Venous thromboembolic complications (VTE) are an actual problem for all surgical specialties, and neurosurgery was no exception. Data on the incidence of deep vein thrombosis and pulmonary embolism vary over a wide range: from 0 to 34 % andfrom 0 to 3.8 %, respectively. According to some estimates, VTE are in second place among the causes of postoperative mortality in neurosurgery, which makes the study of this topic relevant and undoubtedly important for improving the quality of care for patients. The article provides an overview of modern scientific literature, relevant data on the frequency of occurrence of VTE. The issues of pathogenesis, risk stratification and methods for the prevention of deep vein thrombosis and pulmonary embolism are highlighted.

Transcranial and transnasal approaches are the most common techniques for treatment of diseases and injuries of the eye socket and the base of the skull. However, development of endoscopic technology, microsurgical devices and minimally invasive techniques promotes increased interest in transorbital endoscopic approaches which allow to perform manipulations in the eye socket and structures of the base of the skull, namely, the anterior and middle cranial fossa. There are 4 types of such approaches: pre-caruncular, superior transpalpebral, lateral retro-canthal and inferior preseptal. Currently, precise indications for transorbital approaches are not formulated, and there are no algorithms for approach selection. The article describes the results of using these approaches in treatment of diseases and injuries of the orbit and the base of the skull.

In injuries and tumors of the orbit and the base of the skull, cerebrospinal liquid leakage, infectious diseases, endocrine ophthalmopathy, transorbital endoscopic techniques provide good functional and cosmetic results. Among the advantages of these approaches are larger orbitotomy area and preservation of nasal structures, absence of large neurovascular bundles in the way of the approach, small incision, minimal brain retraction, good visibility and illumination of the structures.

Transorbital endoscopic approaches to the base of the skull aren’t associated with significant neurological or vascular complications, hemorrhage, hematomas, infections. Diplopy, ptosis, enophthalmia are also quite rare. In literature, there are no descriptions of cases of loss of vision or postoperative cerebrospinal liquid leakage.

Our work is a review of various classification options for complex vascular pathology of the spinal cord, taking into account its historical changes as experience accumulates. Classifications of spinal arteriovenous malformations are very complex and the literature on this problem is presented in a small number of works. We conducted an analysis of 33 scientific articles in order to understand the classification of spinal arteriovenous malformations, its evolution and presented the most significant options for practicing neurosurgeons, endovascular surgeons. However, we did not find a classification that could satisfy the entire scientific community.

The study objective is to evaluate the effectiveness of intracranial pressure (ICP) monitoring in patients with severe head injury in a multispecialty hospital.

Materials and methods. A retrospective study included 2343 patients who underwent surgical treatment at the N. V. Sklifosovsky Research Institute of Emergency Medicine between 2012 and 2018. Patients admitted in atonic coma, who died in the space of 48 hours after hospitalization, with intracranial hematoma volume >200 cm3, and older than 65 years were excluded. Additionally, results of conservative therapy in 69 patients with severe cerebral contusion were included. ICP monitoring was performed in 249 patients (22.5 % of all patients who underwent surgery with indications for monitoring and no counterindications). A binary logistic regression model included age, sex, type of intracranial injury, depression of consciousness severity at admittance as variables. For treatment outcomes, odds ratio (OR) with 95 % confidence interval and p <0.05 were calculated.

Results. Postoperative mortality among patients without ICP monitoring was 64.6 %, among patients with ICP monitoring — 51.2 %. Probability of death in the patient group without ICP was somewhat higher than among patients who underwent ICP (odds ratio (OR) 1.74; 95 % confidence interval (CI) 1.31—2.34). No significant differences were observed in outcomes between patients with or without ICP monitoring for level of consciousness of 4—6 points per the Glasgow Coma Scale (OR 1.01; 95 % CI 0.43—2.37). Among patients with 7—8 points per the Glasgow Coma Scale, outcomes were significantly better among patients who underwent ICP monitoring (OR 1.65; 95 % CI 1.23—2.20). In patients with acute epidural hematomas (AEH), time to death was significantly different: in patients with 7—8points per the Glasgow Scale it was 15 days, with ICP monitoring 52 days; for patients with 4—6points it was 7 and 39 days, respectively. Among patients with multiple hematomas who underwent surgery in moderate coma, outcomes of surgical treatment were a little better with ICP monitoring (OR 1.82; 95 % CI 1.09—3.41). Time to death was significantly different: in patients without ICP monitoring it was 16 days, in patients with ICP monitoring it was 29 days. In patients with microfocal cerebral contusions, probability of death with ICP monitoring was 40 % lower than among patients without ICP monitoring (OR 1.43; 95 % CI 1.01—3.12). Per our data, invasive ICP monitoring is an independent predictor of infectious complications in the postoperative period (OR 1.39; 95 % CI 1.17—3.19). On day 1 after intracranial hemorrhage, hyperosmotic solutions were used in 35 % of patients who underwent ICP monitoring, and in 19 % of patients without ICP measurement (p < 0.05).

