Background. The application of cortical and subcortical stimulation during awake craniotomy mitigates the risk of persistent postoperative speech deficits. However, the functions of some white matter pathways remain inadequately understood, particularly the frontal aslant tract (FAT) of the dominant hemisphere. Aim. To evaluate the efficacy of cortical and subcortical stimulation techniques in the localization of glial tumors near speech centers and pathways (SLF / AF, FAT, IFOF) within the context of awake surgery. Materials and methods. A cohort of 17 patients (6 males, 11 females) underwent surgical intervention using intraoperative awakening technique at the Federal Neurosurgical Center in Novosibirsk between 2020 and 2023. Comprehensive assessments of neurologic and neurolinguistic status were conducted preoperatively, postoperatively, and during follow-up. Additionally, MR-tractography was performed. Tract reconstruction and tumor volumetry were performed using semi-automatic segmentation methods on the BrainLab workstation. Results. Employing subcortical bipolar stimulation and continuous monopolar stimulation, the mean extent of resection (EOR) achieved was 89.3 % (IQR = 26, Q1 = 74, Q3 = 100). Transient speech deficit manifested in 10 out of 17 patients (59 %). In these cases, the white matter tracts (SLF / AF, FAT, IFOF) were either contiguous with the tumor or within a distance of 4 mm from it. Speech impairments resolved within the first three months post-surgery, with only one patient exhibiting persistent neurologic deficit. Conclusion. The implementation of cortical and subcortical stimulation (monopolar and bipolar) in the surgical resection of glial tumors in the speech dominant hemisphere demonstrates a high degree of radical resection while minimizing the incidence of persistent postoperative speech deficits. Transient postoperative speech disturbances were observed in all patients whose preoperative tractography indicated that associative tracts (SLF / AF, FAT, IFOF) were located within 4 mm from the tumor margin.
Background. Pituitary tumors are a common pathology in neuro-oncology. They constitute 10 % of all intracranial tumors; and for a long time, they may not have any clinical manifestations. In situations where pituitary apoplexy is the first manifestation of the disease, the choice of optimal tactics is particularly relevant. Considering cases of spontaneous tumor resorption after pituitary apoplexy, the standard approach to this pathology as an exceptional urgent one requires revision. Aim. To review the treatment strategy of patients with pituitary apoplexy, identifying factors contributing to both tumor resorption and achievement of a better clinical result. After specification of the indications for surgery, to create an algorithm for treating patients with pituitary apoplexy. Materials and methods. The paper analyzes the results of treatment of 82 patients with pituitary apoplexy. Only 45 patients were operated on. In 37 patients, the need for surgery ceased during preparation. Results. Analysis of treatment results of 82 patients with pituitary apoplexy identified optimal tumor parameters and radiological characteristics for which the probability of spontaneous resorption is the highest: 89.2 % (33 out of 37) cases. The use of dexamethasone as part of therapy has shown to play a key role in achieving optimal results. The analysis of the data allowed us to formulate criteria for which a wait-and-see tactic in pituitary apoplexy can provide a result comparable to the surgical method of treatment and even surpassing it in terms of preservation of pituitary functions. Conclusion. As a result of the study, an algorithm for treatment of patients with pituitary apoplexy was proposed. The application of the proposed algorithm will allow, in some cases, to forego an emergency surgery and obtain a comparable clinical result with less risk for the patient.
In intracranial drug users (IVDU), there are case reports of spinal subdural empyema. However, there is single case report of intracranial subdural empyema in IVDU. Why is it rare? We report second case and its analysis pertaining to our case. Case Description: a 26‑years male, chronic IV drug abuser of impure opium («Chitta»), HCV positive, presented with altered sensorium. CT head revealed subdural collection right side with 11 mm shift. We did right side hemicraniotomy and evacuated pus. Postoperatively he recovered well. Conclusions – Subdural empyema can occur due to bacteremia, infective endocarditis. In IVDU, presence of HCV infection may predispose to intracranial subdural empyema.
