JUBILEE
The author describes the life’s journey of Fyodor Andreevich Serbinenko, the founder of endovascular surgery, creator of a new chapter in the teaching on cerebral blood flow, and shares memories of friendship with this great scientist and beautiful person.
F.A. Serbinenko had developed a brand‑new approach to treatment of cerebral vascular pathologies, namely, low‑trauma intravascular reconstructive interventions, as well as a complex of original endovascular operations for severe vascular pathologies, opened the first in the world department of endovascular surgery in Moscow, became the founder of the Russian school of endovascular surgeons.
The principles and techniques of intravascular interventions developed by F.A. Serbinenko has been continuously developed and improved by his disciples and followers and are widely used in current clinical practice.
ORIGINAL REPORT
Aim. To present the experience of stenting of the extracranial internal carotid artery (ICA) in case of tandem steno-occlusive carotid lesion in the most acute phase of ischemic stroke.
Materials and methods. From December 2018 to December 2021, 29 patients with acute ischemic stroke, because of tandem steno-occlusive lesions of the ICA and intracranial arteries, underwent endovascular surgery to restore cerebral blood flow.
Results. Successful restoration of cerebral blood flow (according to the mTICI 2b–3 scale) achieved in 22 (75.9 %) patients. Four (13.8 %) patients had stent thrombosis in the early postoperative period. The incidence of symptomatic hemorrhagic transformation observed in 2 (6.9 %) patients. The frequency of a favorable functional outcome (Rankine 0–2) on the 30th day was 20.7 %, mortality – 24.1 %.
Conclusion. Stenting of the extracranial ICA in patients with acute ischemic stroke improves the efficiency of restoration of cerebral blood flow. The use of low doses of glycoprotein receptor blockers prevents stent thrombosis in the early period after implantation and does not increase the incidence of symptomatic hemorrhagic complications.
Background. Due to rare occurrence of distal cerebral aneurysms, there are very few publications devoted to endovascular treatment. Due to current progress in the endovascular surgery, the number of successfully cured patients with distal aneurysms has been increasing recently.
Aim. To determine technical capabilities and evaluate results of endovascular treatment of patients with distal intracranial aneurysms.
Materials and methods. The work is based on analysis of data of endovascular treatment among 45 patients with distal cerebral aneurysms in two neurosurgical departments of federal medical centers. Of the 45 analyzed cases 30 were without aneurysm rupture and 15 were with rupture.
Results. Endovascular treatment of the distal aneurysms made it possible to achieve good treatment results (4–5 points on the Glasgow Outcome Scale (GOS)) in 97.8 % of cases: 5 points on GOS – in 68.9 %, 4 points on GOS – in 28.4 %. One (2.2 %) fatal outcome was obtained. The most frequent methods of embolization were embolization of aneurysm by coils with stent assistance (37.8 %) and installation of a flow-diverter stent (28.9 %). Embolization with only coils (20 %) or occlusion of parent artery (13.3 %) were used less frequently. In 3 out of 6 patients, the occlusion of parent artery was not planned.
Conclusion. Development of endovascular surgery and technical capabilities of performing operations in the distal cerebral arteries has made it possible to form a multidisciplinary approach to choosing the optimal method of shutting off the distal aneurysm from the bloodstream, taking into account the modern possibilities of open surgery. This is especially important for patients in serious condition due to ruptured aneurysm.
Background. Despite its long history, cranioplasty remains a topical problem of neurosurgery, due to the increasing number of traumatic brain injury, the consequences of which are the main driver in preserving the population of patients with postcranioectomy skull defects. As a rule, these defects are extensive, and the use of individual implants in these cases is the method of choice. Over the past 5 years, the use of products created by medical additive manufacturing has increased, in this regard, the assessment of long-term results of surgical interventions with their use is an actual issue of modern medicine.
Aim. To evaluate the results of surgical treatment of patients with skull defects of various etiologies using individual titanium implants made by three-dimensional printing.
