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Russian journal of neurosurgery

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Vol 27, No 3 (2025)
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JUBILEE

ORIGINAL REPORT

24-31 21
Abstract

Aim. To investigate the gender-specific social and demographic characteristics of neurosurgical patients with drug-resistant epilepsy.

Materials and methods. The study design was single-center, non-randomized, retrospective, in parallel groups. It was conducted at A.L. Polenov Neurosurgical Institute - branch of the V.A. Almazov National Medical Research Centre, in the department of functional neurosurgery in 2022-2023.

The study is part of the state assignment commissioned by the Government of the Ministry of Health of Russia (topic No. 123021000127-7 “Development of a new neurorehabilitation procedure for patients after surgical treatment for drug-resistant epilepsy”).

The object of the study were neurosurgical patients with drug-resistant epilepsy. The subject of the study was gender-specific socio-demographic indicators.

The study is based on the results of the examination and treatment of 100 patients with drug-resistant epilepsy after neurosurgical treatment at A.L. Polenov Neurosurgical Institute. There were 2 heterogeneous groups: group 1 - male, group 2 - female. Social functioning was assessed by social activity. Indicators of social functioning were educational level, employment, and disability group. The analysis of the statistical data obtained during the study was done using SPSS 12.

Results. Group 1 comprised 53 (53 %) men and Group 2 comprised 47 (47 %) women. The age of the cohort ranged from 18 to 43 years, with a mean of 29.65 ± 6.35 years. The average duration of disease before surgery was 18.79 ± 8.64 years.

The educational level in the cohort was characterized by the prevalence of vocational education - 42 % versus secondary education - 25 % and higher education - 33 %. In group 1, patients with secondary and specialized secondary education predominated, while in group 2 about half of the patients had higher education. There were twice as many unemployed people in the cohort as employed - 62 % and 31 % respectively and 5 % were studying.

The number of patients with disabilities was 41 %, without disabilities - 59 %, in group 1 and group 2 patients without disabilities predominated.

Conclusion. No gender-specific differences in social functioning were found in the long-term course of epilepsy. The long-term course of the disease has a negative impact on the indicators of social functioning of people with epilepsy in the preoperative phase. The cohort of the neurosurgical profile with pharmacoresistant epilepsy is characterized by problems of social adaptation: two thirds of them are not employed, a quarter of patients have only a high school diploma and no special education, 40 % have a disability.

It is necessary to actively inform doctors and patients about the existing possibilities of surgical treatment of epilepsy in order to achieve a wider application of modern methods of epilepsy neurosurgery and early referral to surgical care, thus improving the effectiveness of treatment.

32-45 19
Abstract

Background. Endoscopic transnasal transsphenoidal surgery (standart/extended) is commonly used for resection tumors in the sellar and parasellar regions. However, because of its anatomical location, cerebrospinal fluid leakage (CSF) is a major complication of this approach. Skull base reconstruction after endoscopic transsphenoidal surgery is essential to prevent postoperative CSF leakage.

Aim. To determine specific recommendations and develop an algorithm for dural reconstruction after tumor removal in the sellar region.

Materials and methods. All patients who were treated at Nagoya University Hospital from April 2013 to March 2017 who underwent sellar floor reconstruction using dural suturing with abdominal fat or fascia after tumor removal via a standard and extended endoscopic transsphenoidal approach were included in the study.

Results. Endoscopic transsphenoidal surgery was performed in 176 patients (the standard transsphenoidal approach was used for 141 patients and the extended transsphenoidal approach was used for 35 patients). In 76 patients, intraoperative CSF leak was classified as grade 2 and 3 according to Esposito. There were 3 cases of CSF leakage after the surgery (1.7 %).

Conclusion. Dural suturing is a basic and key method of skull base reconstruction, with continuous suturing being the most effective approach. Due to the localization of tumors, we developed a differentiated approach and algorithm for dural reconstruction after tumor removal in the sellar region.

46-57 21
Abstract

Background. Gunshot wounds are the most common type of spinal cord and spinal cord injury in battlefields. In some cases, spinal cord injury leads to instability in the spinal motion segment. A protocol for scoring tactical classification of unstable gunshot wounds of the thoracolumbar spine was developed.

Aim. To analyze the interexpert agreement in assessing the “significance” of a fracture of a specific anatomical structure and deciding on the influence of this injury on the necessity to perform stabilizing intervention.

Materials and methods. An evaluation of 30 anonymized clinical and radiological cases by 15 surgeons was performed. Each surgeon completed 30 questionnaires based on the computed tomography images. A kappa (к) coefficient was used to determine the degree of agreement between surgeons in the points of view on the stability and contribution to destabilization of each anatomic structure.

