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The study objective is an assessment of long-term results of cerebral revascularization performed in the acute period of subarachnoid hemorrhage due to rupture of cerebral aneurysms.Materials and methods. This cross-sectional study includes 74 patients, operated in N.V. Sklifosovsky Research Institute for Emergency Medicine in the acute period of aneurysmal subarachnoid hemorrhage. Patients were divided into two groups. The first group contained patients with EC—IC bypass performed in the acute period of aneurysmal subarachnoid hemorrhage. The Control group contained patients without bypass. In the long-term period, 11 patients were examined. Computed tomography of cerebral vessels, duplex ultrasound examination of the aortic arch, brachiocephalic arteries and intracranial vessels, transcranial Doppler ultrasonography with a breathing function test, single-photon emission computed tomography of the brain followed by stress test with acetazolamide, Modified Renkin Scale, Mini-Mental State Examination, Montreal Cognitive Assessment, Index Bartel, The Hospital Anxiety and Depression Scale, Holms-Rahe were performed. For descriptive results, a mathematical model was used.Results. The best treatment outcomes in severe patients with subarachnoid hemorrhage and cerebral ischemia were observed when performing simultaneous clipping of the aneurysm and EC-IC bypass (57.1 % versus 41.0 %) there was no statistically significant difference in outcomes. EC-IC bypass functioned in 37.5 % of cases. The rate and acceleration of the fall in volumetric blood flow and the passage of blood from the aortic bulb to the cerebral arterioles affect the perfusion values in the region of the brain concerned. Evaluation of long-term results of simultaneous interventions revealed persistent disturbances in the regulation of cerebral blood flow at the microcirculatory level. Patients with EC-IC bypass had a higher level of cognitive function and stress potential.Conclusion. The results of this study showed us the necessity for a comprehensive exploration of cerebral blood flow.

BACKGROUND Structural damage to the brain substance in adults is one of the most common causes of epilepsy. Currently, such patients are prescribed drug therapy and/or surgery. With this approach, epileptic symptoms can persist in a significant proportion of patients (up to 30%, depending on the disease).AIM OF STUDY To clarify the efficacy of stereotactic radiosurgery (STS) as part of the complex treatment of patients suffering from pharmacoresistant symptomatic epilepsy with hippocampal sclerosis, vascular malformations, and some benign tumors of the brain and its membranes.MATERIAl AND METHODS Examination and radiosurgical treatment were carried out in 45 patients with various brain diseases accompanied by symptomatic epilepsy, provided that the previous conservative or surgical treatment was insufficiently effective. During the observation period, the frequency of seizures was assessed and the presence and nature of postoperative complications were recorded.RESUlTS With a median follow-up of 30 months, good outcomes (class I–II according to J. Engel’s scale) were observed in 5 out of 8 patients with hippocampal sclerosis who underwent STS after amygdaloghippocamplobectomy; seizure frequency decreased in all patients. Complications of STS were noted in 2 patients and had a transient nature. In the group of patients with meningiomas, in 4 out of 8 patients, seizures completely stopped, in 3 patients the frequency of seizures decreased by more than 90%, in another 1 the frequency of seizures decreased by 60%. There were no complications of STS during the observation period. Inintracerebral tumors (diffuse astrocytoma), Engel Ia outcome was observed in both patients. In the group of patients with cavernous angiomas, there were good outcomes (class I–II according to J. Engel’s scale) in 17 patients (85%). Deterioration (Engel IVc outcome) was observed in 1 patient (5%), 2 patients (10%) had complications of STS. In the group of patients with arteriovenous malformations, good outcomes (classes I–II according to J. Engel’s scale) were found in all 7 patients. The complication after STS was revealed in 1 patient.CONClUSION The presented results confirm the high efficiency and low risk of side effects when using stereotactic radiosurgery in the complex treatment of patients with epilepsy associated with common structural brain lesions.

AIM OF STUDY To compare the effectiveness of surgical treatment of patients with hypertensive intracerebral hematomas (ICHs) of subcortical location and methods of endoscopic aspiration and open removal.MATERIAl AND METHODS The results of surgical treatment of 97 patients with hypertensive subcortical hematomas were analyzed. In group 1 (n=52),endoscopic aspiration of the ICH was performed using a frameless navigation station, in group 2 (n=45), open removal of the ICH was performed using a microsurgical method.RESUlTS Mortality among patients in the age group over 71 years after endoscopic aspiration of ICH was significantly lower than after open removal (30.8% and 60%, respectively). With a decrease in the level of wakefulness to sopor, the mortality rate with endoscopic removal was 50%, and with open intervention — 66.7%, with a decrease to coma — 100% in both groups. Among patients of the 1st group with the volume of ICH less than 40 cm3, the lethality was 11.1%, while in the 2nd group this indicator was almost 2 times higher — 20%. With endoscopic removal of an intrauterine device with a volume of 40 to 60 cm3, the mortality rate reached 14.3%, and with an open removal of a hematoma of the same volume, this indicator reached 30%, while the mortality rate in both groups was similar with a volume of an intrauterine device from 61 to 100 cm3 and amounted to 23.1% and 21.4% in the 1st and 2nd groups, respectively. The radicality of hematoma removal in the 1st and 2nd groups was 86.4% and 86%, respectively.CONClUSION Endoscopic removal of hypertensive subcortical hematomas revealed a greater number of patients with good recovery, and postoperative mortality was 11.3% lower than with open removal, which, along with the simplicity of execution and minimally invasiveness, indicates the safety and efficiency of endoscopic aspiration for surgical treatment of patients with intracerebral hematomas of subcortical location.

We present two cases of minimally invasive posterior transarticular screw fixation of C1-C2. The points for screw insertion were visualized by endoscopy via the instrumental port. A patient with a type III odontoid fracture with subluxation underwent a minimally invasive posterior stand-alone transarticular screw fixation. Despite the application of compression screws, for technical reasons, only minimal compression on the anterior third of the C1-C2 lateral joint was achieved. However, complete fracture fusion was achieved with stable fibrous C1-C2 fusion 2.5 years postoperatively. A second patient with a chronic type II odontoid fracture underwent percutaneous C1-C2 fixation by the same method. After 2 years, fracture fusion and C1-C2 lateral mass ankylosis were achieved. The use of a tubular retractor and endoscopy in stand-alone screw fixation of C1-C2 allows direct visualization of the screw entry point and decreases surgical trauma. This procedure might be an alternative to other methods of transarticular instrumentation.

Objective : to explore microsurgical anatomy of the anterior incisural space (AIS), its topography and size in the skull, and to assess the topography of the basilar artery apex in AIS and find possible craniometric correlations. Materials and methods . In this anatomical study, we used 100 non-fixed heads of people who died from somatic pathology without diseases of the central nervous system. All heads were dissected using standard methods. Then we modelled the topography of the tentorial incisure (TI) in the skull by cutting off the hemispheres at the level of the brain stem in parallel to the free margin of TI. We measured length and width of TI, analyzed its topography in the cranial cavity, performed TI morphometry, and measured cranial indices and angular parameters of the skull base relief. Morphometric analysis of our data was conducted by calculating coefficients and indices. Data analysis was performed using the STATISTICA Statsoft. Microsurgical anatomy of the AIS and TI was studied using the operating microscope MBS-10 and digital video camera Sony HDR-CX560 E. The photos were taken with a 2–8-fold magnification. Results . Results. AIS length varied between 14 and 24 mm, whereas its width was between 24.0 and 36.0 mm. Almost half of all TI samples (42%) had AIS with a length of 17–19 mm. In all series of measurements, the length of the AIS was minimal – 14 mm (6%); 15–16 mm (19%), medium – 17–19 mm (42%), large – 20–22 mm (24%) and maximum – 23–24 mm – 9%. AIS were divided by TI types into four groups: A, B, C, and D. Minimum and small AIS were grouped into into ‘short-size AIS’ [14–16] mm, while large and maximum AIS were grouped into ‘long-size AIS’ [20–24] mm. The proportions of short AIS, long AIS, and medium AIS were 25%, 33%, and 42%, respectively. In group A, long-size AIS were found in 53.68% of samples; in garup B, long-size AIS were found in 3.7% of samples, in group C, there were only large AIS–33.3%; in group D, the maximum size of 24 mm was more frequent – 18.2 %, but the total number of samples with large AIS was two times lower–27.3% than in group A. Group A (sub- and brachycephaly) had the highest percentage of long AIS with a length of 20–24 mm (~54% of cases). The position of the BA in the AIS depends on the AIS length and clivus tilt. Conclusion. The size and topography of the AIS in the cranial cavity vary significantly; this must be taken into account when planning neurosurgical approaches. The concept of limited AIS boundaries, their structural flexibility in terms of surgical approach is the basis for choosing an optimal approach or its direction. The size of the AIS, its anatomical structure, and topography of the borders, access paths through AIS, possibility of manipulations with the content and boundaries of the AIS, the degrees of freedom or limits in acceptable surgical corridors, etc. should be taken into account when planning surgical intervention and choosing an optimal approach.

