Background. Glioblastoma is the most common primary malignant brain tumor with an extremely unfavorable prognosis. The frequency of the “longevity” phenomenon (>3 years of overall survival – OS) in this disease is 5–10 %. The reasons for the more favorable prognosis in these patients are still unclear.

Aim. To compare the clinical and MRI data as well as features of complex treatment of patients with supratentorial glioblastomas among the control group (OS <2 years) and study group (with the phenomenon of “longevity”, OS >3 years).

Material and methods. This study included 41 patients with hemispheric glioblastomas: 17 with the “longevity” phenomenon (study group – long-term survival (LTS), prospective set); 24 patients in the control group (retrospective set). Taking into account the average age of patients, the following MRI features were examined: tumor localization relative to the frontal lobe; invasion of deep brain structures; the ratio of contrastenhancing and non-contrast-enhancing parts of the glioma; tumor contrast intensity; localization of recurrent tumor (local / distant) in case of  disease progression. Comparative analysis of complex treatment took into account the following parameters: the number of chemotherapy (ChT) courses and radiation regimens after the 1^st operation and after disease recurrence; the fact and number of repeated tumor resections after recurrence; the presence of IDH1 mutation.

Results. The localization of the lesion relative to the frontal lobe, the number of affected lobes of the brain and the invasion of deep structures did not differ significantly in the examined groups. Patients of study group (LTS, prospective set) were significantly younger than the patients of the control group (p <0.05). The tendency towards a single-lobe lesion was noted in the LTS group (p = 0.085). The average volume of the contrast-enhancing part of the tumor (according to MRI data in the T1 mode) in patients of LTS group was 34 cm³, and the non-contrast-enhancing part (in the T2-FLAIR mode) was 105 cm³, the ratio was 1: 3 (p >0.05). The tumor contrast intensity was 1.5 in average compared to the intact cerebral hemisphere. Among patients of LTS group, 8 patients (47 %) were re-operated due to disease recurrence, while in the control group there were no repeated operations (p <0.05). The results of the analysis of radiation therapy after the 1^st operation were the follows: for LTS patients the median total radiation dose (TRD) was 58 (35–66) Gy, with no significant differences between the groups (p >0.05); the number of temozolomide courses in the LTS group were 9 (6–22), while in the control group it was 6 (3–10), p <0.05. The repeated radiotherapy (RT) in different regimens was applied in the LTS group in 52 % of patients, in the control group – 0 (p <0.05). The repeated ChT (17 (9–23) courses, mainly with bevacizumab) was applied in the LTS group in 65 % of patients, in the control group – 0 (p <0.05). The IDH1 mutation was studied only in 15 patients: positive – in 1 (LTS group); negative – in 14 patients (7 from the control group).

Conclusion. The following significant differences were revealed: patients with supratentorial glioblastomas were younger in the LTS group. The important features of the complex treatment of patients in LTS group included statistically higher frequency of repeated resections in case of recurrence (47 %) and repeated sessions of radiotherapy (RT) in various modes (52 %); significantly more aggressive and prolonged ChT (with the predominance of temozolomide in the 1^st line of treatment and bevacizumab in case of recurrence). There were no significant differences between two examined groups in tumor localization, intensity of its contrasting, the ratio of contrasted and non-contrast parts of the tumor, invasion of deep structures of the brain, involvement of functionally significant areas (FSA).

Background. Hemorrhage from cerebral arteriovenous malformation (cAVM) is a formidable manifestation of the disease, which is characterized by a high risk of death and disability. Individual assessment of the hemorrhage risk from cAVM would allow choosing the most adequate treatment tactics taking into account the expected rupture risk and the patient’s age at hemorrhagic manifestation.

 Aim. to develop a method for individual prediction of the cAVM risk rupture during the natural course of the disease.

Material and methods. A retrospective analysis of demographic characteristics, clinical manifestations, and instrumental research data was performed in 104 patients with cAVM who underwent treatment from 2011 to 2023.