Conclusion. ICP monitoring does not decrease postoperative mortality and does not improve outcomes in patients with epidural and subdural hematomas. In these patients, ICP control significantly increases time to death. ICP monitoring significantly decreases postoperative mortality in patients with intracranial hematomas and cerebral contusions. ICP monitoring is effective in patients with consciousness levels of moderate coma and above. ICP control allows to accurately diagnose intracranial hypertension and perform targeted therapy. In the absence of ICP monitoring, hyperosmotic solutions are used empirically or for increased negative neurological symptoms.

The study objective is to study the results of the differentiated method of surgical revascularization of the brain for the treatment of pediatric patients with moyamoya angiopathy.

Materials and methods. Twelve surgical interventions were performed on 12 hemispheres in 8 patients (4 male, 4 female) with moyamoya angiopathy from December 2015 to March 2020. The age of patients ranged from 6 months to 14 years old, the average age is 8 years old. To clarify the clinical course of the disease the Y. Matsushima classification was used: type I (n = 3), type III (n = 2), type IV (n = 2) and type V (n = 1) of Y. Matsushima. Stages of the disease are classified according to J. Suzuki: stage III was revealed in 5 patients, stage IV— in 3. Cerebral angiography, magnetic resonance imaging of the brain and vessels were performed; computed tomography perfusion of the brain was made in every patient. Encephaloduroarteriomyosynangiosis was used in 2 hemispheres. Extra-intracranial bypass and encephaloduro-myosynangiosis in 1; extracranial-intracranial bypass and encephaloduroarteriomyosynangiosis — in 2; extracranial-intracranial bypass and encephaloduromyoperiosteosynangiosis in 5 hemispheres; double-barreled bypass and encephaloduromyosynangiosis — in 1 hemisphere; double-barreled bypass and encephaloduromyoperiosteosynangiosis — in 1 hemisphere. In the follow-up period (6—36 months) neurological status testing, digital subtraction angiography (6 vascular territories), magnetic resonance imaging of the brain and vessels and computed tomography perfusion of the brain were performed.

Results. All patients in the follow-up period had no clinically significant ischemic events on the side of surgical intervention; there was an increase in the perfusion of the brain in comparison with preoperational values. In 1 case, transient ischemic attack occurred on the nonoperated hemisphere that did not recur after surgery. There was a regression of symptoms among children with initial neurological deficits. The angiographic result, in accordance with the method suggested by Y. Matsushima, was excellent (A group) and good (B group), except the case of moyamoya syndrome and case after indirect revascularization in zone of brain atrophy. Based on our experience, we have determined the optimal method of suturing the wound with a good cosmetic effect.

Conclusion. We can assume, that differentiated method in surgical treatment of pediatric patients with moyamoya angiopathy is highly effective for the prevention of ischemic stroke, and also has good clinic, angiographic and cosmetic result. With suitable arterial sizes, combined revascularization showed better results than indirect, especially in the clinically significant hemisphere.

The study objective is researching of neurological deficit (ND) increasing risk factors in early postoperative period after intracranial arterial aneurysms clipping, in the cases of a transient loss of responses (TLR) during transcranial motor evoked potentials (TcMEP) and somatosensory evoked potentials (SSEP) registration.

Materials and methods. One hundred and eighty-four (184) patients, operated in the neurosurgical department of IRCH by intracranial arterial aneurysms from 2014 to 2019 using intraoperative neurophysiological monitoring were included. In the acute period, 67 (36.4 %) patients were operated, in the subacute period — 40 (21.7 %), in the cold period — 77 (41.8 %), of which 7 patients have a history of aneurysm rupture, 70 patients have no break. Eighty-one (44.0 %) patients registered SSEP, 75 (40.8 %) — TcMEP, 28 (15.2 %) — successively SSEP and TcMEP.