The study objective is to evaluate value of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (PET-CT) and whole-body scintigraphy (131I-WBS) performed during the first course of radioiodine therapy for its ability to detect persistence metastatic foci and for its role in the management of differentiated thyroid cancer patients.Materials and methods. Forty patients with DTC underwent both post-therapeutic 131I-WBS and PET-CT. PET-CT performed on a positron emission tomograph combined with a 16-slice computer tomograph. Post-therapeutic 131I-WBS performed during radioiodine therapy on the single-detector gamma camera.Results. Sensitivity in detecting of the tumor persistence for PET-CT was 84 %, for post-therapeutic 131I-WBS 66 % (р >0.05). In 17 (42.5 %) patients additional PET-CT foci were found that negative on 131I-WBS, including 11 (27.5 %) cases of distant metastases. Fifteen percent of patients had metastatic foci visualized only on 131I-WBS, including 4 (10 %) cases of distant metastases. In 17 (44 %) patients tumor foci were identified by both methods. A high pre-ablative level of stimulated thyroglobulin was the only independent predictor of the presence of PET-CTpositive metastatic foci (p = 0.001).Conclusion. 18F-fluorodeoxyglucose PET-CT can be recommended during the first radioiodine therapy in differentiated thyroid cancer patients with a high risk progression group, as well as with suspected the tumor persistence in case of a high pre-ablation thyroglobulin level, to complete staging, improve the quality of management and ongoing risk stratification.

The radioiodine therapy is the most well-known branch of radionuclide therapy. The therapy composed of thyroidectomy and iodine-131 radiopharmaceutical is the “gold standard” for treat-ment of differentiated thyroid cancer patients (DTC). Given metastases in lymph nodes such therapy is absolutely exclusive treatment mode. At the same time, despite the targeted effect of radioiodine on pathological foci a side internal exposure of healthy organs and tissues is noted in the course of radioiodine therapy. Therefore, a reliable assessment of the side exposure is nec-essary taking into account the individual characteristics of patients considering that the side dose varies significantly from patient to patient. For this reason, the identification of significance of personal clinic-diagnostic factors determined the side whole body exposure is the vital and im-portant task. In this aspect, the cytogenetic examination of DTC patients by means of the analysis of chromosomal aberrations in peripheral blood lymphocytes is the goal of essential importance. The certain types of chromosomal aberrations are specific radiation markers that unequivocally indicate radiation exposure. Using the frequency of radiation markers the side absorbed dose can be reliably estimated. In the present work, the statistical analysis of the significance of vari-ous clinic-diagnostic factors in relation to the induction of radiation markers in the blood lympho-cytes was performed. For that end the results of the cytogenetic examination of the group com-prised of 38 DTC patients have been used. The examined patients underwent a course of radio-iodine therapy in the department of radionuclide therapy of the A.F. Tsyb MRRC, Obninsk. The slide preparation and cytogenetic analysis were carried out in the laboratory of radiation cytoge-netic of the same Center. The performed analysis of the correlation matrix with respect to the dependence of the increased frequency of stable and unstable markers resulted from a one-time course of radioiodine therapy showed no meaningfulness at the level R>0.3 for all the studied factors. For the absolute value of the frequency of radiation markers, both before and after radioiodine therapy, the meaningful relationship was found at the level R>0.7 for unsta-ble and at the level R>0.8 for stable markers with a total administered activity of radioiodine dur-ing all the previous courses of radioiodine therapy.

Background . Exact notion about the timing of acute traumatic intracranial hematomas (ATIH) generation is very important to gain a better understanding of the primary and secondary traumatic brain injury (TBI) pathophysiology. The variety of TBI and individual anatomical features of the victims determine the complexity of the issue, as well as the relevance of studies that bring it closer to its solution. Aim of the study was to assess the possibility of using multispiral computed tomography (MSCT) to determine the average timing of the formation of epidural and subdural ATIH. Materials and methods . It is a retrospective study of 84 MSCT investigations of 55 patients with ATIH (epidural – 15, subdural – 40) in Irkutsk City Clinical Hospital N 3 (2018–2019). The ATIH volume calculated by the MSCT. The cor relation of ATIH volumes with the period of trauma was studied, as well as a comparison of average volumes of ATIH among patients distributed in groups in line with the hour of primary MSCT after injury. The dynamics of ATIH of small volumes (up to 40 ml) were assessed in 21 patients left under observation. Results . The volume of epidural ATIH and the time of their detection had no a direct correlation in the period 1 to 4 hours after the injury (p = 0.05). There was no reliable difference in their average volumes per hour of diagnosis, amounting to a total of 54.1 ± 19.7 ml. A direct correlation between the volume of subdural ATIH and the duration of trauma was identified during periods of 1–2 hours (p = 0.02) and 1–3 hours (p = 0.002; t = 3.77) after injury; a true difference in their average volume of 1 and 2 hours after the injury (52 ± 20.2 ml and 106.4 ± 14 ml, respectively). Increase in small ATIH found in 14.3 % of patients left under observation. Conclusions . The MSCT allows us to estimate the average timing of the formation of the main volume of ATIH when hospitalized victims with TBI. The average rate of accumulation of ATIH is about 50 ml per hour, and the direct correlation of their volume and time of diagnosis is reliable the first 2–3 hours after the injury for subdural ATIH only.

The latest recommendations of the American Thyroid Association have caused serious disagreements between the nuclear medicine and endocrinologist communities regarding the radioactive iodine use. In 2018 eighteen experts from 8 countries and 4 leading organizations (ATA, EANM, SNMMI and ETA) met for the first time to establish mutual understanding in the role of radioiodine therapy for differentiated thyroid cancer. After much discussion and exchange of experience, the participants developed a consensus document based on the so-called nine principles of Martinique. We present an overview of the article published 2019 in Thyroid, entitled «Controversies, consensus, and collaboration in the use of 131 I therapy in differentiated thyroid cancer: a joint statement from the American Thyroid Association, the European Association of Nuclear Medicine, the Society of Nuclear Medicine and Molecular Imaging, and the European Thyroid Association».

The article covers the current concepts of cerebral edema development, the mechanisms of cerebral oxygenation and perfusion impairments, as well as delayed morphological and cognitive disorders in non-traumatic subarachnoid hemorrhage due to the rupture of intracranial aneurysms.

