The study objective is to compare the efficacy and safety of the fourth ventricle tumor removal using median (through the median aperture) or telovelar approach.

Materials and methods. The analysis included 41 patients with space-occupying lesion of the fourth ventricle operated in the Neurosurgery Clinic of S.M. Kirov Military Medical Academy in 2007–2018. The anatomical characteristics (size and extension) and manifestations of the fourth ventricle tumors, as well as surgical factors (surgical approach to the fourth ventricle) which affect the functional outcome of the treatment were estimated. Complications associated with the approach were assessed clinically using diffusion-weighted magnetic resonance imaging. Logistic regression and ROC analysis were used to analyze the anatomical factors and extent of resection as predictors that affect the worsening of gait disturbance, speech/swallowing deficits in the postoperative period.

Results. The analysis revealed main advantages of the median approach in comparison to the telovelar approach: a lower frequency of C laminectomy; no need for prolonged constant tonsillar retraction; a shorter surgery duration and lower number of ischemic changes in the surgical area, caused by approach. Meanwhile the telovelar approach was used to remove lesions bigger in size. Other factors, such as tumor extension, the need to preliminary insertion of an external ventricular drain, the frequency of postoperative complications, the extent of resection and the functional outcomes did not differ significantly between the approaches. Lesion size ≥37.5 mm is a significant prognostic factor for speech/swallowing deficits after the surgery with sensitivity of 86 % and specificity of 84 %.

Conclusion. Median aperture approach is a reasonable alternative to telovelar or transvermian approaches in the surgery of small fourth ventricle tumors (<30 mm). The median approach allows to reduce the surgical injury rate and the likelihood of postoperative complications. If a lesion has a size ≥37.5 mm, an increase speech/swallowing deficits should be expected.

The study objective is to evaluate the effectiveness of various methods of surgical treatment of malignant cerebellar infarction.

Materials and methods. There were 47 patients with malignant cerebellar infarction retrospectively analyzed in this study. The group 1 included all patients who underwent surgical treatment (n = 31), the group 2 included all patients who underwent conservative treatment (n = 16). In the group 1, 15 patients underwent isolated ventriculostomy, 4 – posterior fossa decompression (PFD), 14 – combination of ventriculostomy and PFD. The criteria of efficacy of surgery were: restoration of consciousness, restoration of forth ventricle and the quadrigeminal cistern configurations. Results of treatment were assessed according to the Glasgow outcome scale.

Results. The recovery of consciousness level was observed in 7 out of 15 patients after isolated ventriculostomy on average 13 day; the efficacy was 47 %. Four patients underwent only PFD. Among them 2 patients needed additional external ventricular drainage installation as 2nd operation. The efficacy was 50 %. After PFD with simultaneous ventriculostomy the recovery of consciousness was observed on 4 day in 11 out of patients. The efficacy was 79 %. Combined ventriculostomy and PFD were 32 % more effective than ventriculostomy alone, and 29 % more effective than PFD alone.

Conclusion. In patients with malignant cerebellar infarction with a decrease in consciousness and signs of brainstem compression, ventriculostomy with PFD are advisable, because isolated ventriculostomy does not always provide a necessary effect in decompensation of dislocation syndrome.

The study objective is to evaluate the results of endovascular treatment of patients with subarachnoid hemorrhage due to rupture of the vertebrobasilar artery aneurysm.

Materials and methods. From 2011 to 2017, 26 patients underwent endovascular occlusion of the ruptured vertebrobasilar artery aneurysm in an acute period of hemorrhage in Surgut Clinical Hospital for Traumatology.

Results. Endovascular interventions were performed in 1–14 days after the episode of the primary subarachnoid hemorrhage. Among the patients 53.8 % were in good condition at admission (Hunt–Hess grade I–II), 46.2 % had moderate and severe neurologic disability (Hunt–Hess grade III–IV). A good and satisfactory degree of aneurysm occlusion was achieved in 18 (69.3 %). Favorable outcome (modified Rankin Scale (mRS) 0–2) was achieved in 21 (80.7 %); 1 (3.7 %) had severe disability (mRS 4), 2 (7.8 %) – vegetative state (mRS 5). Lethal outcome (mRS 6) occurred in 2 (7.8 %). Unfavorable outcomes were caused by a severe vasospasm.