Results. Hemorrhage occurred in 40 (38.5 %) of 104 patients, while in 35 (33.7 %) patients it was the first manifestation of cAVM. The median age of patients at time of cAVM rupture was 55 (95 % CI 49–61) years. A new method for predicting the risks of cAVM rupture was developed based on 4 factors that were identified as a result of regression analysis and rupture risk analysis (Cox and Weibull models), as well as clinical considerations. The developed DSSF scale takes into account the following parameters: deep outflow deficit (p = 0.022), maximal node size (p = 0.012), side of cAVM location (p = 0.014), absence of fistula (p = 0.072). Patients can be divided into 3 categories based on the sum of points obtained while assessing 4 characteristics of cAVM using the DSSF scale. The proposed cAVM assessment system was the following: +3 points – left side of the brain; – 1 point – maximum size of the cAVM node per each 1 cm; +4 points – deep outflow deficiency; +2 points – absence of fistula. The low-risk group (group A) included patients with the following set of parameters: – 2 points or less for cAVM; 43 % of the sample; median patients’ age at the time of cAVM rupture – 64 [60, 72] years. The moderate risk group (B) included the following parameters: from –1 to +1 points for cAVM; 39.4 % of the sample; median patients’ age at the time of cAVM rupture – 50 [44, 59] years. The high risk group (C) included the following parameters: +2 or more points for cAVM; 17.3 % of the sample; median patients’ age at the time of cAVM rupture – 38 [30, 48] years. The risk of hemorrhage from cAVM for patients in group A was 0 at 20; 8 at 30; 12 at 40; 17 at 50; 17 % at 60 years old. In the same age categories, these data for group B were 0, 8, 19, 41 and 80 %, for group C – 11, 29, 60, 79 % and about 100 %.

Conclusion. The proposed method for assessing the hemorrhage risk for cAVM allows ranking patients into groups with low, moderate or high risk of intracranial bleeding, suggesting the patients’ age at time of cAVM rupture and choosing the adequate treatment tactics in terms of surgical aggression and time to cAVM elimination.

Background. The problem of pathogenetic treatment of spinal cord injury (SCI) is extremely acute, especially against the background of the growing number of SCI in modern conditions. The world literature widely presents the scientific research on the development and application of regenerative technologies and cell therapy effective for patients with SCI. One of the most promising areas is the use of stem cells. The human umbilical cord blood cells (HUCBCs) is one of the sources for obtaining stem cells having a number of serious advantages such as high efficiency in the patients’ treatment with traumatic lesions of the central nervous system.

Aim. To evaluate the safety and primary efficacy of serial systemic (intravenous) administration of allogeneic mononuclear cells of the HUPBC to adult patients with gross neurological deficit because of acute period of severe contusion SCI.

Material and methods. Phase I of the SUBSCI I / IIa study included 10 patients (experimental and control groups) with severe SCI (cervical / thoracic / upper lumbar) in the acute period with gross neurological deficit (A / B on the ASIA scale). The conducted treatment included 4 systemic (intravenous) administrations of HUCBCs (allogeneic and compatible by AB0 and Rh factor) within 3 days from the moment of SCI, strictly after the primary surgical intervention. Observation period lasted 12 months after trauma. Safety assessment included the registration of all adverse events (AE) during the observation period with their further classification by severity (CTCAE v. 5.0) and potential connection with the cell therapy. The primary efficacy assessment was the identification of the neurological deficit dynamics (ASIA) – assessment of the restoration degree of motor and sensory functions of the lower extremities during the 1st year.

Results and discussion. A total of 419 AEs were detected in 10 patients, but only 2 of them (clinically insignificant) were assessed as probably related to cell therapy, the remaining 417 were not related to therapy. All patients had no signs of immunization to the administered HUCBCs samples. The analysis of the neurological deficit dynamics indicates the reliable restoration of motor functions in patients after cell therapy, compared with the control group.

Conclusion. Based on the results obtained, the systemic administration of allogeneic HUPBC, selected without taking into account the HLA system, can be considered as a safe and effective method for treating contusion SCI in the acute period.