Radiopharmaceuticals previously used to treat patients with metastatic castrate-resistant prostate cancer and skeletal metastases were positioned as means to suppress pain, reduce analgesics consumption and improve the quality of life. They were usually administered once in case of progressive pain syndrome. Radium chloride [223Ra] is registered to treat patients with castrate-resistant prostate cancer and multiple skeletal metastases, but without visceral metastases. The ALSYMPCA study showed a significantly increased overall survival in the group receiving radium chloride [223Ra] compared with placebo. This became the basis to register the drug, as well as to include the treatment into the clinical guidelines of professional associations in various countries of the world. The secondary endpoints of the ALSYMPCA study were evaluation of the quality of life, the influence of radium chloride [223Ra] on pain severity, the dynamics of tumor and biochemical markers, and the time to the first skeleton associated complication. Thus, the main goal of radium chloride [223Ra] therapy is to prolong patients’ life, and it can be prescribed to those with or without pain syndrome. The data served as the basis for widespread use of radium chloride [223Ra] to treat patients with castrate-resistant prostate cancer and skeletal metastases

Background. The implementation of tyrosine kinase inhibitors into clinical practice improved treatment outcomes in patients with radioiodine-refractory differentiated thyroid cancer (RR-DTC). Lenvatinib is recommended as a first-line drug for these patients. The study objective is to analyze clinical experience with lenvatinib in patients with RR-DTC in the Russian Federation. Materials and methods. The data from 18 clinical sites in Russia was analyzed for the period December 2015 and September 2019. Seventyseven patients with histologically verified DTC, proven resistance to radioactive iodine therapy, and tumor progression (according to the Response Evaluation Criteria In Solid Tumors 1.1 criteria) were included in the study. Results.Median progression-free survival in patients included into analysis (n = 72) was 26.1 months. In patients who responded to therapy (including those with partial and complete response), median progression-free survival reached 36.2 months, which is higher than that reported in the updated results of the SELECT study (33.1 months). Lenvatinib-associated adverse events (AEs) were observed in 87 % of patients. Severe AEs were registered in 18.2 % of participants. In 6.5 % of cases, AEs lead to lenvatinib cessation; in 74 % of cases, AEs required dose reduction.Conclusion. Our findings suggest high efficacy and good tolerability of lenvatinib in patients with RR-DTC in routine clinical practice in the Russian Federation.

The study objective was to investigate the role of 18 F-fluorodeoxyglucose (18 F-FDG) positron emission tomography combined with computed tomography (PET-CT) as an indirect determination of the differentiation status of metastases and for the prediction of radioactive iodine (RAI) therapy response in patients with metastatic differentiated thyroid cancer.Materials and methods. The 40 metastatic differentiated thyroid cancer patients were enrolled in the study that underwent both post-therapeutic radioiodine scan and PET-CT at the same period.Results. The study found that 12 (30 %) patients responded to RAI therapy. The remaining 28 (70 %) patients not responded to RAI therapy showed stabilization or progression. The accumulation of radioiodine by metastases positively correlated with the total response rate, while the 18 F-FDG avidity is negative. Significant direct correlation with response rate was observed in the group with only radioiodine uptake. However, this correlation was not observed in the patients with both tracers uptake. The patients with 18 F-FDG-positive metastases showed poor response to RAI therapy, regardless of the degree of radioiodine uptake.Conclusion. The 18 F-FDG uptake by metastases is a predictor of a poor response to RAI therapy, even in the presence of RAI uptake. The use of 18 F-FDG PET-CT in patients with metastatic differentiated thyroid cancer can be recommended at the beginning of RAI therapy to clarify the prognosis and provide a personalized approach to the treatment and observation of the most difficult category of patients.

THE AIM OF THE STUDY. was an index creation for both single and multiple acute traumatic intracranial hematomas (ATIH) for objectification of the surgical treatment indications and using multispiral computed tomography (MSCT) and based on up-to-date clinical recommendations.MATERIAL AND METHODS. We performed a retrospective study of 3 groups of patients with ATIH. Group 1 included 19 patients who were treated conservatively and discharged from the hospital without complications (group of conservative treatment). Group 2 included 9 patients who were observed after hospitalization and were treated in a delayed manner surgically due to growth of the intracranial hematoma volume or the patient condition deterioration (group of observation). Group 3 included 18 patients who were operated due urgent indications (group of surgical treatment). For each patient, the acute traumatic hematoma index (ATHI) was calculated by our original formula. It took the ATIH location, volume in milliliters according to the first MSCT, and risk factors significant for poor outcomes into account. After a preliminary assessment of the significance of differences between the studied characters of groups, a discriminant analysis was carried out with determination of the ATHI values in each group.RESULTS AND CONCLUSIONS. The suggested ATHI index has been shown to be effective in assessing single and multiple ATIHs of any location in accordance with current recommendations. The index is an objective (digital) and easy-to-use for determining ATIH surgical treatment indications and statistical treatment. If ATHI is less than 3 points, there are no indications for surgery and the repeated MSCT of the brain is indicated at least 12 hours after the first checkup or if the suspicious clinical sings appear; if ATHI is 3–4, the indications for surgery are relative and the repeated MSCT of the brain is required 6 hours later even if the patient condition is unaltered; the surgery is indicated if ATHI is more than 4 points.Authors declare lack of the conflicts of interests.

Castration-resistant prostate cancer (CRPC) has a very negative prognosis. The average life expectancy even using modern treatment methods is 1.5–2 years. When the majority of CRPC patients show signs of resistance to therapy aimed at lowering testosterone levels, distant metastases are often determined in the bones. Bone metastases in CRPC patients often worsen life quality due to pain and risk of bone complications, such as pathological fractures and spinal cord compression. Not all treatment regimens to increase their life expectancy patients are effective. Radiopharmacy using alpha-emitting radium-223 chloride is not only one of the methods of palliative treatment, but also one of the most promising therapies that increase life expectancy of these heavy patients. Results of large randomized trials showed that alpha-therapy with radium-223 chloride leads to a significant increase of the overall life expectancy, and significantly improve the patients’ life quality. The article presents literature review as well as the analysis of the results of large randomized trials, which assess the effectiveness of the therapy in CGRG patients, and a clinical case of its use in real clinical practice.

The purpose: to develop Doppler criteria in the evaluation of cerebral hemodynamics in predicting the outcome of the disease in patients with cerebral aneurysm rupture.Materials and methods. 172 patients (76 male, 96 female) with cerebral aneurism rupture were participated in the research. All patients were continuously monitored by Doppler studies (a total of 803 studies) in the period from 1 to 20 days after the rupture of the arterial aneurysm. TCD was performed on the apparatus DWL MULTI-DOP T (Germany) with sensors 2 and 4 MHz. All patients were divided into 5 groups depending on the Glasgow outcome Scale (GOS) assessment. Group 1 (n = 87; 50.6%): with an excellent outcome of the disease (GOS 1); group 2 (n = 27; 15.7%): with an good outcome of the disease (GOS 2); group 3 (n = 8; 4.65%): with an acceptable outcome of the disease (GOS 3); group 4 (n = 6; 3.48%): with an acceptable outcome of the disease (GOS 4); group 5 (n = 8; 4.65%): with a lethal outcome of the disease (GOS 5) Systolic blood flow velocity (BFV), Lindegaard index and pulsatility index were estimatedResults. Doppler prognostic criterion of disease outcome were developed: early and progressive increase in blood flow velocity (development of spasm on the 1 day delay after hemorrhage); the development of critical spasm (blood flow velocity over 300 cm/s) by 7–8 days after subarachnoid hemorrhage, the rise of the blood flow velocity per day more than 36 cm/s; the duration of the spasm more than 16 days; increase in pulsatility index (more than 1.0) and Lindegaard index (more than 4.8), the presence of diffuse spasm.Conclusion. The transcranial Doppler can be an additional screening non-invasive diagnostic method for cerebral hemodynamic evaluation and for determination complications in ruptured cerebral aneurysm.

The study objective is to evaluate the effectiveness and the safety of different cerebrospinal fluid drainage methods and intrathecal fibrinolytic therapy in the prevention of cerebral vasospasm and improving outcomes in patients with massive subarachnoid hemorrhage. Materials and methods. The study was performed on 86 patients with massive aneurismal subarachnoid hemorrhage (Hijdra score >15) who had clipping surgery within 72 h after symptoms onset. We used lumbal drainage in 12 patients (group 1), combined lumbal and cisternal drainage in 24 patients (group 2), lumbal and cisternal drainage with intrathecal fibrinolytic therapy with recombinant staphylokinase in 25 patients (group 3); control group (group 4) included 25 patients with similar clinical and instrumental data. Results. Incidence of unfavorable outcome and symptomatic cerebral vasospasm was 83 and 83 %, respectively (in group 1), 36.8 and 47.4 % (in group 2), 9.1 and 9.1 % (in group 3), 76 and 60 % (in group 4). Conclusion. The proposed intrathecal fibrinolytic therapy with recombinant staphylokinase may be effective and safe to reduce the severity of cerebral vasospasm, improve clinical outcome and lower frequency of normal pressure hydrocephalus after aneurysm rupture.