Materials and methods. The study analyzed 94 cases of cranioplasty using individual titanium implants made by three-dimensional printing using DMLS (Direct Metal Laser Sintering) technology. The minimum follow-up period was 12 months from the moment of the intervention. Traumatic brain injury and its consequences was the dominant cause of skull bone defects (n = 56, 59.6 %). The average area of defects in the study group was 99.2 ± 43.4 cm2. For men (n = 53), this parameter corresponded to 106.7 ± 44.7 cm2, for women (n = 41) – 89.5 ± 40.1 cm2.
Results. The total number of complications in the study group was 12 (12.7 %) cases, of which 5 (5.3 %) cases were recorded during the in hospital stay of patients, 7 (7.4 %) – during outpatient follow-up. One complication was not related to the performed surgical intervention. Removal of the implant was required in 7 (7.4 %) cases. The terms of implant removal varied from 0 to 14 months from the moment of the performed intervention. The survival rate of individual titanium implants for more than 12 months was 92.6 %.
Conclusion. The data on the presence of complications after cranioplasty vary from study to study, while the results of reconstructive interventions performed using individual titanium implants are of significant interest, the use of which has increased significantly over the past five years due to the introduction of additive medical production into clinical practice.
Background. Hydrocephalus can be developing by a traumatic brain injury, intracranial hemorrhage, tumor, meningitis of congenital malformation of the central nervous system. When the cause of the hydrocephalus is unclear it is supposed as idiopathic hydrocephalus. The most important classification features are the etiology and level of CSF obstruction. The classification was improved and developed with diagnostic and surgical methods simultaneously. Currently, the neurosurgeons have the possibility for usage of various methods and techniques of surgical treatment with their advantages and disadvantages. Systematization of radiological parameters is necessary to make a decision about the type of the surgery.
Aim. To analyze and systematize the neuroimaging characteristics of various forms of idiopathic hydrocephalus in adults, to assess the possible classification of idiopathic hydrocephalus.
Materials and methods. Between October 2011 and March 2021 290 patients with idiopathic adult hydrocephalus were operated at the N.N. Burdenko National Medical Research Center of Neurosurgery of the Ministry of Health of Russia: onset of symptoms in adulthood; no indications of the etiology of hydrocephalus and congenital hydrocephalus. The age of the patients was 50 ± 18.2 (18–85) years. The magnetic resonance images of patients were evaluated for the size of the ventricles, condition of convexital and basal subarachnoid spaces, obstruction of the CSF pathways, and changes in the position of the premamillary membrane, septum pellucidum, the roof of the 3rd ventricle and the tonsils of the cerebellum, the size of the sella turcica, the angle of the corpus callosum. The frequency of each of these parameters is statistically estimated for each form of idiopathic hydrocephalus.
Results. Aqueduct stenosis has become the most frequent form of idiopathic hydrocephalus. Hydrocephalus in obstruction of the foramen of Monroe, aqueduct, foramen of Magendie, and cisterns of the posterior cranial fossa was significantly more characteristic of young people (p <0.05). Hydrocephalus with obstruction of convexital CSF spaces can be called hydrocephalus of the elderly (p <0.001). Hydrocephalus without verified signs of occlusion CSF pathways occurs equally in all age groups. The FOHR index was significantly more important, and only in case of cisternal obstruction. Enlargement one or both lateral ventricles and flattening of the roof of the 3rd ventricle is characterized for Monro’s foramen obstruction (p <0.001). The membrane at the outlet of the 4th ventricle and the absence of the “flow void” was typically only for patients with obstruction of the foramen of Magendie (p <0.001). Ventral dislocation of the premamillary membrane was characteristic of obstruction of the cerebral aqueduct, the foramen of Magendie, and cisterns of the posterior cranial fossa. Compression of the convexital CSF spaces occurred in case of obstruction of the aqueduct, the foramen of Magendie, but CSF spaces of the posterior cranial fossa – only with obstruction of the foramen of Magendie. Dilation of the 4th ventricle was significantly associated with obstruction of the foramen of Magendie and cisterns of the posterior cranial fossa (p <0.05). DESH symptom was significantly associated with obstruction of convexital CSF spaces (p <0.001). Additional membranes in the cisterns of the posterior fossa were found only in cases of cisternal obstruction (p <0.001). Cerebellar tonsils herniation was observed with obstruction of the foramen of Monroe, cerebral aqueduct, and foramina of Magendie.