Results. MEP TLR was noted in 27 (14.7 %) cases, of which in 15 (55.6 %) cases — without an increase in ND, and in 12 (44.4 %) cases — with an increase in ND by 5.17 ± 4.63points according to NIHSS (National Institutes of Health Stroke Scale), SSEP TLR was noted in 20 (10.9 %) cases, of which in 13 (65 %) cases — without an increase in ND, and in 7 (35 %) cases — with an increase in ND by 5.14 ± 4.91 points according to NIHSS. MEP TLR with the subsequent ND increase significantly more often developed during operations performed in cold period (66.7 %) vs in acute period (25.0 %), and in subacute period (8.3 %). MEP TLR without ND increase was more often observed in acute period (46.7 %) and subacute period (33.3 %) vs in cold period (20.0 %) (p = 0.044). Transient MEP TLR during approach to an aneurysm were significantly more often (36.4 %) associated with ND increase, and MEP TLR which developed within 10 min after the final clipping, with timely correction taken were significantly more often (66.7 %) associated with a favorable outcome.

Conclusion. Transient MEP TLR is more significant in predicting of postoperative ND, in the case of clip intracranial arterial aneurysms in cold period. MEP TLR during approach to an aneurysm more often associated with ND increasing.

The objective is to describe clinical observations and literature data of possibility of using stent retriever technologies as a new treatment for cerebral vasospasm.

Materials and methods. In the period from January 2017 to May 2019, 117 patients in the acute period of subarachnoid hemorrhage were treated at the Interregional Clinical Diagnostic Center (Kazan). Clipping was performed in 59 patients, endovascular occlusion in 58 patients. Vasospasm of varying severity estimated according to transcranial Doppler ultrasonography was observed in 115 (98.2 %) patients. Stent-assisted angioplasty was performed in three patients with vasospasm refractory to medical therapy using stent-retriever pRESET (Phenox, Germany).

Results. The clinical efficacy of stent-assisted angioplasty with decreasing in speed indicators according to transcranial Doppler ultrasonography and neurological symptoms was achieved in all patients. No complications were observed.

Conclusion. Stent-assisted angioplasty of cerebral arteries using stent retriever technologies is an additional option for the treatment symptomatic vasospasm in the acute period of subarachnoid hemorrhage.

Introduction. The development of minimally invasive technologies in recent decades has expanded the indications for the use of endoscopic transnasal transsphenoidal approaches in surgery of skull base tumors. It became possible to perform surgical interventions aimed at removing tumors of the base of the skull that spread to the area of the passage of cranial nerves (cavernous sinus, clival area, cerebello-pontine angle), which is associated with the risk of damage to certain cranial nerves.

The study objective is to evaluate the effectiveness of trigger electromyography in providing anatomical and functional preservation of cranial nerves during endoscopic endonasal transsphenoidal removal of skull base tumors.

Materials and methods. The study is based on statistical analysis and comparison of the results of surgical treatment of two groups of patients with various tumors of the base of the skull: the main group (30 patients with using trigger electromyography to identify cranial nerves intraoperatively) and the control group (43 patients without using this method). The effectiveness and safety of using the method of intraoperative identification of cranial nerves was evaluated based on a comparison of basic characteristics, treatment outcomes, and factors potentially affecting them.

Results. Fifty-seven (57) cranial nerves were identified intraoperatively in the main group. The frequency of radical removal was 1.6 times higher in the main group (70 % vs 44.2 %, p = 0.03). When analyzing the dynamics of the state of motor cranial nerves after surgery in the main and control groups, it was shown that negative dynamics prevailed in the control group — 37.2 % vs 13.3 % (p = 0.03), and positive dynamics prevailed in the main group (37.3 % vs 13.9 %), 2.8 times (p = 0.08).

Conclusion. The obtained data indicate that the use of the intraoperative identification method in endoscopic transnasal surgery of skull base tumors can positively affect the radical removal of tumors and the preservation of cranial nerve function in the postoperative period.

The objective is to describe a rare clinical case of a suprasellar cyst formed after implantation of a ventriculoperitoneal shunt.