The study objective is to report 2 cases of endoscopic transsphenoidal removal of hypothalamic hamartomas (HH). This surgical method has not been previously considered in both Russian and foreign publications. Materials and methods. A 16-year-old male patient (R.) was admitted to hospital with complaints of epileptic seizures occurring once every 5–6 days; the disease duration was 9 years. A 23-year-old female patient (M.) was also admitted to hospital with complaints of epileptic seizures occurring once a week; the disease duration was 16 years. Results. Magnetic resonance imaging of the brain of patient R. revealed a HH (1.5 cm × 1.4 cm × 1.4 cm) and focal cortical dysplasia in the right occipital lobe. During a 3-day video electroencephalogram monitoring, we registered 3 secondary generalized complex partial seizures. Patient R. underwent endoscopic transsphenoidal removal of the HH. After surgery, he experienced no epileptic seizures during the next 18 months, even though he continued to receive the same doses of antiepileptic drugs. Magnetic resonance imaging of the brain of patient M. demonstrated a HH (2.44 cm × 2.79 cm × 2.68 cm). During a 4-day video electroencephalogram monitoring, we registered 2 secondary generalized complex partial seizures. The patient underwent transsphenoidal removal of the HH. During the next 8 months, the patient experienced no seizures. Conclusion. Our results suggest that transnasal removal of HH is a highly effective and safe procedure for patients with drug-resistant epilepsy. Surgical removal of HHs ensures effective control of the disease, which was previously resistant to pharmacotherapy.

High-grade gliomas have a diffuse and infiltrative nature of the growth of tumor cells, due to which the achievement of radical resection is difficult. Surgical resection completeness of brain tumors is an important factor in prolonging the life of patients. An accurate definition of tumor boundaries and residual fluorescent regions is impossible due to imperfections of the equipment used for fluorescent imaging. 5-aminolevulinic acid (5-ALA) is a precursor of protoporphyrin IX (PpIX) in humans and is clinically used to detect and treat tumors. Currently, fluorescence-guided surgery with PpIX used a surgical microscope with an excitation wavelength in the blue spectrum range. Because of its low ability to penetrate into biological tissue, blue light is ineffective for providing high-quality fluorescent navigation. Also, when performing an operation using radiation in the blue spectrum range, the photosensitizer’s surface layer (PS) often bleaches out, which leads to frequent errors. The use of red light emission makes it possible to slow down the PS bleaches out due to the absorption properties of PpIX, but this task is technically more complicated and requires highly sensitive cameras and specialized optical filters. The new two-channel video system for fluorescent navigation has a radiation source in the red range of the spectrum, the penetration depth of which is greater than the blue light, which makes it possible to increase the depth of probing into biological tissues. The study’s clinical part involved 5 patients with high grade glioma and 1 patient with low grade glioma: grade III oligodendrogliomas (2), grade IV glioblastomas (3), and grade II diffusion astrocytoma (1).

The study objective is to describe a clinical case of surgical treatment of a patient with pathological distal tortuosity of the left internal carotid artery (ICA) and present a comprehensive description of a proposed surgical technique, as well as compare advantages and disadvantages of the chosen and alternative surgery types.Materials and methods. At the 1st stage, we performed computed angiography and triplex scanning of the main head arteries and modelled operative approach. At the 2nd stage, we mapped the ICA approach, redressing and resection. At the 3rd stage, using endoscopic assistance we separated the ICA along its entire length, found its pathological kink, performed ICA redressing and resection with subsequent reanastomosis with high accuracy and minimal injury.Results. ICAblood flow was 320 ml/min (prior to surgery: 140 ml/min). In the postoperative period, positive dynamics of the patient’s neurological status were observed. Computed angiography and triplex scanning confirmed removal of pathological tortuosity. Compared to the proposed technique, other surgery types (open access) are characterized by high risk of injury of the cranial nerve branches, submandibular and parotid glands, necessity of dissection of the digastric, stylohyoid muscles, subluxation of the mandibula, etc.Conclusion. The method of allocation of hard to reach tortuosities of the carotid artery developed based on previously known endoscopic manipulations on the vessels of the extremities using endoscopic assistance allows to decrease injury during the intervention and achieve maximal technical and clinical effect.

To evaluate the results of surgical treatment of patients with unilateral MRI-positive temporal forms of drug-resistant epilepsy.A prospective analysis of 50 patients with unilateral MRI-positive temporal forms of drug-resistant epilepsy, who had undergone resective surgery in the Scientific Research Institute of Emergency Medicine of N.V. Sklifosovsky (Moscow) and in University Clinic of Moscow State University of Medicine and Dentistry between 01.01.14 and 12.12.17, has been performed. MRI-positive temporal symptomatic epilepsy was identified in 79 (55%) patients. MRI results showed unilateral temporal epileptogenic lesions in 50 (67%) patients. These patients were assigned to medial frontal lobectomy.82% patients become 'seizure free' 12 and 24 months after surgical treatment. In other cases, seizures become less frequent and severe.The results confirm the efficacy and safety of surgical treatment of drug-resistant MRI-positive temporal forms of epilepsy.Цель исследования. Оценка результатов хирургического лечения пациентов с фармакорезистентными МРТ-позитивными височными формами симптоматической эпилепсии. Материал и методы. Обследовали 145 пациентов с фармакорезистентными формами симптоматической эпилепсии. Височная МРТ-позитивная форма симптоматической эпилепсии была выявлена у 79 (55%) пациентов. Из них у 50 (67%) по данным МРТ головного мозга были обнаружены односторонние височные эпилептогенные поражения. Этим пациентам была проведена передняя медиальная лобэктомия. Результаты и заключение. У 82% больных после хирургического лечения через 12 и 24 мес приступы стали контролируемыми или отсутствовали. У остальных пациентов приступы стали менее тяжелыми и частыми. Получены данные, подтверждающие эффективность и безопасность хирургического лечения фармакорезистентных МРТ-позитивных височных форм симптоматической эпилепсии.

Objective is to analyze the results of introduction of simulation training in skills of surgical revascularization of the brain in the practice of rendering neurosurgical care to patients with carotid stenosis. Materials and methods. Simulation training in skills of surgical revascularization of the brain was performed by the original method in the framework of the 5-day course. Regions have been identified, of which the largest number of doctors were trained, and calculated target surgical activity indicators with carotid stenosis, depending on the population of these regions. Comparison of target and achieved by 2016 indi cators of surgical activity allowed to judge the effectiveness of the implementation of a simulation training results in health care practice. Results. In the period from 01.01.2014 to 31.12.2016 were trained 52 doctors from 20 subjects of the Russian Federation. Across the country, there was an increase the number of operated patients from 302 in 2002 to 4305 in 2015, and 5377 in 2016 which however does not exceed 4 % of the required number of surgical interventions. By 2016 78 % of carotid stenosis surgeries were made outside of Moscow and St. Petersburg. The ratio of interventions performed by neurosurgeons and vascular surgeons in the Russian Federation in 2002 was 1:8, and by 2016 – already 1:4. Conclusion. Organization of simulation training in skills of surgical revascularization of the brain in a master class format is an effective tool for increase surgical activity in carotid stenosis.

Purpose Navigated transcranial magnetic stimulation (nTMS) provides noninvasive visualization of eloquent brain areas. The nTMS is usually applied in presurgical planning to minimize the risk of surgery-related neurological deterioration. The aim of this study was to evaluate the usefulness of nTMS data for GammaKnife treatment planning for patients suffering from brain metastases. Methods Motor cortex mapping with nTMS was performed in eight patients with brain metastases within or adjacent to the precentral gyrus. The nTMS data set was imported into the planning software and fused with anatomical MRI. Then contouring of the target and critical structures was performed. Treatment plans with and without visualization of the functional structures by nTMS were analyzed and compared by neurosurgeon and medical physicist. Results The primary motor cortex was successfully delineated even in all cases despite significant peritumoral edema. Beam shaping and combined isocenters were used for conformal dose distribution and steeper dose fall-off near the identified eloquent zone. Compared with plans without nTMS data, treatment plans with integration of cortical nTMS mapping data showed a 2% to 78% (mean, 35.2% ± 22.7%) lower 12-Gy volume within the motor cortex without reduction of the dose applied to the tumor. Conclusions The presented approach allows the easy and reliable integration of neurophysiological mapping data into GammaKnife treatment plans by the standard GammaPlan software. Diminishing the dose to critical structures might help to minimize side effects and therefore improve quality of life for brain metastasis patients.

