent early decompression of the cervical segment of spinal canal, the outcomes of treatment may be better compared with the treatment outcomes of patients who underwent delayed intervention. The benefit of early decompression of the thoracic and lumbar spinal cord is not statistically significant. The difference in the rate of intraand postoperative complications and lethality between early and late decompression groups is also statistically insignificant.

Conclusion. Early decompression of the spinal canal and spinal stabilization (≤24 h) should be performed in a specialized hospital as fully as possible and as early as the severity of the patient condition allows.

The study objective is to analyze currently available publications on spinal deformity in patients with degenerative lumbar spinal stenosis.

Materials and methods. We analyzed 90 manuscripts published between 1980 and 2017.

Results. We describe the parameters used to assess spinal deformity and evaluate their role for predicting the course of degenerative spinal disease. We provide the results of latest studies assessing the impact of spinal deformity on the outcome of surgical treatment in patients with degenerative lumbar spinal stenosis. We identified the following risk factors for scoliosis progression: wedge-shaped intervertebral disc in the frontal projection, low middle sacral axis, lateral spondylolisthesis, small L vertebral body, vertebral rotation, Cobb angle >20°, and sagittal imbalance.

Conclusion. We recommend decompressive interventions with facet joint preservation in patients with spinal deformity and degenerative lumbar spinal stenosis with no risk factors for scoliosis progression and radicular symptoms only (without pronounced low back pain). In patients with no risk factors for scoliosis progression, radicular symptoms, and low back pain, it is advisable to combine decompression with short fixation. For individuals at risk of scoliosis progression, we recommend supplementing decompression with long fixation exceeding scoliosis curve.

This is a publicistic essay devoted to Aleksandr Konovalov, academician of the Russian Academy of Sciences. It covers the main stages of his career, his contribution to national neurosurgery, and, most importantly, his unique personality.