Conclusion. Because of statistical analysis, general signs found in all types of hydrocephalus, and private ones, characterizing only specific signs of the type of the disease, both were found. The classification is logical and justified, it is well applicable in neurosurgical and radiological practice. It allows rational planning of diagnostic evaluation and treatment of patients. A modern magnetic resonance imaging protocol should include T2 scans (with “flow void”) and FIESTA/CISS scans in the required planes, axial FLAIR scans.
Aim. To evaluate the results of intraoperative ultrasound examination (IOUS) in surgery of degenerative diseases of the lumbar spine.
Materials and methods. To evaluate the results of the use of IOUS in the surgery of degenerative diseases of the lumbar spine, an analysis of prospective examination data of 147 patients operated on for degenerative diseases of the lumbar spine in the neurosurgical department of the B.V. Petrovsky National Research Center of Surgery from 2014 to 2018. To study the accuracy of the ultrasound method for determining the level of surgical access and assessing the degree of radiation load reduction, to study the quality of ultrasound imaging of the structures of the spinal canal, a descriptive study was conducted that included 100 patients (a group of method descriptions). To determine the effectiveness of the use of IOUS, a randomized controlled trial was conducted based on a statistical comparison of the results of surgical treatment of 2 similar parallel groups of patients (control and experimental) consisting of 47 patients each, who differed only in the use of IOUS. Patients of the control group were selected from the method description group. The control and experimental groups of patients were compared according to the following criteria: the duration of surgery, the volume of intraoperative blood loss, the duration of hospitalization, the degree of root pain after surgery, the level of quality of life after surgery, the number of recurrences of herniated disc. For IOUS, we used BK Medical Pro Focus 2202 and BK Medical Flex Focus 400 ultrasound machines with neurosurgical sensors Craniotomy 8862 and Burr-Hole 8863. We performed IOUS before flavotomy, after flavotomy and after decompression of nerve structures.
Results. The method of determining the level of surgical access using IOUS has a high accuracy (100 %) and allows you not to use radiography and reduce the radiation load (on average by 0.02 mSv per patient). IOUS allows to adequately visualize the structures of the spinal canal in patients with degenerative pathology of the lumbar spine: the sensitivity of the method before flavotomy is 93 %, after flavotomy – 97 %, and after decompression of nerve structures – 100 %. Due to the high sensitivity of the IOUS method, it allows optimizing surgical access, controlling the radicality of decompression of nerve structures, documenting the fact of their decompression. The use of IOUS in patients with degenerative diseases of the lumbar spine can improve the results of surgical treatment by reducing the number of recurrences of disc herniation, reducing the degree of radicular pain after surgery, reducing the duration of surgery and the volume of intraoperative blood loss.
Conclusion. IOUS is a simple, harmless and widely available method of intraoperative imaging, which allows to improve the results of surgical treatment of patients with degenerative pathology of the lumbar spine.
Aim. To describe clinical and instrumental characteristics of patients with primary solitary and multiple tumors of the peripheral nerves.
Materials and methods. Data from 45 patients were analyzed. In accordance with the examination results, the patients were retrospectively divided into 2 groups: 1) with solitary tumors: schwannomas (n = 22), neurofibromas (n = 10), perineuriomas (n = 5), neurofibrosarcomas (n = 2); 2) with multiple tumors: schwannomatosis (n = 3) and neurofibromatosis (n = 3).
Results. The study did not show differences in the severity of motor deficit and the results of neurophysiological exams between solitary and multiple tumors; however, differences between pathomorphological types were observed. The most benign disease course was observed in patients with schwannomas, including multiple schwannomas; severe motor deficit was observed in patients with neurofibrosarcomas and crossover neurofibromas. Pain component was characteristic of neurofibrosarcomas, neurofibromas and melanotic schwannoma; perineuriomas were characterized by painless progression.