Objective. To estimate the efficacy of surgical treatment of internal carotid artery (ICA) thrombosis in patients suffered from acute ischemic stroke (AIS). Material and methods. Author operated 25 patients suffered from AIS and ICA thrombosis from 01 Feb, 2014 till 31 Aug, 2016 in Neurosurgical Department of N.V. Sklifosovsky Research Institute for Emergency Medicine. Among them, 15 patients had total thrombosis of ICA and were operated on, 10 patients had partial mural thrombosis or floating thrombus (6 patients were operated on). There were 7 thrombectomies with the removal of intima, 13 superficial temporal artery (STA)-middle cerebral artery (MCA) bypasses, 1 ICA stent installation. Results. The excellent outcomes were seen in 7 (33.4%) patients, good outcomes — in 11 (52.3%) and satisfactory outcomes were observed in 3 (14.3%) patients. The improvement of functional deficit in the early post-operative period was 4.85 scores according to NIHSS, 1.2 scores according to Rankin scale and 2.3 scores according to Rivermead mobility index. The regress of neurological deficit was more significant among patients with severe focal disturbances; better outcomes were among patients operated on within first 3 days from an onset of the disease. There was no significant improvement among non-operated patients at the moment of discharge from hospital. Thrombectomy with the removal of intima performed in 2 (40%) patients with partial mural thrombosis was complicated by repeated thrombosis of ICA. The improvement of cerebral blood supply was verified in 16 (76.2%) operated patients according to the data of cerebral perfusion examination. Conclusions. The early surgical treatment is indicated for patients with acute total thrombosis of ICA. It is possible to perform STA-MCA bypass in case of inability to perform endovascular thrombextraction or open thrombectomy with the removal of intima. The conservative treatment is indicated for patients with partial mural thrombosis while urgent operation is necessary among patient with floating thrombus to decrease the risk of cerebral embolism.

The article is focused on the problem of evidence-based and individual approach relations in patient management, especially if a patient is on the periphery of statistical ranges. Recent literary data analyzed, on the opportunities for management individualization. Clinical case is provided of young female patient with spontaneous dissections of coronary arteries and myocardial infarction development.

To investigate the informativeness of long-term scalp EEG monitoring in patients with acute traumatic brain injury (TBI).The informativity of long-term EEG monitoring (LTM) was performed in 60 patients with acute severe TBI. Odd ratios (OR) of unfavorable outcome and non-convulsive status epilepticus (NCSE) among clinical, neurophysiological and radiological features were calculated.EEG features of the unfavorable outcome are: slowing of the dominant background rhythm below q range (OR 3.5, CI 1.2-10.7), absence of frontal-occipital gradient (OR 10.2, CI 1.89-10.12), absence of reactivity (OR 8.75, CI 2.14-35.7), absence of variability (OR 6.25, CI 1.72-22.6) and absence of NREM sleep, stage 2 (OR 5.8, CI 1.79-18.91). Clinical features associated with the unfavorable outcome are: a decrease in GCS score (OR 1.25, CI 1.07-1.47), TBI severity (OR 2.46, CI 1.16-5.18), axial dislocation (OR 4.45, CI 1.08-18.29). ORs for NCSE are significant for the following EEG features: presence of rhythmic and periodic patterns (RPP) (OR 11.92, CI 1.37-103.39), stimulus induced RPP (OR 23.14, CI 2.56-209.34), "plus" modifier (OR 4.11, CI 1.13-14.91) and electrographic evolution (OR 13.05, CI 3.59-47.39). Background rhythm slowing below q range reduces NCSE probability (OR 3.33, CI 1.09-10).Long-term EEG monitoring is an informative tool for prognosis of outcome and diagnosis of NCSE in patients with severe TBI. The risk of NCSE increases with Marshall score but NCSE is not associated with poor outcome that requires an individual selection of intensive care.Изучить информативность длительного мониторирования скальповой электроэнцефалограммы (ЭЭГ) у пациентов с тяжелой черепно-мозговой травмой (ЧМТ).Проанализированы данные ЭЭГ 60 больных с тяжелой ЧМТ с вычислением отношения шансов (ОШ) развития неблагоприятного исхода и бессудорожного эпилептического статуса среди устойчиво классифицируемых клинических, нейрофизиологических и радиологических признаков.ЭЭГ-признаками неблагоприятного прогноза были: замедление доминирующего фонового ритма ниже q-диапазона (ОШ 3,5, ДИ 10,7—1,2), исчезновение лобно-затылочного частотно-амплитудного градиента (ОШ 10,2, ДИ 1,89—10,12), реактивности (ОШ 8,75, ДИ 2,14—35,7), вариабельности (ОШ 6,25, ДИ 1,72—22,6) и графоэлементов 2-й стадии NREM-сна (ОШ 5,8, ДИ 1,79—18,91) в фоновой ЭЭГ. Клиническими признаками, связанными с неблагоприятным прогнозом ЧМТ, были: уменьшение количества баллов по шкале комы Глазго (ОШ 1,25, ДИ 1,07—1,47), тяжесть ЧМТ (ОШ 2,46 ДИ 1,16—5,18), наличие аксиальной дислокации (ОШ 4,45, ДИ 1,08—18,29). ОШ развития бессудорожного эпилептического статуса было статистически значимым для следующих признаков: регистрация ритмичных и периодических паттернов (РПП) (ОШ 11,92, ДИ 1,37—103,39), появление РПП в ответ на стимуляцию (ОШ 23,14, ДИ 2,56—209,34), модификатор РПП «плюс» (ОШ 4,11, ДИ 1,13—14,91) и эволюция паттерна (ОШ 13,05, ДИ 3,59—47,39). Замедление частоты фоновой ритмики ниже q-диапазона снижало риск развития бессудорожного эпилептического статуса (ОШ 3,33, ДИ 1,09—10).Длительное мониторирование ЭЭГ информативно для прогнозирования течения и диагностики бессудорожного эпилептического статуса у пострадавших с тяжелой ЧМТ. Риск бессудорожного эпилептического статуса повышается при увеличении количества баллов по шкале Marshall, однако его развитие не связано с неблагоприятным исходом лечения ЧМТ и требует индивидуального подбора интенсивной терапии.

Epilepsy surgery is effective in 30-82% of patients with drug-resistant epilepsy. However, risk factors of unfavorable outcomes after epilepsy surgery require further study.To evaluate risk factors of favorable and unfavorable long-term postoperative outcomes in patients with drug-resistant epilepsy.Postoperative outcomes in a large cohort of patients with epilepsy are reported for the first time in the Russian Federation. There were 271 patients with drug-resistant scheduled for surgery. Preoperative examination and surgical treatment were carried out between January 1, 2014 and December 12, 2019 at the Evdokimov Moscow State University of Medicine and Dentistry and Sklifosovsky Research Institute for Emergency Care. We used Engel grading system to assess postoperative outcomes after 12, 24, 48 and 60 months. We distinguished favorable (Engel I-II) and unfavorable (Engel III-IV) outcomes and analyzed the factors influencing postoperative results in these patients.There were 319 surgical procedures in 271 patients (217 primary resections, implantation of vagus nerve stimulator in 31 patients, 9 redo resections and 8 radiosurgical procedures). Focal cortical dysplasia (FCD) was found in 162 (60%) patients, «dual pathology» - in 118 (44%) cases. In 12 months after surgery, favorable outcomes (Engel l-II) were observed in 69% of patients (Surgical resection is effective approach for drug-resistant epilepsy.Хирургическое лечение эффективно у 30—82% пациентов с фармакорезистентными формами эпилепсии. Однако требуется дальнейшее изучение факторов риска неблагоприятных исходов нейрохирургического лечения.Оценка факторов благоприятных и неблагоприятных долгосрочных исходов нейрохирургического лечения пациентов с фармакорезистентной эпилепсией.В статье впервые в Российской Федерации представлены результаты хирургического лечения большой когорты пациентов с эпилепсией. Прооперирован 271 пациент с фармакорезистентной структурной эпилепсией. Предоперационное обследование и хирургическое лечение проводили в период с 01.01.14 по 31.12.19 на базе Университетской клиники ФГБОУ ВО «МГМСУ им. А.И. Евдокимова» Минздрава России и ГБУЗ «НИИ СП им. Н.В. Склифосовского ДЗМ». Исходы оперативных вмешательств оценивали по шкале исходов хирургического лечения J. Engel (1993) через 12, 24, 48 и 60 мес после вмешательства. Выделяли благоприятный (Engel I—II) и неблагоприятный (Engel III—IV) исходы, проводили поиск факторов, оказывающих влияние на исход хирургического лечения.Выполнено 271 пациенту 319 хирургических вмешательств (из них 217 первичных резекционных вмешательств, 31 установка стимулятора блуждающего нерва, 9 повторных резекционных вмешательств и 8 — радиохирургических). У 162 (60%) пациентов выявлена фокальная кортикальная дисплазия (ФКД), у 118 (44%) — «двойная патология». Через 12 мес после операции благоприятные исходы (Engel I и II) выявлены у 69% пациентов (Резекционные вмешательства являются эффективным методом лечения фармакорезистентных форм эпилепсии.