Background. Surgical tactics in treatment of patients with brain metastases and significant cystic component are ambiguous due to the complexity of resection of such tumors in compliance with the principles of thorough oncological treatment.

Aim. Presentation of a method for treatment of patients with metastatic lesions in the brain with a large cystic component using minimally invasive neurosurgical intervention: implantation of a chronic subcutaneous drainage system – the Ommaya reservoir.

Materials and methods. At the National Medical Research Center of Oncology named after N. N. Blokhin of the Ministry of Health of the Russian Federation, from 2007 to 2022, Ommaya reservoir implantation was performed in 100 patients with various forms of tumors of the central nervous system and significant cystic component.

Results and discussion. The use of the technique of implantation of a constant subcutaneous drainage system – the Ommaya reservoir – in complex treatment of patients with brain metastases in most cases allowed to control the size of the cystic component of the tumor with subsequent local radiation exposure. Direct neurosurgical intervention in the form of tumor resection usually does not comply with the principle of thorough oncological treatment of neoplasms with a significant cystic component due to fragmentation of pathological tissue that leads to rapid local recurrence and dissemination.

Conclusion. Surgical treatment of patients with brain metastases is a difficult problem due to the need for a combination of adequate neurosurgical and oncological approaches and tactics. Functional accessibility (neurosurgery) and thoroughness (oncology) cannot always be achieved together to an adequate extent. The use of the Ommaya reservoir in complex treatment of patients with brain metastases with a large cystic component has shown its effectiveness and should be used in the routine practice of a neurosurgeon.

Introduction. Currently diagnosis of cerebrospinal fluid (CSF) leak involves the use of instrumental and laboratory techniques. Computed tomography of the brain (CT brain) is the preferred instrumental method. However, it is not always effective for visualization of skull base defects less than 2 mm in size.

Aim. To confirm nasal CSF leak primarily using laboratory diagnostic methods, rather than instrumental diagnostic methods.

Materials and methods. Instrumental diagnosis of nasal CSF leak (outpatient): high-resolution CT brain with subsequent image analysis in multiplanar projections. Laboratory diagnosis: quantitative test of glucose in nasal fluid using test strips (Russia) and quantitative test using hexokinase method and biochemical analyzers (Japan, USA).

Results. Diagnostic tactics and types of surgical treatment for 34 patients are presented. CT brain was performed in all patients, and no bone defect was found in 5 (14.7 %) cases. However, thinning of the bone tissue in the area of the cribriform plate of the ethmoid bone with the presence of a soft tissue inclusion (meningoencephalocele), as well as a low position of the olfactory fossa (8.16 ± 0.14 mm) was observed. Through laboratory diagnostics, admixture of CSF in nasal fluid was verified in 5 (14.7 %) patients. Reconstruction of CSF fistulas was performed in all patients through endoscopic endonasal access using multilayer closure technique with allo- and autografts. In the postoperative period, no recurrence of CSF leak was observed. Follow-up period ranged from 6 months to 3 years.

Discussion. In verification of CSF in nasal fluid, CSF fistula diagnosis requires CT brain; in the absence of obvious defects of the skull base according to CT results, endoscopic examination of the nasal cavity and cribriform plate of the ethmoid bone should be performed without the use of invasive diagnostic methods.

Conclusion. In the context of negative CT and positive laboratory results, the area of the cribriform plate of the ethmoid bone should be regarded as the most likely source of CFS.

Aim. To present a clinical case of successful recanalization of chronic total internal carotid artery occlusion and results of literature review on the topic.

Clinical case. The patient (55 years) with diagnosed in 2021 occlusion of the right carotid artery (from bifurcation of the common carotid artery to the ostium of the ophthalmic artery) underwent drug therapy. He was discharged from the Saint-Petersburg I. I. Dzhanelidze research institute of emergency medicine (Saint Petersburg, Russia) with complete regression of the symptoms. In 2022, after his condition worsened, computed tomography angiography showed occlusion of the internal carotid arteries on both sides. We recommended revascularization surgery which the patient declined. A course of dual antiplatelet therapy was prescribed. In 2023, after another cerebrovascular event the patient was admitted into the Institute: cerebral angiography confirmed bilateral occlusion of the left internal carotid artery up to ophthalmic arteries’ origins (type С / D per the classification by D. Hasan et al.). At the Institute, the patient underwent intravascular recanalization of chronic left internal carotid artery occlusion (29.09.2023). Control examination (cerebral angiography) 12 months later showed preserved permeability of the left carotid artery without signs of restenosis. In the absence of repeat cerebrovascular events, revascularization of the right carotid system is considered unnecessary.