Conclusion. Compulsory scan along the nerve allows to find tumors in clinically intact areas and other nerves.
FROM PRACTICE
The most common secondary target organs in patients with colorectal cancer are the liver and lungs. Cranial metastases from sigmoid colon cancer are rare. Giant cranial metastases are currently diagnosed in exceptional cases.
The article presents a clinical case of a secondary extra‑intracranial lesion with a stable primary tumor focus in the sigmoid colon in a young patient with a high functional status.
Juxtafacet cysts include both synovial cysts directly from the facet capsule and ganglion cysts arising from the ligamentum flavum. Ganglion cysts of the cervical spine are extremely rare benign masses. The inner surface of the capsule of ganglion cysts consists of fibroblasts and has no anatomical connection with the capsule of the facet joint. Magnetic resonance imaging is the method of choice for the diagnosis of ligamentum flavum cysts, with a hyperintense round mass on T2‑weighted images with clear margins and no perifocal edema. On T1‑weighted images, an isointense signal is noted, and with contrast enhancement, the cyst wall more often accumulates a contrast. The method of choice in the surgical treatment of cysts is their total removal with sparing bone resection of the posterior vertebral structures. The outcome of surgical treatment of these formations is good with no risk of recurrence.
Background. Approximately from 0.5 to 8 % professional musicians may suffer from focal dystonia. Stereotactic surgery is option if conservative therapy is failed. Thalamotomy has been reported in limited series in the world literature.
Aim. To demonstrate a clinical case of thalamotomy with focused ultrasound in a professional guitarist with focal dystonia of the hand.
Materials and methods. A 40‑year‑old patient suffered from spasms of the fingers while playing the guitar since 2009. Patient lost professional skills and changed his activities due to progression and severity of disease. He visited our clinic for surgical treatment, stereotactic ventro‑oral thalamotomy by transcranial focused ultrasound was considered.
Results. Thalamotomy provided complete reduction of dystonia without complications. On the 2nd day after the procedure, the patient discharged. In a week mild dysarthria was noticed, which did not affect daily activities and completely regressed within a month. A month later, the patient was able to return to concert performance. The follow‑up period was 6 months with no symptoms of the disease.
Conclusion. Successful clinical case of focused ultrasound thalamotomy in patient with musician’s dystonia is presented.
Spinal stenosis is a pathological narrowing of the central spinal canal, lateral pocket, or intervertebral foramen due to age‑related changes, including pathology of the discs, facet joints, ligament hypertrophy, osteophyte formation and destruction of the arches. Clinically, the disease can manifest itself with pain, as well as numbness, or weakness in the arms or legs. The complexity of differential diagnosis is due to the lack of correlation between the degree of stenosis according to neuroimaging data and the severity of clinical manifestations. Spinal stenosis among 21 % of people may have an asymptomatic course.
Spinal stenosis has to be differentiated from atherosclerosis of the vessels of the lower extremities, rheumatoid arthritis, piriformis syndrome, sacroiliitis, spondylitis/spondylodiscitis, amyotrophic lateral sclerosis, Guillain–Barré syndrome and other polyneuropathies. Isolated weakness should be of a particular concern in the clinical picture. Muscle hypotrophy, brisk tendon reflexes, the presence of pyramidal signs, muscle fasciculations, as well as patients’ complaints of simultaneous weakness in both the upper and lower extremities accompany them.
We present and discuss three clinical cases of patients with a presumptive diagnosis of spinal stenosis. Two of them were held surgical treatment, which did not produce the expected result. Subsequently, it was found that the cause of progressive muscle weakness in the limbs was amyotrophic lateral sclerosis in two patients and the third one had Guillain–Barré syndrome, a form of acute demyelinating polyneuropathy.