Background: In humans, early pathological activity on invasive electrocorticograms (ECoGs) and its putative association with pathomorphology in the early period of traumatic brain injury (TBI) remains obscure. Methods: We assessed pathological activity on scalp electroencephalograms (EEGs) and ECoGs in patients with acute TBI, early electrophysiological changes after lateral fluid percussion brain injury (FPI), and electrophysiological correlates of hippocampal damage (microgliosis and neuronal loss), a week after TBI in rats. Results: Epileptiform activity on ECoGs was evident in 86% of patients during the acute period of TBI, ECoGs being more sensitive to epileptiform and periodic discharges. A &ldquo, brush-like&rdquo, ECoG pattern superimposed over rhythmic delta activity and periodic discharge was described for the first time in acute TBI. In rats, FPI increased high-amplitude spike incidence in the neocortex and, most expressed, in the ipsilateral hippocampus, induced hippocampal microgliosis and neuronal loss, ipsilateral dentate gyrus being most vulnerable, a week after TBI. Epileptiform spike incidence correlated with microglial cell density and neuronal loss in the ipsilateral hippocampus. Conclusion: Epileptiform activity is frequent in the acute period of TBI period and is associated with distant hippocampal damage on a microscopic level. This damage is probably involved in late consequences of TBI. The FPI model is suitable for exploring pathogenetic mechanisms of post-traumatic disorders.

The objective of this study was to evaluate the results of surgical treatment of cerebral aneurysms in the Russian Federation.We analyzed performance indicators in neurosurgical departments of regional and federal health institutions of the Russian Federation for 2017. The results of surgical treatment of cerebral aneurysms (CAs) were analyzed in 19 regional vascular centers (RVCs) in several federal districts and in 3 federal centers (FCs) with the most dynamically developing vascular neurosurgery and smoothly running system of statistical data processing.The study included 3160 patients hospitalized to 22 medical institutions in 2017. Of these, 1808 patients were treated in RVCs, and 1352 patients were treated in FCs. We analyzed factors affecting the treatment outcome in CA patients. We identified features of CA treatment in clinics with a different amount of surgical intervention.An increase in the surgical activity in centers and simultaneous development of microsurgical and endovascular treatments for cerebral aneurysms reduce postoperative mortality. Due to the presence of a RVC network in the Russian Federation, many patients could receive necessary specialized treatment. The number of operations for cerebral aneurysms has increased 6-fold for the past 10 years.Цель исследования - оценить результаты хирургического лечения церебральных аневризм в Российской Федерации. Материал и методы. Проведен анализ показателей работы нейрохирургических отделений региональных и федеральных учреждений здравоохранения Российской Федерации за 2017 г. Результаты хирургического лечения церебральных аневризм (ЦА) исследованы в 19 региональных сосудистых центрах (РСЦ) нескольких федеральных округов и 3 федеральных центрах (ФЦ) с наиболее динамично развивающейся сосудистой нейрохирургией и отлаженной системой статистической обработки данных. Результаты. В исследование вошли 3160 пациентов, госпитализированных в 2017 г. в 22 медицинских учреждения. Из них лечение 1808 пациентов проводили в РСЦ, 1352 - в ФЦ. Проанализированы факторы, влияющие на результат лечения больных с ЦА. Определены особенности лечения ЦА в клиниках с различным объемом хирургических вмешательств. Заключение. Увеличение объема хирургической активности в центрах, одновременное развитие микрохирургических и эндоваскулярных методов лечения аневризм головного мозга позволяют уменьшить послеоперационную летальность. Благодаря наличию сети РСЦ в РФ многие больные получили необходимое специализированное лечение. Количество операций по поводу аневризм головного мозга за последние 10 лет увеличилось в 6 раз.

The review presents the methodology of electroencephalography (EEG) background analysis, sporadic epileptiform discharges classification, and description of the rhythmic and periodic patterns in patients with primary and secondary brain damage. It describes the process of decision making in starting non-convulsive status epilepticus treatment of patients with EEG-verified non-convulsive status epilepticus and the signs of 'malignant' patterns indicating the irreversibility of brain injury.В обзоре представлена методология анализа фоновой биоэлектрической активности, спорадически возникающих эпилептиформных графоэлементов и ритмичных и периодических паттернов у пациентов с первичным и вторичным повреждением головного мозга, описан порядок принятия решения о начале интенсивной терапии при верифицированном бессудорожном эпилептическом статусе и риске его развития, приведены признаки 'злокачественных' паттернов, свидетельствующих о необратимости возникших изменений нейронов.

Vascular diseases of the brain and heart are the main cause of death and disability of the population of the Russian Federation. The social and economic burden of acute cerebral circulation disorders necessitated the development of a national program for the care of patients with acute vascular diseases. As a result of the implementation of a set of measures to improve medical care for patients with stroke over the past decade, the regions of the Russian Federation managed to create an 'insult network', equip the departments with high-tech diagnostic and therapeutic equipment, and train medical personnel. Due to the implementation of modern methods of treatment of stroke, the rates of disability and mortality from stroke have decreased.Сосудистые заболевания мозга и сердца являются основной причиной смертности и инвалидизации населения РФ. Социальное и экономическое бремя острых нарушений мозгового кровообращения обусловило необходимость разработки национальной программы помощи пациентам с острыми сосудистыми заболеваниями. В результате реализации 'Комплекса мероприятий по совершенствованию медицинской помощи пациентам с ОНМК' за прошедшее десятилетие в регионах РФ удалось создать 'инсультную сеть', оснастить отделения высокотехнологичным диагностическим и лечебным оборудованием, обучить медицинский персонал. Благодаря внедрению современных методов лечения инсульта снизились показатели инвалидизации и смертности от ОНМК.

The meeting of experts, concerning the treatment of thyroid cancer was held in Moscow in June 2016. The aim of the meeting was unsolved tasks in the field of therapy of the patients with radioactive iodine-refractory differentiated thyroid cancer. Nowadays, this group of patients still has a poor prognosis with respect to life expectancy. The experts are faced with some difficulties in choosing the treatment tactics in patients after radioiodine therapy have become ineffective and we observe disease progression. And still valid questions remain unsolved: when should doctors stop therapy using radioactive iodine? When should patient start therapy using targeted agents? What kind of targeted agent should specialist choose for treatment of this desiase? How should one manage the developing side effects against the backdrop of targeted therapy? These and some other problems have been discussed within the framework of this counsel.

In the beginning of the present century the epidemic situation on tuberculosis in the Tver region after a long period of deterioration under the influence to implemented medico-social and anti-epidemic measures received the tendency to the gradual improvement.