Conclusions. Endovascular occlusion of vertebrobasilar artery aneurysms in the acute period of hemorrhage is an effective and safe method of treatment in patients with Hunt–Hess grade I–IV.

The study objective is to estimate treatment success of gamma knife radiosurgery (GKRS) in the patients with subtentorial cavernous malformation (CM) based on follow-up data and magnetic resonance imaging (MRI).

Materials and methods. The long-term follow-up of GKRS in 87 patients with CM in brain stem and cerebellum was obtained. The clinical outcomes were observed using phone-based SF-36 health status survey in 55 patients. MRI data was collected before and after GKRS within 1, 2, 3 and more years. The natural history of CM without GKRS were observed in 20 patients.

Results. The 1st year MRI observation after GKRS have demonstrated CM reduction in 66,6 % patients. At subsequent MRI-control the tendency of increase in number of CM, reacted on irradiation, and continuation of started processes of its sclerotization is revealed. The fast reduction of CM sizes was associated with lower risk of recurrent hemorrhages, that were observed in 3 patients with slow reduction. The CM reduction was also associated with good clinical outcomes, that was observed in 64,5 % patients.

Conclusion. The presence of CM reduction (72,4 %) and good clinical outcome in suggests GKRS as a frontline treatment modality in patient with subtentorial CM. In the cases of slow rate of treatment response and unexpired risk of repeated hemorrhage no mortality and significant disability were mentioned.

The study objective is to describe a clinical case of surgical treatment of a patient with pathological distal tortuosity of the left internal carotid artery (ICA) and present a comprehensive description of a proposed surgical technique, as well as compare advantages and disadvantages of the chosen and alternative surgery types.

Materials and methods. At the 1st stage, we performed computed angiography and triplex scanning of the main head arteries and modelled operative approach. At the 2nd stage, we mapped the ICA approach, redressing and resection. At the 3rd stage, using endoscopic assistance we separated the ICA along its entire length, found its pathological kink, performed ICA redressing and resection with subsequent reanastomosis with high accuracy and minimal injury.

Results. ICA blood flow was 320 ml/min (prior to surgery: 140 ml/min). In the postoperative period, positive dynamics of the patient’s neurological status were observed. Computed angiography and triplex scanning confirmed removal of pathological tortuosity. Compared to the proposed technique, other surgery types (open access) are characterized by high risk of injury of the cranial nerve branches, submandibular and parotid glands, necessity of dissection of the digastric, stylohyoid muscles, subluxation of the mandibula, etc.

Conclusion. The method of allocation of hard to reach tortuosities of the carotid artery developed based on previously known endoscopic manipulations on the vessels of the extremities using endoscopic assistance allows to decrease injury during the intervention and achieve maximal technical and clinical effect.

The recommendations on the diagnosis of urinary disorders (developed by the International Continence Society and the European Association of Urology) are presented. The effectiveness of drug treatment and catheterization in patients with traumatic spinal cord injury and neurogenic bladder, as well as contraindications to catheterization and the frequency of complications were analyzed. Intermittent catheterization, by the trials’ data, it seems the preferred method of treatment. Different types of urethral catheters are described. There are 3 methods of intermittent catheterization, as well as the basic principles of its implementation on the recommendations of the European Association of Urology. Emphasized that only the cooperation of specialists in the interdisciplinary team creates the conditions for the optimal management of neurogenic bladder that is able to bring the life expectancy of people with traumatic disease of the spinal cord to the indicators in the general population.

The study objective is to analyze scientific sources describing features of surgical treatment of aneurysms of the pericallosal artery (APcA) and unfavorable outcome risk factors.

Materials and methods. The analysis included 4 russian and 57 foreign sources.