Results. A good level of inter-expert agreement was demonstrated in surgeons' detection of posterior osseous-ligamentous complex injury (к = 0.854), assessment of its significance (к = 0.56), detection of transverse processes fracture (к = 0.664), arch joints (к = 0.521), arch root (к = 0.717) and its significance (к = 0.4), and vertebral body (к = 0.655). All surgeons found that fracture of two arch roots resulted in absolute fracture instability. A good level of agreement was also demonstrated in the overall assessment of the fracture: unstable fracture, к = 0.41; stable fracture, к = 0.55; the level of agreement on the applicability of the McCormack classification was 0.406.

Conclusion. High level of inter-expert concordance on the fact of injury of the structures proposed in the questionnaire was obtained which demonstrates accuracy of identification of skeletal elements affecting development of instability. Preliminary evaluation of the results does not allow to make judgement on certain concordance in assessment of significance of injuries of these structures. Critical impact of bilateral fractures of the articular processes or pedicles of the vertebral arch requiring stabilizing intervention was established. The aim of further studies is final analysis of inter-expert and intra-expert concordance. Based on the analysis of the experts' answers, classification of primary spinal instability in thoracic and lumbar gunshot wounds will be developed. Additionally, evaluation of clinical situations by expert surgeons with subsequent statistical analysis will be performed to improve reliability and reproducibility of the new classification system.

58-68 23
Abstract

Background. Awake craniotomy is a modern technique of neurosurgical operations allowing to preserve speech while trying to achieve maximal tumor resection. For a long time, during awake surgeries the main importance was assigned to electrostimulation of the language centers. Currently, the mapping of the long association tracts during resection of gliomas of the speech-dominant hemisphere is the necessary requirement for speech preservation.

Aim. To analyze the results of intraoperative electrostimulation of the arcuate fasciculus in comparison with magnetic resonance tractography data (MR tractography), as well as speech disorders before and after surgical interventions in patients with left hemisphere gliomas adjacent to the arcuate fasciculus who underwent awake craniotomy.

Materials and methods. Awake surgeries were performed in 23 patients aged between 19 and 67 years old (mean age 41) with left hemisphere glionas. Tumor was located in the frontal lobe in 11 patients, in the temporal lobe - in 8 patients, in the parietal lobe - in 4 patients. The malignancy grade was the following: Grade 2-7 patients, Grade 3-12 and Grade 4-4 patients. In all patients, the cortical electrophysiological stimulation to control localization of the cortical language centers and subcortical electrophysiological stimulation for identification of the arcuate fasciculus were performed during awakening. Speech disorders before and after surgery were evaluated by a neuropsychologist using the Luria method; intraoperatively, automated test with picture naming was additionally used. The mean current intensity during direct subcortical electrostimulation was 4 mA. MR tractography with reconstruction of the arcuate fasciculus and volumetry using magnetic resonance imaging (MRI) were performed in all 23 cases before and after surgery.

Results. During intraoperative electrostimulation, Broca's area was identified in 8 of 11 patients with frontal lobe tumors, cortical temporal speech areas were identified in 5 of 8 patients with temporal lobe tumors. In 16 (70 %) of 23 patients, the arcuate fasciculus was mapped in the form of mixed speech abnormalities in the depth of operative wound in the frontal, parietal and temporal lobes. In 17 (75 %) of 23 patients, worsening the speech function was observed in the early postoperative period: in 13 of them a combination of frontal and temporal types of speech disorders (conduction aphasia caused by the surgery near the arcuate fascisulus) was observed. The postoperative MR tractography performed in 23 patients showed the direct intraoperative injury of the arcuate fasciculus in 3 (13 %) cases and adjacent ischemia - in 2 (9 %) cases. The MR volumetry showed total tumor resection in 8 cases, subtotal - in 9 cases, and partial - in 6 cases.

Conclusion. During awake surgeries for left hemisphere tumors, it is important to map the arcuate fasciculus in the deep parts of the frontal, temporal and parietal lobes. The subcortical stimulation allowed to identify the arcuate fasciculus in 70 % of presented cases; the MR tractography showed the damage of the anatomical integrity of the arcuate fasciculus in 22 % of cases (direct injury or ischemia). Worsened speech function after surgery was observed in 75 % of patients. In the early postoperative period, the main cause of worsened speech function related to the arcuate fasciculus is its functional insufficiency but not an anatomical damage. These speech disorders regress in the majority of patients (85 %) in 3-6 months after surgery.

69-78 20
Abstract

Background. Destructive surgical methods for the treatment of drug-resistant trigeminal neuralgia in the Russian clinical recommendations are classified as options, but at the same time they are in demand and often found in clinical practice. One of them is glycerin rhizotomy by S. Hakanson.