To determine a prognostic role of leukocyte count in the venous blood in the acute stage of cerebral aneurysm (CA) rupture.Fifty-one patients with CA rupture, aged from 20 to 65 years, hospitalized in the first 72 h over the period from 01.10.12 to 01.02.16 were examined. The severity of disease and anatomical form of hemorrhage was corresponded to III-IV degree on the W. Hunt - R. Hess scale and Fisher scale. All patients underwent surgery. Outcomes after open and endovascular surgeries were similar.Normal leukocyte number in the venous blood at admission was identified in 12 (24%) of patients (on average 7.3±1.4·109/L), leukocytosis in 39 (76%) (14.3±3.1·109/L) (p0.0001). Leukocyte number in the acute stage of CA rupture was correlated with the frequency and severity of the vessel spasm. In 28 (55%) of patients with ischemic lesions of the brain matter, mean leukocyte number in the first 72 h after hemorrhage was higher by 2-24% (3±4.8·109/L) compared to patients without ischemia (11.9±2.5·109/L) (p=0.06). The level of leukocytes in survivors was lower by 3 - 28% (122±3.4·109/L) compared to patients with fatal outcome and patients with severe neurological deficit after the surgery (14.5±3.9·109/L) (p0.05).The increase in leukocyte number in the venous blood in the first 72 h after CA rupture ≥10,1·109/L is a reliable risk factor of marked vessel spasm. The level of leukocytes in patients with cerebral ischemia and poor prognosis in the first 72h after aneurysmal hemorrhage was higher by 2-28% compared to survivors without neurological impairment or mild neurological deficit.Цель исследования. Определение прогностической роли концентрации лейкоцитов в венозной крови в остром периоде разрыва церебральных аневризм (ЦА). Материал и методы. Обследовали 51 больного в возрасте от 20 до 65 лет, поступивших в стационар в первые 72 ч с момента разрыва ЦА, проходивших лечение в НИИ СП им. Н.В. Склифосовского в период с 01.10.12 по 01.02.16. Тяжесть состояния и анатомическая форма кровоизлияния больных соответствовали III-IV степени по шкале W. Hunt-R. Hess и шкале С. Fisher соответственно. Все пациенты были оперированы. Исходы заболевания при открытых и эндоваскулярных вмешательствах не различались. Результаты. Нормальную концентрацию лейкоцитов в плазме венозной крови при поступлении в стационар определили у 12 (24%) больных (в среднем 7,3±1,4·109/л), лейкоцитоз - у 39 (76%) (в среднем 14,3±3,1·109/л) (p0,0001). Выявлена связь между концентрацией лейкоцитов в венозной крови в остром периоде разрыва ЦА, частотой и выраженностью сосудистого спазма. У 28 (55%) больных с ишемическим повреждением вещества головного мозга средняя концентрация лейкоцитов в первые 72 ч после кровоизлияния была выше на 2-24% (в среднем 13±4,8·109/л), чем у пациентов без ишемии (в среднем 11,9±2,5·109/л) (p=0,06). Уровень лейкоцитов у выживших был ниже на 3-28% (в среднем 12,2±3,4·109/л), чем у больных с летальным исходом заболевания или развитием грубого неврологического дефицита (в среднем 14,5±3,9·109/л) (p0,05). Заключение. Повышение концентрации лейкоцитов в венозной крови в первые 72 ч после разрыва ЦА до 10,1·109/л и более являлось достоверным фактором риска развития выраженного сосудистого спазма. Уровень лейкоцитов у пациентов с ишемией головного мозга и неблагоприятным исходом заболевания в первые 72 ч после аневризматического кровоизлияния был выше на 2-28%, чем у выживших больных без неврологического или с негрубым неврологическим дефицитом.

Assessment of rupture risk for intracranial aneurysms (IA) is a particular challenge in cases of so-called complex aneurysms due to their variable morphometric characteristics. Arterial branch arising from the dome or the neck of IA is one of the least explored features of complex aneurysms. The methods of computational fluid dynamics may be valuable to determine the influence of arterial branches of IA on local hemodynamics.To analyze local hemodynamics in IA with arterial branch arising from the cupola or the neck depending on the structure of the aneurysm and blood flow rate in the parent vessel.CT angiography data of 4 patients with IA were estimated in this study. Modifications of the baseline 3D models of the aneurysms resulted 12 patient-specific models included into analysis. Hemodynamic calculations were made by using of ANSYS Workbench 19 software package.Wall shear stress (WSS) was characterized by the most significant variability, especially in case of sidewall aneurysms. Small cross-sectional area of additional branch in relation to the neck of IA was not followed by considerable changes of blood flow patterns inside IA after «virtual» removal of the vessel. Otherwise, the intensity of flows was drastically reduced. Simulation of high inlet flows demonstrated substantial variation of WSS in the area of jet.Additional arterial branch arising from the dome or the neck of IA significantly influences local hemodynamics. This influence depends on the localization of IA in relation to the parent vessel and the diameter of additional arterial branch.В оценке риска разрыва интракраниальных аневризм (ИА) особое место занимают сложные аневризмы, характеризующиеся значительной вариабельностью строения. Одним из наименее изученных факторов является наличие сосуда, отходящего от шейки или купола ИА. Его влияние на гемодинамику в аневризме может проявляться при наложении временных клипс, в том числе при выполнении реваскуляризирующих операций. Моделирование этих вмешательств может быть реализовано с помощью методов вычислительной гидродинамики.Изучить гемодинамические особенности ИА с отходящим от их купола или шейки сосудом в зависимости от строения ИА и скорости кровотока в несущем сосуде.Использованы данные компьютерной томографии сосудов (КТ-ангиографии) четырех пациентов с ИА. С учетом модификации исходных трехмерных реконструкций всего построено 12 математических моделей. Гемодинамические расчеты выполнены с помощью программного комплекса ANSYS Workbench 19.Анализ параметров гемодинамики выявил, что наибольшей вариабельностью характеризовались показатели пристеночного напряжения сдвига (Wall shear stress, WSS), особенно при латеральном расположении ИА. При небольшой площади сечения отходящего сосуда относительно шейки ИА виртуальное «удаление» этого сосуда не приводило к значительному изменению характера потоков в полости ИА. В других случаях наблюдалось резкое снижение интенсивности потоков. Симуляция патологически высоких скоростей потока в несущих артериях во всех случаях показала выраженную вариацию WSS в месте гемодинамического удара.Наличие сосуда, отходящего от шейки или купола интракраниальных аневризм, оказывает значительное влияние на локальную гемодинамику в аневризме. Степень и характер этого влияния зависят от положения интракраниальной аневризмы относительно несущего сосуда, а также от диаметра сосуда, отходящего от аневризмы.