Meningeal melanocytoma is a pigmented tumor arising from leptomeningeal melanocytes and occurring with a of 1 case per 10 million people. The main method of diagnosing meningeal melanocytoma is contrast‑enhanced magnetic resonance imaging, however, it is quite difficult to distinguish it from other skull base tumors. We present a case of successful treatment of a patient with this rare pathology
LECTURE
Degenerative disc disease and facet joint disease involving the lumbar spine are common in the aging population and are the most frequent causes of disability. Surgical interbody fusion of degenerative levels is the most common management technique. This is an effective treatment option to stabilize the spine and reduce mechanical pain and provides indirect decompression of the neural elements while restoring lordosis and correcting the deformity. Depending on the direction of the approach to the vertebral column, various techniques have been described. Anterior lumbar interbody fusion (ALIF) offers clear and wide visualization of the disc allowing the use of large interbody grafts, which provide a significant biomechanical advantage over other types of fusion. The transperitoneal approach is a much older technique and it is not commonly performed unless in isolated cases with extensive retroperitoneal scaring following multiple abdominal surgeries. The transperitoneal approach has been associated with higher rates of bowel injury, ileus, and retrograde ejaculation, and is limited at the L5–S1 segment, hence many spine surgeons favor a retroperitoneal approach. The major setback of ALIF is the need for great vessel mobilization. This manipulation of the vessels may lead to deep vein thrombosis and a direct vascular injury. This makes vascular anatomy studies in the preoperative stage invaluable in avoiding vascular injury. Other complications include possible injury to intraperitoneal and retroperitoneal organs, especially in patients with previous surgery and adhesions. Manipulation of the intestines causes postoperative ileus which lasts a few days. Sexual dysfunction in form of retrograde ejaculation is another complication seen in patients following ALIF and this has been attributed to injury to the superior hypogastric sympathetic nerves in the lower lumbar region.
This article reviews the ALIF procedure i. e., transperitoneal and retroperitoneal approaches, and the associated intraoperative, early, and late complications.
The basal forebrain is a complex anatomic region with a lot of nuclei and fibers. Tumors or direct lesions of this area do not always manifest clinically despite it taking a part in behavior, emotion and cognition. A deep understanding of the anatomy of the gray matter and associative pathways passing through the basal forebrain allows us to take a different look at clinical manifestations in the preand postoperative period. Based on the literature review, we tried to describe the anatomical, phylogenetic and functional connections of the basal forebrain with surrounding regions and analyze what changes in clinical symptoms appear when it is locally damaged.
The presented lecture is dedicated to analysis of morphogenetic characteristics of glial tumors in adults in the framework of the World Health Organization (WHO) classifications of 2007, 2016, 2021, changes in the classifications and their significance for clinical practice. This topic is important because the most difficult changes for neurosurgeons to understand in comparison of the WHO classifications of 2007, 2016 and 2021 involved sections on glial tumors and children’s tumors.
The authors focus on increasing practical significance of genetic component in tumor characterization. The classification of 2007 was the last purely morphological classification of central nervous system tumors, it did not include genetic principles of tumor division in different groups. In the following years, knowledge on the significance of various mutations for prognosis of glial tumor progression and selection of optimal treatment based in genetic characteristics of the neoplasm has been actively accumulated. In the 2016 edition, morphological and genetic tumor characteristics were consolidated for the first time which was unquestionably a necessary step. Complex integrative analysis of glioma genomes has shown that genetic characteristics have higher prognostic value compared to the WHO Grade. In the classification of 2021, names of the tumors proposed in 2016 were changed, and practical significance of the genetic component in tumor characterization was increased. However, this can further complicate interpretation of histological diagnosis by practicing neurosurgeons.
Implementation of the 2021 WHO classification in clinical practice assumes expansion of the spectrum of genetic diagnostic methods. The neurosurgical community should be ready to interpret morphogenetic results and select treatment tactics in tandem with oncologists based on genetic characteristics of the tumor.
PUBLICISM
LETTER TO THE EDITOR
Review of the article: Ulitin A.Yu., Odintsova G.V., Nezdorovina V.G., Malyshev S.M. Dostoevsky’s epilepsy. Russian Journal of Neurosurgery 2021;23(3):113–21. (In Russ.).
DOI: 10.17650/1683‑3295‑2021‑23‑3‑113‑121
ISSN 2587-7569 (Online)