Literature review. A review of scientific publications on the capabilities of intravascular recanalization of chronic occlusions of the internal carotid artery is presented. Indications, techniques and results of intravascular interventions are discussed, predictors of recanalization and its complications are described.

Conclusion. The development of endovascular methods allows successful recanalization of chronic and subacute occlusions of the internal carotid artery in most cases. Indications for surgery are based on the clinical features of the disease, effectiveness of drug therapy, and angiographic characteristics of the occlusion.

This article reviews the literature and presents a clinical case of surgical correction of fixed cervicomedullary compression (FCC) in rheumatoid arthritis (RA) involving the craniovertebral region. To demonstrate the possibilities of decompression-stabilization surgery in the surgical rehabilitation of a patient with severe RA. The observation period was more than 11 years.

At the first visit, the patient underwent a two-stage surgical correction in one operation: stage 1 – transoral decompression – resection of the dens and 2 / 3 of the C2 vertebral body; stage 2 – occipitocervical fixation C0-C3-C4-C5-C6.

The surgical treatment allowed to completely restore the patient’s functional independence. Upon re-admission (after 11 years), the elements of the fixing structure were reinstalled.

A clinical observation is presented that demonstrates the effect of FCC in the late stage of RA on the functional status of the patient, as well as the possibilities of two-stage reconstructive-stabilizing surgery. Two-stage surgical correction for FCC is a key point of surgical rehabilitation, ensuring the possibility of returning patients to functional independence.

Background. The treatment of complex cerebral aneurysms is still remained the great challenge for neurosurgeons. There is a large choice of intravascular techniques for excluding the complex cerebral aneurysms from the blood flow: endovascular embolization with microcoils, usage of flow-diverting stents, balloon angioplasty and stenting of extra- and intracranial segments of the main cerebral arteries. At the same time, the microsurgical treatment of cerebral aneurysms has not lost its relevance and remains the most radical method of treatment. However, simple clipping or reconstruction of complex aneurysm wall is not always possible. In such cases, trapping of parent artery and revascularization of the required blood supply territory are used.

Aim. To present the two clinical cases of patients with complex intracranial aneurysms without the possibility of endovascular treatment, who underwent parent artery trapping and alternative middle flow extracranial-intracranial (EC–IC) bypass as well as to conduct the literature review concerning the key aspects of this topic.

Clinical cases. This article presents two patients operated on for complex intracranial aneurysms. The first patient had a complex fusiformsaccular aneurysm of the left middle cerebral artery (MCA) with a frontal M2 segment of the left MCA extending from the fusiform dome; the second patient had a giant saccular aneurysm of the supraclinoid segment of the left internal carotid artery (ICA) and a complete posterior trifurcation on the left. Endovascular treatment was considered as impossible. The trapping of the parent artery and performing of middle-flow EC–IC bypass using the distal branches of the external carotid artery (ECA) were conducted. Intraoperative frameless neuronavigation was used. Conclusion. The use of terminal branches of the ECA (maxillary artery and proximal part of superficial temporal artery) expands the possibilities of cerebral revascularization performing in cases where low- or middle-flow EC–IC bypasses are required. The relatively rare use of these arteries in practice and few publications about these types of bypasses require careful selection of patients with preoperative assessment of the brachiocephalic arteries and hemodynamic parameters.

Aim. To describe a clinical case of surgical treatment of dysphagia caused by ventral osteophyte of the first two cervical vertebrae.