Anterior clinoidectomy has a significant advantage in excluding paraclinoid aneurysms from the blood flow, but it carries a potential risk of developing postoperative cerebrospinal fluid rhinorrhoea. Development of cerebrospinal fluid rhinorrhoea can lead to various intracranial purulent-inflammatory complications. Conservative treatment of cerebrospinal fluid rhinorrhoea is not effective, and currently, there is no established surgical strategy for this complication. This article describes a successful surgical treatment of postoperative cerebrospinal fluid rhinorrhoea following resection of the anterior clinoid process using endoscopic transnasal repair of the skull base defect using autografts and xenografts.
Ultrasound scan is a minimally invasive and highly informative method of examination of patients with atherosclerotic lesions of the brachiocephalic arteries. The article presents an algorithm of examination of patients with symptomatic occlusion of the internal carotid artery who are scheduled for revascularization interventions. The aims and capabilities of ultrasound diagnostics at various stages of treatment of the patients with this pathology are described. Special attention is paid to discussion of indicators predicting failure of extracranial-intracranial low-flow bypasses. Examples of functioning and failed anastomoses are presented.
The article analyzes a psychological sketch by V. V. Kramer «The Mystery of Leonardo da Vinci», which provides an original interpretation of the painting «The Last Supper». V. V. Kramer believes that the artist justifies Judas and condemns Apostle Peter. He claims that the painting is painted in mirror writing. Currently, mirror writing is considered a right-hemisphere phenomenon, and the case of Leonardo da Vinci clearly illustrates this.
Background. Non-traumatic optic neuropathy is damage of the optic nerve caused by its progressive compression by a tumor or other hyperplastic process which leads to atrophy and constant visual impairment. Therefore, the optic nerve needs to be decompressed but there are no methods of predicting the results of decompression. Aim. To identify factors affecting dynamics of visual impairment after decompression and their prognostic value. Materials and methods. The results of surgical treatment of 64 patients with non-traumatic optic neuropathy were analyzed. All patients were examined using visometry, visual filed test, and ophthalmoscopy. Visual field changes were classified per 7 grades of severity. Determination of predictive significance of quantitative variables for favorable surgical results was performed using ROC analysis. The obtained threshold values were used to identify key predictors of favorable outcome and to develop a prognostic model employing multivariable logistic regression. Results. The most significant predictors of improvement in vision after surgery are severity of visual field change and visual acuity prior to surgery. These characteristics gave prognostic accuracy of more than 80 % independently of other factors. The least significant characteristic for predicting visual improvement was duration of anamnesis. The final regression model included 3 predictors: duration of visual impairment less than 12 months (3 points), visual acuity >0.1 (4 points), and degree of visual filed change <5 (5 points). For maximal points, calculated probability of improvement in vision is 93.5 %. The model is statistically significant (Wald χ2 test; p <0.001) and complies with factual data (Hosmer–Lemeshow test; p = 0.504). The developed model explains 60.8 % of outcome variability, and accuracy of prognosis is 90.5 %. Conclusion. Factors affecting dynamics of visual function in patients with compression non-traumatic optic neuropathy after microsurgical decompression of the optic nerve were identified. Identification of these predictors allowed to develop a score for evaluation of probability of vision improvement after surgery.
Vestibular schwannomas are one of the most common tumors of the cerebellopontile angle area. Current level of surgical technique provides very low mortality rate (less than 0.5 %) but postoperative neurological deficits, specifically facial musculature dysfunction and hearing loss on the side of the tumor, are quite frequent complications. Treatment of patients with these tumors requires intraoperative neuromonitoring. Aim. To analyze different methods of intraoperative neuromonitoring in surgery of vestibular schwannomas with evaluation of functional condition of the facial nerve in the postoperative period, as well as prognostic significance of each method. The search for scientific sources was performed in the PubMed, Cochrane Library, MedLine databases. Inclusion criterion: detailed descriptions of intraoperative neurophysiological monitoring techniques in surgery of vestibular schwannomas. Exclusion criterion: absence of description of neurophysiological monitoring techniques in surgery of vestibular schwannomas. Sources not older than 20 years were selected.