Clinical observation. A female patient, 51 years, suffered non-traumatic subarachnoid intraventricular hemorrhage, acute obstructive and subsequently normal pressure hydrocephalus requiring implantation of a ventriculoperitoneal shunt. In several years, the patient developed a suprasellar cyst manifesting through cerebral symptoms.

Results. Two (2) surgeries were performed. During the 1st surgical intervention, endoscopic ventriculostomy was performed with positive outcome (full regression of the symptoms). After 6 months, cyst recurrence was confirmed, and endoscopic ventriculocystocisternostomy with replacement of a low pressure pump with intermediate pressure pump was performed. Full regression of neurological disorders was observed; magnetic resonance imaging did not show cyst recurrence 6 months after the 2 nd surgery.

Conclusion. This clinical observation expands our knowledge on the diversity of mechanisms of suprasellar arachnoid cyst formation and demonstrated effectiveness of one of the techniques for prevention of cyst formation in the context of ventriculoperitoneal shunt.

The objective is to present first-hand experience of microsurgical operations in patients with neuro-oncological diseases, vascular pathology and COVID-19 in the absence of unified standards of work during the pandemic, as well as summarize literature data on this problem.

Clinical cases. Five cases of surgical interventions in patients with moderate COVID-19 pneumonia are presented: 1) microsurgical clipping of a saccular aneurysm of the posterior communicating artery which caused massive basal subarachnoid hemorrhage with bleeding into the IV ventricle; 2) microsurgical resection of glioblastoma of the right temporal lobe; 3) resection of an intracerebral hematoma in the right temporal, occipital and parietal lobes with total volume of 100 cm3 which caused transverse brain dislocation up to 10 mm to the left; 4) micro coil embolization of a ruptured aneurysm of the posterior communicating artery; 5) microcoil embolization of a ruptured aneurysm of the right middle cerebral artery. All surgeries were performed in personal protective gear and FFP3 masks.

In 3 patients, positive pneumonia dynamics were observed; in 2 patients (with glioblastoma and subarachnoid hemorrhage from an aneurysm of the right middle cerebral artery), dynamics were negative. Among 5 patients, 4 were discharged in stable condition, 1 case ended in death (despite the absence of coagulopathy, massive brain ischemia with hemorrhagic transformation developed, probably due to endothelial cell dysfunction, high vascular permeability of cerebral arteries in conjunction with coronavirus effect on angiotensin transforming enzyme receptors).

Literature analysis. Summarizing experiences of other researchers, the following changes in organization of neurosurgical practice during the pandemic can be recommended: 1) all patients should be considered potentially infected; 2) emergency surgeries should be performed under local anesthesia and/or in separate operating rooms; 3) in emergency cases of vascular pathology of the brain, endovascular interventions are the preferred approach; 4) surgeries should be performed in FFP2/FFP3 masks, protective goggles, two pairs of gloves, protective suits and shoe covers; 5) the number of personnel in the operating room should be minimized; 6) manipulations that can potentially lead to increased formation of aerosol (craniotomies, coagulations) should be performed with special care, craniotome rotation speed should be decreased to minimize formation of bone particles, opening of paranasal sinuses and mastoid cells should be avoided if possible; 7) negative pressure (—5 Pa) should be maintained in the operative room, frequency of interruption of the artificial lung ventilation machine circuit should be minimized, patients’ nose and mouth should be covered with wet wipes; 8) the personnel should be divided into several teams working in turns; 9) personnel older than 65 years should be isolated; 10) planned surgeries should be postponed indefinitely and patients should be consulted by phone, hospitalized only if their condition worsens; 11) during admission, patients should be placed in observation rooms, where thermometry, computed tomography of the lungs and pharyngeal swab for SARS-CoV-2 should be performed; 12) regardless of the SARS-CoV-2 analysis result, patients after surgery should be quarantined for 14 days.

Conclusion. Our experience shows that patients with concomitant COVID-19 infection can receive neurosurgical help. Compliance with the guidelines leads to low risk of infection for the personnel and sufficient quality of medical care.

The review summarizes knowledge on treatment of patients with pituitary adenomas. Pituitary adenomas comprise 15 % of all intracranial tumors being the third most common tumors after meningiomas and gliomas. Multiple studies dedicated to different aspects of this pathology have been conducted. International guidelines on diagnosis and treatment of pituitary adenomas with varying hormonal activity have been developed covering use of pharmaceutical, surgical and radiation techniques.