Material and methods. At the Russian University of Medicine (Moscow, Russia) clinical medical center, a female patient underwent surgical treatment due to complaints of difficulty swallowing (dysphagia) and periodic respiratory difficulty, and symptomatic ventral osteophytes of the first to cervical vertebrae. Considering the location of the osteophyte, it was resected through transoral access.

Results. For 2 weeks after surgery, the patient received nutrition through nasogastric tube. After transitioning to normal eating, the patient noted regression of dysphagia compared to the preoperative level.

Conclusion. Ventral osteophyte of the cervical spine compressing the esophagus and pharynx is one of the rare causes of dysphagia. If osteophyte is located at the atlantoaxial level, transoral access allows to fully resect it and cure the patient’s dysphagia.

Background. The rate of mechanical complications (screw system instability and hardware migration) associated with dorsal instrumental fixation of the cervical spine after injury ranges between 2 and 5 %. Implant migration, particularly of rods, following dorsal screw fixation of the cervical spine is a rare but potentially dangerous complication. Such complications can lead to severe neurological consequences and requires timely intervention.

Aim. To analyze a clinical case of instability and migration of metal hardware following screw fixation of the C1–C2–C3–C4 segments in a patient with traumatic fractures of the C2 and C3 vertebra, and to review literature to identify risk factors and methods for preventing such complications.

Material and methods. The study includes one clinical case of a patient who experienced complications – implant migration – after multilevel fixation of the cervical spine. Clinical examination, computed tomography (CT) were used to assess the condition of the patient and implants, along with a review of the literature on this issue.

Results. The patient was diagnosed with instability of the metal hardware and migration of the rod into the posterior cranial fossa (Fossa cranii posterior) causing neurologic symptoms. A second surgical intervention was performed to remove the metal hardware. The literature review revealed that such cases are rare and require careful approach to selection of fixation methods and postoperative monitoring.

Discussion. The analysis of the clinical case and the literature revealed possible causes of migration, including inadequate fixation and technical errors. Recommendations on prevention of such complications and patient management are proposed.

Conclusion. Rare cases of instability and migration of the metal hardware following multilevel screw fixation of the cervical spine require personalized approach to diagnosis and treatment. Performing spinal fusion with strict adherence to surgical technique, increased awareness, and strict postoperative monitoring can reduce the risk of complications and improve treatment outcomes.

The Department of Neurosurgery of the S. M. Kirov Military Medical Academy has developed and implemented a new concept for providing assistance to the wounded with injuries to peripheral nerves.

During previous military conflicts, wait-and-see tactics for treating such victims were standard. Reconstructive interventions on nerves were performed no earlier than 3–6 months after injury. This was justified by the fact that impaired nerve function is often associated with a contusion mechanism and restoration of conductivity could occur without surgery.

In recent years, neuroimaging methods such as magnetic resonance neurography and ultrasound examination of peripheral nerves have been actively developed at the Military Medical Academy. Their use (immediately upon achieving healing of the surgical wound after primary surgical treatment, and for magnetic resonance neurography – after removal of metal foreign bodies), in addition to electroneuromyography, which is not always informative in the early stages, but traditionally used, makes it possible to confirm or exclude a complete anatomical break of the nerve trunk and determine the pathomorphological form of its damage. While maintaining the morphological integrity of the nerve, the wounded person is prescribed adequate conservative (neurotrophic, analgesic) therapy. In the presence of pathomorphological changes, reconstructive surgical interventions on peripheral nerves are now carried out in the early stages after injury (3–6 weeks). The sooner reconstructive intervention on the nerve is performed, the greater the likelihood and the faster its function will be restored.

The most important element of the new concept of providing care to patients with peripheral nerve injuries is close interaction between neurosurgeons and neurologists, ensuring continuity of care at all stages of treatment. Firstly, it made it possible to timely identify patients with clinical signs of damage to the peripheral nervous system in the flow of incoming surgical patients. Secondly, it has proven its effectiveness in the treatment of neuropathic pain syndrome in this category of patients at the stage before and after neurosurgical intervention. Thirdly, early reconstructive intervention is followed by early restorative treatment under the supervision of a neurologist.