Aim. To compare results of surgical treatment of patients with distal aneurysms of the middle cerebral and pericallosal arteries who underwent surgery with frameless neuronavigation and without it. Materials and methods. The study was performed at the N. V. Sklifosovsky Research Institute for Emergency Medicine, Russian Сenter of Neurology and Neurosciences, Moscow City Hospital named after S. S. Yudin between January 1st 2009 and December 31st 2023. Analysis included 45 patients with distal aneurysms of the pericallosal and middle cerebral arteries. Taking into account surgical technique, the patients were divided into 2 groups: the 1st group (n = 21) included patients who underwent surgery with frameless neuronavigation; among them 10 (47.6 %) patients had distal aneurysms of the middle cerebral artery, 11 (52.4 %) patients had distal aneurysms of the pericallosal artery. The 2nd group (n = 24) included patients who underwent surgery without frameless neuronavigation; among them 10 (41.7 %) patients had distal aneurysms of the middle cerebral artery, 14 (58.3 %) patients had distal aneurysms of the pericallosal artery. Results. The use of frameless neuronavigation helps in the search for distal aneurysms during the main stage of the surgery, decreases time between dissection and clipping of a distal aneurysm (p = 0.0001), decreases operative time (р = 0.0001) but requires more time for access planning (p = 0.008). Frameless neuronavigation helps to determine optimal size and location of craniotomy for the most direct and safe trajectory to the distal aneurysm (p = 0.008), decreases the risk of intraoperative injury of the frontal sinus (p = 0.025). Patients, in whom distal aneurysm clipping was performed using frameless navigation, had lower rate of neurologic deficit (p = 0.0001), postoperative (p = 0.025) and systemic (p = 0.005) complications, repeat surgeries (p = 0.002). Conclusion. The use of frameless neuronavigation decreases search time for distal aneurysms and operative time, allows to decrease craniotomy area and prevent intraoperative injury of the frontal sinus, statistically significantly decreases the risk of postoperative neurologic deficit, and improves clinical outcomes.
Cerebral aneurysms are most often located on the proximal segments of the arteries of the circle of Willis, with some predisposition towards the anterior communicating artery. However, aneurysms can develop on any cerebral arteries including abnormal ones. In this clinical observation, a case of rupture of an aneurysm located in the distal segment of the hypertrophied medial frontobasal artery is presented. The case was complicated by the presence of an aneurysm on the middle cerebral artery, the rupture of which, according to the conclusion from the primary vascular center, caused subarachnoid hemorrhage, while an aneurysm of the frontobasal artery was not detected. It was only after the patient was transferred to a regional vascular center and a targeted review of angiograms during the preparation of the patient for surgery that a distal aneurysm of the frontobasal artery was detected, which, according to the intraoperative picture, was the cause of the hemorrhage.
The development of anesthesiology was one of the turning points in the history of medicine. Its development as a specialty was influenced by many pioneers of neurosurgery. Victor Horsley, Harvey Cushing, William McEwen and many others made significant contributions to the evolution of anesthesiologic techniques, increasing safety of surgical interventions and ultimately contributing to the development of neuroanesthesiology as an independent medical profession.
Background. Mucoceles are benign pseudocysts with mucous content in the paranasal sinuses that can expand, destroying bone and invading adjacent structures. Case report. A 69‑year-old female patient presented with an initially painless tumor in the left frontal region 5 years ago, which progressively increased in volume, causing frontal pain and difficulty opening the eyelid. Physical examination revealed a 6 × 5 cm rounded tumor in the left supraciliary region. A mucocele of the left frontal sinus with the erosion of the table was diagnosed, and the patient underwent surgery, performing a bi-coronal incision, total excision of the mucocele, cranialization of the left frontal sinus, and cranioplasty with titanium mesh and self-drilling screws. Discussion. The formation of mucoceles is of variable etiology; the most frequent location is at the frontal level, which can erode the internal table of the frontal sinus, producing invasion towards the dura mater and, in some cases, the brain parenchyma, causing infections. The clinical picture is variable and depends on the location. Surgical management should be focused on optimizing a definitive resolution of the symptoms, maintaining an anatomy with normal drainage of the paranasal sinuses, and preventing the risk of recurrence. Conclusion. Mucoceles constitute a benign pathology. However, they should be treated immediately through a surgical approach, preferably with an open approach that allows direct access to the frontal sinus, adequate removal of the mucocele, and complete obliteration to prevent the risk of infections or recurrence.