Results and conclusion. Conservative treatment of patients with ruptured APcAs yields unsatisfactory results due to high mortality. Data on surgical outcomes of ruptured APcAs are contradictory: per some sources, they do not differ from results of treatment of cerebral aneurysms of other locations; another sources state that they are worse. The main risk factors are severity per the Hunt–Hess scale ≥IV, large size of intracranial hematoma. Outcomes of surgical treatment of unruptured aneurysms are mostly favorable. Microsurgical clipping allows to achieve favorable results both for ruptured and unruptured APcAs. Due to deep APcA localization, the majority of revascularization surgeries can be performed only using intracranial-to-intracranial bypass. Extracranial-intracranial bypass in the anterior cerebral artery system is rarely performed. For surgical treatment, choice of its timeframe in critically ill patients (grade IV–V by the Hunt–Hess scale) causes difficulties: early surgery prevents repeated hemorrhages, while postponed surgeries eliminate the possibility of affecting this and other factors. There are arguments for preventive exclusion of APcA from blood flow even if its size is <5 mm because of high frequency of APcA ruptures and more severe consequences. For combination of an unruptured APcA with a ruptured aneurysm in another location, either simultaneous exclusion of all aneurysms is performed or two-stage surgery with primary exclusion of the ruptured aneurysm, but the first approach is not always possible. Selection of optimal approach depends on the location of the aneurysm: pterional approach is used for clipping infracallosal aneurysms, variations of interhemispheric accesses – for exclusion of supracallosal aneurysms and aneurysms located at the genu of corpus collosum. Temporary pharmacological cardioplegia is considered a promising method which potentially can replace temporary APcA clipping.

This study is devoted to the accuracy of the optic navigation system “Neuroplan”. To assess the complex error of the system, a plastic model of the skull with 8 radiocontrast target points was developed. Twelve neurosurgeons with different levels of training participated in the study. The design of the study provided for each doctor performance of registration in the “Neuroplan” system at various positions of the model with subsequent hit at the target points. To select the optimal method of registration for different patient positions on the operating table, the registration table for anatomical landmarks (from 3 to 7) and on the surface was used. The analysis of the obtained results showed a high accuracy of the optic navigation system “Neuroplan”: in the side position of the scull model the target error averaged 1.57 [1.11; 2.13] mm, in the face down position – 1.69 [1.26; 2.19] mm, which is comparable with the declared accuracy of foreign analogues. When the experiment was repeated, it was shown that the system has high retest reliability.

The publicistic essay reveals the details of the life path of a major scientist-neurotraumatologist Lev Khatskelevich Khitrin, his contribution to the study of traumatic intracranial hematomas, especially important in the pre-computer era.

The study objective is to describe a clinical case of intracranial aneurysmal bone cyst in a 9-year-old patient with peripheral facial nerve paresis on the left.

Materials and methods. In a 9-year-old patient with facial asymmetry and pain syndrome on the results of magnetic resonance imaging of the brain with contrast in the upper edge of the left temporal bone pyramid revealed inhomogeneous encapsulated lesion with the level of media separation in the structure, high-intensity zones on T1and T2-weighted images, additional intracranial lesion in the left temporal region. Multispiral computer tomography of the brain revealed a cystic-solid lesion with clear contours, causing destruction of the pyramid of the left temporal bone. Lesion spreads to the middle cranial fossa with compression of the basal parts of the left temporal lobe. The diagnosis was made: neoplasm of the left temporal bone (possibly primary cholesteatoma) with destruction of the pyramid and petrosal part of the temporal bone and clivus with suppuration and formation of abscess of the left temporal lobe. Left facial nerve paresis. Osteo-plastic trepanation of the skull in the left temporal region, microsurgical removal of the tumor of the base of the middle cranial fossa on the left and plastic of the skull base defect with abdominal fat were performed.

Results. The postoperative period was uneventful. The patient complained of moderate headaches in the area of operative access. The wound healed by primary tension. Positive dynamics in neurological status in the form of regression of left facial nerve paresis was noted. Based on the data of morphological and immunohistochemical studies, an aneurysmal bone cyst was diagnosed.