Aim. To evaluate the effectiveness of the treatment of trigeminal neuralgia using glycerin rhizotomy by S. Hakanson.

Materials and methods. A retrospective cohort study was carried out: the results of treatment with glycerol rhizotomy were analyzed in 202 patients with trigeminal neuralgia, who were treated at the Irkutsk City Clinical Hospital No. 1 from 2009 to 2022 years. To study the follow-up, the telephone interview was carried out with 107 patients. Based on the analysis of the literature, the data were compared with the results of the treatment of other surgical methods.

Results. Initial pain relief after surgery was noted in 95 % of patients. Recurrence of pain syndrome (III-V class on the Barrow Neurological Institute Pain Scale) was observed in 32.7 % of patients, while the medium pain intensity on the visual analogue scale score was 7.3 ± 0.26. Pain-free period was 27.7 ± 3.6 of months. There were no deaths.

Conclusion. Glycerin rhizotomy provides immediate pain relief in patients with drug-resistant trigeminal neuralgia. This procedure is effective, minimally invasive, safe, simple and painless for patients in compliance with the algorithm.

79-88 20
Abstract

Background. Currently, pituitary adenomas, also known as neuroendocrine pituitary tumors, are one of the most common intracranial tumors in adults, accounting for up to 15 % of all tumors of the central nervous system. Transsphenoidal removal using endoscopic or microscopic surgery remains the main and the most widely used method for their treatment. However, some questions remain regarding the optimal surgical technique and the reducing of complications incidence.

Aim. To analyze the features of endoscopic transsphenoidal access in tumors of the chiasmal sellar region as well as surgical complications and strategies for their prevention and treatment; also this article describes the latest technical developments in this field and the issues identifications requiring constant and future development.

Materials and methods. The technique of transsphenoidal endoscopic removal of chiasmal sellar tumors is described as well as the structure of this approach complications, methods of their prevention and treatment are analyzed based on personal experience over the past 25 years and the experience of foreign colleagues.

Results. A variety of medical and surgical complications may occur after endoscopic transsphenoidal surgery, but it is important to note that their number has been steadily decreasing over the past decade. So, if in our first series of endoscopic operations the percentage of postoperative relapses was 26 %, complications - 78 %, mortality - 2.1 %, then gradually the recurrence rate was 9-11 %, complications - 2-7 %, and mortality is approaching zero, now amounting to 0.12 % in the total series. The operation time has also significantly decreased from 1.5-3 hours with the first endoscopic surgeries to 15-25 minutes in the modern period.

Conclusion. In pituitary tumors surgery, the introduction of endoscopic techniques has allowed to solve the main problem of transsphenoidal operations - to expand the overview and lighting of the surgical field as well as to detail the structures of the chiasmal sellar region and to perform the selective intervention. The analysis of all errors and complications, the dynamics of the learning curve allows us to conclude that the development of transsphenoidal endoscopic surgery should be carried out in a large specialized center with extensive experience in such interventions, and the first surgeries should be performed by a training surgeon only with the mandatory assistance of an experienced specialist.

89-100 16
Abstract

Background. Invasive monitoring of electrical activity of the brain (invasive electroencephalography (EEG)) can have a number of advantages in diagnosis of early damage and delayed ischemia of the brain during cerebral vascular spasm due to its higher sensitivity and lower number of artifacts compared to noninvasive (scalp) monitoring. However, there are no standards of invasive electrode placement and registration of invasive recording. We present clinical experience of invasive prolonged EEG monitoring in patients during the acute period of cerebral aneurysm rupture.

Aim. To develop technique of invasive EEG monitoring in patients with cerebral aneurysm rupture and to evaluate characteristics of the observed electrographic changes.

Materials and methods. Series of clinical observations are presented: 6 patients who were operated on in the acute period of nontraumatic subarachnoid hemorrhage and who underwent simultaneous scalp and invasive EEG monitoring.

Results. Pathologic changes observed during EEG correlated with development of areas of cerebral ischemia. Changes registered during invasive EEG were more pronounced and appeared earlier than during scalp monitoring.

Conclusion. Informativity of invasive EEG monitoring in diagnosis of delayed cerebral ischemia and seizureless epileptiform activity is higher compared to scalp EEG monitoring.

FROM PRACTICE

101-109 29
Abstract

Solitary forms of cerebral toxoplasmosis can mimic brain tumors, so sometimes such patients end up in neurosurgical hospitals. The situation becomes more complicated when the patient‘s HIV (human immunodeficiency virus) status is unknown, there is no history of drug addiction and there are no external manifestations of opportunistic infections. According to the literature, such patients are periodically operated on with a diagnosis of brain tumor.