Background. Neuroplasticity of the brain cortex is a unique phenomenon. It has both scientific and clinical significance for neurology and neurosurgery.

Aim. The aim of this study is to analyze literature data on human brain neuroplasticity in various diseases and describe factors affecting it. Materials and methods. Analysis of literature presented in the PubMed database was performed using searches for words “neuroplasticity”, “cortical plasticity” and “glioma surgery”. Several clinical cases from the authors’ practice are used as illustrations.

Results. Based on literature data, the article presents the main types of neuroplasticity depending on: type of pathological process; location of cortical zones participating in neuroplasticity formation; level of compensation of lost brain function; time of phenomenon development; rate of pathological process development. The special role of preservation of white matter tracts in neuroplasticity is highlighted. Clinical significance of this phenomenon for neurosurgery is demonstrated using the example of intracerebral tumors located in functionally important parts of the brain.

Conclusion. Neuroplasticity of the brain cortex is predominantly characteristic of “slow” pathological processes such as low-grade gliomas in contrast to “fast” processes (such as malignant tumors, injuries, strokes). Language areas of the cortex are more susceptible to plasticity than motor cortex (except the supplementary motor cortex). Areas neighboring the lesion, as well as distant areas including the contralateral hemisphere, can contribute to compensation mechanisms. Phenomenon of neuroplasticity helps to compensate functions of the affected cortex both during disease progression and multistage neurosurgical interventions. Transcranial magnetic stimulation is a promising technique for managing neuroplasticity in tumors and other types of brain diseases.

Background. Hemifacial spasm (HFS) is a chronic condition that significantly affects patients’ quality of life. Currently, there are no standardized scales to assess the severity of this condition and the impact on quality of life in both surgical and conservative treatment.

Aim. To highlight the currently existing tools for assessing HFS severity, as well as the quality of life and the effectiveness of treatment of this pathology.

Material and methods. A search of published data in electronic databases MEDLINE (PubMed) and RSCI (eLIBRARY) was performed.

Results. The main advantages and disadvantages of currently available scales for assessing the severity of HFS (score-rating scale, Tan scale, Clinical General Impression Scale (CGI-S), Chong scale for assessing HFS, Hemifacial Spasm Grading Scale (HSGS)), quality of life of patients with HFS (HFS-7, Cohen scale, HFS-30 scale), as well as the effectiveness of vascular decompression (classification of assessment of surgical treatment of HFS, scale proposed by N. Shorr) were analyzed. Data from studies including more than 50 participants in which the above scales were used are also presented.

Conclusion. It is advisable to use several instruments to assess all aspects of HFS in order to obtain the most complete information on the patients’ condition.

Background. The frequency of traumatic cerebrospinal fluid (CSF) leaks in fractures of the skull base is 33–40 %, intracranial purulent complications occur in 10–37 % of cases, and mortality rate is 30 % even with antibiotic therapy. The difficulty of diagnosing CSF leaks in patients with severe traumatic brain injury is caused by several factors: impossibility of gathering complaints from a patient with decreased alertness; difficulty to position a patient for instrumental diagnostics due to concomitant injuries; artificial ventilation; cerebrospinal fluid leak being masked by hemorrhagic secretions from the nose.

Aim. To review the effectiveness of various diagnostic methods and algorithms for detection of cerebrospinal fluid leak and to access their feasibility in cases of potentially penetrating traumatic brain injury.

Results. The study identified the main challenges of diagnosing cerebrospinal fluid leaks in intensive care patients, including difficulties in  performing invasive neuroimaging methods, challenges in collecting nasal secretions for laboratory detection of CSF-specific markers, and the absence of fluorescein approved for intrathecal use in the Russian Federation. It was established that in severe cases, the most informative methods are brain CT and glucose oxidase test with radionuclide cisternography recommended in cases of uncertain results. Upon confirmation of cerebrospinal fluid leak, endoscopic nasal cavity revision and, if necessary, CSF fistula repair are advised.

Conclusion. The findings emphasize the need for further research and refinement of diagnostic algorithms to improve the accuracy of traumatic CSF leak detection in patients with severe traumatic brain injuries.