Conclusion. The method of choice in the treatment of an aneurysmal bone cyst of the skull base is the en block removal. In case of impossibility of carrying out radical operation radiotherapy and embolization of the vessels feeding a cyst can be used, however convincing researches about their efficiency in such cases are not published. Aneurysmal bone cyst is uncommon, and to differentiate it from chondroblastoma, teleangiectatic osteosarcoma and giant cell tumors is rather difficult, therefore, it is necessary to increase the level of knowledge about this nosology.

The study objective is to present a clinical case of using transradial access for embolization of an aneurysm of the basilar artery (BA) bifurcation. 

Materials and methods. A patient, 67 years old, sought medical help at the I.I. Dzhanelidze Saint Petersburg Research Institute of Emergency Medicine complaining of headaches. Computed angiography of the brain had shown a large aneurysm of the BA with an absolutely wide neck. Embolization of the aneurysm using stent assistance (Y-stenting) was performed with access through the radial artery. The results were compared to data from scientific literature (about 16 cases).

Results. Aneurysm embolization level was II or IIIb per the modified Raymond–Roy classification was performed. No complications were observed, blood flow in the radial artery was preserved. The patient was released on day 2 after the surgery. No signs of blood flow through the aneurysm were observed during control selective cerebral angiography 12 months later. According to literature data, transradial access is preferable only with pathology of the vertebrobasilar system, especially if standard access is impossible to form due to atherosclerotic damage of the femoral artery, angling of the aortic arch, and pathological vessel tortuosity.

Conclusion. Routine use of transradial access in surgery of pathologies of the cerebral flow is not justifiable. But in some cases, this alternative access can be more effective and safer compared to the standard access. The main advantages of this access are reduced rate of complications of arterial access and possibility of early patient activization.

The study objective is to present a rare clinical observation, describe a successful 2-stage neurosurgical treatment of a pregnant patient with glioblastoma complicated by acute occlusive hydrocephalus.

Materials and methods. A pregnant woman, 36 years (pregnancy 28–29 weeks), was urgently hospitalized with a suspicion for preeclampsia at a multispecialty hospital with a maternity ward. One day prior to hospitalization the patient developed hypertensive syndrome manifesting through headache, nausea, vomiting, depressed consciousness to stupor, then seizures in the extremities with loss of consciousness. Examination had shown malignant paraventricular tumor of the left temporal and parietal lobes accompanied by perifocal edema, brain dislocation, and acute occlusive triventricular hydrocephalus.

Results. Treatment included the following stages: 1) emergency endoscopic third ventriculocisternostomy under local anesthesia, 2) premature delivery per cesarean section, 3) microsurgical resection of the brain tumor. Histological examination diagnosed glioblastoma (grade IV). The patient was discharged with minimal neurological deficiency (elements of motor and sensory aphasia) for administration of chemoradiation therapy.

Conclusion. Surgical treatment of a patient with glioblastoma and acute occlusive hydrocephalus in the 3rd trimester can be performed safely and effectively for the mother and fetus in 2 stages. Third ventriculocisternostomy under local anesthesia is recommended as a method of cerebrospinal fluid drainage.

Bol’shaya Sukharevskaya Sq., Moscow 129090, Russia

The study objective is to describe the clinical case of intraoperative neurophysiologic monitoring (IONM) using the electromyography-triggered stimulation during the thoracoscopic removal of an extradural Th₂ –Th₃ level tumor.

Materials and methods. The case describes the removal of the right Th₂ –Th₃ pleural cavity paravertebral tumor that has compressed the phrenic nerve. The patient underwent thoracoscopic surgery supported by IONM. An electromyography-triggered stimulation with a monopolar stimulator that was inserted through the thoracoscopic access into the thoracic cavity under video control identified the phrenic nerve. 

Results. The thoracoscopy in combination with electromyography-triggered stimulation allowed to avoid open surgery. The use of traditional IONM for spinal surgery would not identify the diaphragmatic nerve and prevent its unintentional damage.

Conclusion. IONM scenarios can be successfully enhanced with a electromyography-triggered stimulation of the phrenic nerve. Adhesive disposable electrodes for muscle response recording and stimulus return are useful without any deterioration of informativity.