This article presents three clinical cases of patients with cerebral toxoplasmosis who were treated in the neurosurgical department. Two of them had to undergo surgery due to a brain tumor, and one patient had to undergo surgery due to a temporal lobe abscess.

110-115 49
Abstract

Penetrating crossbow head wounds are rare. However, such patients commonly belong to the most severe category of injured persons, with a high mortality rate among these ones. Such wounds are characterized by complex damage patterns with significant destruction of brain matter by an arrow as well as frequent damages of paranasal sinuses. Currently, there is no complete consensus about treatment of such patients. Two clinical cases of patients with head penetrating wounds because of an arrow are presented in this article.

116-124 17
Abstract

Echinococcal brain damage is a fairly rare pathology. Hydatid cysts are an urgent problem of neurosurgery. As a rule, echinococcal cysts of the brain are detected at the stage of clinical manifestations, when the cyst already significantly compresses the brain, thereby causing neurological deficiency. Surgical treatment of hydatid cysts requires special delicacy, appropriate experience and practical skills of the operating neurosurgeon.

A clinical case of successful surgical treatment of a five-year-old patient with a giant echinococcal cyst of the brain, combined with an echinococcal lesion of S3, 4 segments of the right lung is presented. The analysis of the literature is carried out.

A total removal of a giant hydatid cyst of the right hemisphere of the brain was performed, without damaging its walls by hydro dissection with simultaneous mechanical compression. A complete regression of focal neurological symptoms has been achieved.

Radical treatment of the hydatid cyst of the brain is only surgical and consists in its total removal without damaging its membranes. Hydro preparation in combination with gentle manual hydrodynamic compression of the brain allows to remove a hydatid cyst without damaging its walls.

125-133 16
Abstract

Amyloidoma is a non-tumor lesion characterized by local deposits of insoluble protein aggregates of κ/λ immunoglobulin light chains in tissues. This condition is also known as AL-amyloidosis and it is not associated with systemic amyloidosis. The usage of term “amyloidoma” is due to the fact that this lesion acts like a tumor according to clinical and neurovisualization signs but it is not a tumor.

The correct diagnosis is difficult due to small number of described cases as well as absence of specific clinical symptoms and tumor-like natural history. The most reliable diagnostic method is histological examination. We present 2 clinical cases of cerebral amyloidoma, confirmed histologically.

134-142 21
Abstract

The first results of surgical treatment of patients with hypertensive putaminal hematomas using puncture aspiration and local fibrinolysis with Russian medication Fortelyzin are presented. Efficacy of this mediation is demonstrated. In patients with intracerebral hematomas of volume between 40 and 55 cm3, 87.5 to 100 % of hematoma volume were evacuated in 36-72 h. Further studies for determination of optimal dose and fibrinolysis scheme are necessary.

FOR PRACTITIONERS

143-151 21
Abstract

The article discusses the features and advantages of subcutaneous administration of drugs using the peptide analgesic Tafalgin as an example, which is used in neurosurgical practice. The focus is on the need for proper technique for performing subcutaneous injections, common mistakes in subcutaneous administration of drugs and their possible consequences. A step-by-step algorithm of actions is provided, which is designed to avoid violating the correct technique for performing subcutaneous injections. In particular, the article discusses the choice of the optimal site for subcutaneous injections, the choice of a syringe and needle for this procedure, the preparation of the skin at the site of the intended injection, and the process of correctly performing a subcutaneous injection itself. Particular attention is paid to the features of subcutaneous administration of Tafalgin. An example of a violation of the technique of subcutaneous injection of Tafalgin is given, which can lead to unintentional intramuscular administration of the drug. The authors present the provisions formulated for the optimal method of administering Tafalgin, which allows minimizing technical errors when performing subcutaneous injections in the clinical work of doctors.

LECTURE

152-161 24
Abstract

The review provides basic data concerning the anatomical aspects of surgical treatment of pituitary adenomas with maximum preservation of intact gland tissue. Neurosurgeons mainly use endoscopic transnasal access, which provides a wider field of view, high magnification and angular visualization, which gives it an advantage over microscopic access, which has not been used much lately. Only a detailed knowledge of the anatomy and topographic-anatomical relationships of the structures of this area makes it easy to navigate during surgery and plan less invasive interventions. In addition, data on complications in the postoperative period are presented, which are mainly represented by liquorrhea, water-electrolyte disorders, and information on methods of their prevention is analyzed.



ISSN 1683-3295 (Print)
ISSN 2587-7569 (Online)
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