The study was aimed at developing a surgical policy for patients presenting with acute ischaemic stroke induced by lesions of the intra- and extracranial arteries.The patients were enrolled into the study resulting from the current practice of the Department of Emergency Neurosurgery of the Research Institute of Emergency Medicine named after N.V. Sklifosovsky. Sampling of patients was carried out from 1st January, 2014 to 10th October, 2017, eventually comprising all those (n=160) operated on for verified pathology of brachiocephalic arteries and acute impairment of cerebral circulation.During the examination, 101 (63.1%) patients were found to have unilateral or bilateral stenosis of the internal carotid artery, 22 (10.7%) patients were diagnosed with occlusion of the internal carotid artery, and 36 (17.6%) had acute thrombosis of the internal carotid artery. All this was the cause of acute impairment of cerebral circulation. Also, 1 patient was found to have occlusion of the 1st segment of the vertebral artery. Depending on the type of the lesion to the internal carotid artery, the patients were subdivided into 3 groups: 1) patients with internal carotid artery stenosis who received carotid endarterectomy; 2) patients with occlusion of the internal carotid artery, subjected to creation of an extra-intracranial microanastomosis, and 3) those with thrombosis of the internal carotid artery, who depending on the degree of occlusion of the internal carotid artery and patency of the intracranial arteries underwent thrombintimectomy or an extra-intracranial microanastomosis. The indications for and contraindications to interventions were defined based on the existing symptomatic pathology of brachiocephalic arteries, the terms of acute impairment of cerebral circulation, perfusion of the brain, the risk for the development of malignant stroke and cerebral oedema, possible haemorrhagic transformation of the focus of ischaemia, the rehabilitational potential of the patient and the analysis of the current literature. The results of our work demonstrated that surgical treatment of patients in the cute period of ischaemic stroke makes it possible to improve the neurological outcomes in patients as compared with the preoperative status and is not accompanied by a high risk of surgical complications (with the haemorrhagic complication rate amounting to 0.6%).Surgical revascularization of the brain in the acute period of ischaemic stroke is a safe and effective method of treatment in patients with different haemodynamically significant damage of brachiocephalic arteries, once the patients were correctly selected for the operation.Цель: Разработать тактику хирургического лечения у пациентов с острым ишемическим инсультом, вызванным поражением интра- и экстракраниальных артерий. МАТЕРИАЛ И МЕТОДЫ: Пациентов включали в исследование в результате текущей практики отделения неотложной нейрохирургии Научно-исследовательского института скорой помощи имени Н.В. Склифосовского. Выборку осуществляли с 01.01.2014 г. по 01.10.2017 г., в которую включены все пациенты (n=160), оперированные с верифицированной патологией брахиоцефальных артерий и острым нарушением мозгового кровообращения. РЕЗУЛЬТАТЫ: В ходе обследования у 101 (63,1%) больного выявлен односторонний или двусторонний стеноз внутренней сонной артерии, у 22 (10,7%) – окклюзия внутренней сонной артерии, у 36 (17,6%) – острый тромбоз внутренней сонной артерии. Все это послужило причиной острого нарушения мозгового кровообращения. Также у 1 больного отмечена окклюзия 1 сегмента позвоночной артерии. В зависимости от вида поражения внутренней сонной артерии было выделено 3 группы исследования: 1) пациенты со стенозом внутренней сонной артерии, которым выполняли каротидную эндартерэктомию; 2) пациенты с окклюзией внутренней сонной артерии, которым осуществляли наложение экстра-интракраниального микроанастомоза; 3) пациенты с тромбозом внутренней сонной артерии, которым в зависимости от степени окклюзирования внутренней сонной артерии и проходимости интракраниальных артерий выполняли тромбинтимэктомию или экстра-интракраниальный микроанастомоз. Показания и противопоказания к вмешательствам выставляли на основании имеющейся у пациента симптомной патологии брахиоцефальных артерий, сроков острого нарушения мозгового кровообращения, перфузии головного мозга, риска развития злокачественного инсульта и отека головного мозга, возможной геморрагической трансформации очага ишемии, реабилитационного потенциала больного и анализа современной литературы. Результаты нашей работы показали, что хирургическое лечение пациентов в остром периоде ишемического инсульта позволяет улучшить неврологические исходы больных по сравнению с дооперационным статусом и не сопровождается высоким риском хирургических осложнений (геморрагические осложнения составили 0,6%). ВЫВОДЫ: Хирургическая реваскуляризация головного мозга в остром периоде ишемического инсульта является безопасным и эффективным методом лечения у пациентов с различным гемодинамически значимым поражением брахиоцефальных артерий при осуществлении правильного отбора пациентов на операцию.

Traumatic brain injury (TBI) is one of the main causes of mortality and severe disability in young and middle age patients. Patients with severe TBI, who are in coma, are of particular concern. Adequate diagnosis of primary brain injuries and timely prevention and treatment of secondary injury mechanisms markedly affect the possibility of reducing mortality and severe disability. The present guidelines are based on the authors' experience in developing international and national recommendations for the diagnosis and treatment of mild TBI, penetrating gunshot wounds of the skull and brain, severe TBI, and severe consequences of brain injury, including a vegetative state. In addition, we used the materials of international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe TBI, which were published in recent years. The proposed recommendations for surgical treatment of severe TBI in adults are addressed primarily to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in treating these patients.Черепно-мозговая травма (ЧМТ) является одной из основных причин смертности и инвалидизации среди лиц молодого и среднего возраста. Наиболее сложная группа - пострадавшие с тяжелой ЧМТ, находящиеся в коме. Адекватная диагностика первичных повреждений мозга, своевременное предупреждение и лечение вторичных механизмов повреждения во многом определяют возможность снижения летальности и тяжелых инвалидизирующих последствий. При создании данных рекомендаций авторы использовали свой опыт участия в разработке международных и отечественных рекомендаций по диагностике и лечению легкой ЧМТ, проникающих огнестрельных ранений черепа и головного мозга, тяжелой ЧМТ, тяжелых последствий повреждений мозга, включая вегетативное состояние. Кроме того, были использованы материалы международных и национальных рекомендаций по диагностике, интенсивной терапии и хирургическому лечению тяжелой ЧМТ, опубликованные в последние годы. Предложенные рекомендации хирургического лечения тяжелой ЧМТ у взрослых и адресованы прежде всего нейрохирургам, неврологам, нейрорентгенологам, анестезиологам, реаниматологам, повседневно участвующим в лечении данной группы пациентов.

Despite the introduction of new diagnostic and therapeutic methods, traumatic brain injury (TBI) remains one of the leading cause of death and disability worldwide. Standards and recommendations on conservative and surgical treatment of TBI patients should be based on concepts and methods with proven efficacy. The authors present a review of studies of the treatment and surgery of severe TBI: DECRA, RESCUEicp, STITCH(TRAUMA), CRASH, CRASH-2, CAPTAIN, NABIS: H ll, Eurotherm 3235. Important recommendations of the international group IMPACT are considered.Несмотря на применение новейших методов диагностики и лечения, черепно-мозговая травма (ЧМТ) остается одной из ведущих причин смертности и инвалидизации во всем мире. Стандарты и рекомендации по консервативному и хирургическому лечению пациентов с ЧМТ должны быть основаны на положениях и методах с доказанной эффективностью. В статье представлен обзор результатов исследований, посвященных терапии и хирургии тяжелой ЧМТ: DECRA, RESCUEicp, STITCH(TRAUMA), CRASH, CRASH-2, CAPTAIN, NABIS: H II, Eurotherm3235. Рассмотрены актуальные рекомендации международной группы IMPACT.

to evaluate the use of extra-intracranial microanastomosis (EICMA) in the treatment of brain ischemia in patients with nontraumatic subarachnoid hemorrhage (SAH).In the period from 01.01.14 to 01.07.15, there were 229 surgeries for ruptured intracranial aneurysms performed in the urgent surgery unit. Nine patients with marked and widespread angiospasm, subcompensated and decompensated cerebral ischemia underwent the simultaneous clipping of ruptured intracranial aneurysms and EICMA. The age of patients varied from 32 to 52 years (mean 36 years). The severity of patient's state was assessed as III-IV grades on the Hunt and Hess scale before operation. The surgery was performed 1-2 days after admission to the hospital, 1-8 days after the development of SAH.Excellent and good outcome was recorded in 4 patients, severe disability in 3 patients, fatal outcome in 2 patients. The fatal outcome was due to decompensated cerebral ischemia and progressive angiospasm with the high linear blood flow rate and the following reduction in perfusion in the affected hemisphere. The simultaneous clipping of ruptured intracranial aneurysms and EICMA in the acute stage of SAH of patients with subcompensated cerebral ischemia allow to improve treatmentThis technique is most applicable for patients with proximal angiospasm of M1- and M2-segments of the middle cerebral artery in the first 24 h of the development of a focal neurological deficit supported by the reduction in perfusion in the corresponding vascular area.Цель исследования - оценить применение экстра-инракраниального микроанастомоза (ЭИКМА) в лечении ишемии головного мозга у больных с нетравматическим субарахноидальным кровоизлиянием (САК). Материал и методы. С 01.01.14 по 01.07.15 в отделении неотложной нейрохирургии НИИ скорой помощи им. Н.В. Склифосовского оперированы 229 пациентов по поводу разрыва интракраниальных аневризм, из них 9 с развитием выраженного и распространенного ангиоспазма, субкомпенсированной и декомпенсированной ишемией головного мозга симультанно выполнено клипирование разорвавшихся интракраниальных аневризм и наложение ЭИКМА. Возраст пациентов варьировал от 32 до 52 лет (средний - 36 лет). Тяжесть состояния в предоперационном периоде соответствовала III-IV степени по шкале Hunt-Hess. Операцию выполняли на 1-2-е сутки от поступления пациентов в стационар, 1-8-е сутки от развития САК. Результаты и заключение. У 4 больных наблюдали отличные и хорошие исходы, у 3 - глубокую инвалидизацию, 2 - умерли. Ухудшение состояния умерших было связано с развитием декомпенсированной ишемии головного мозга на фоне прогрессирующего ангиоспазма, сопровождающегося высокими линейными скоростями кровотока по артериям головного мозга и дальнейшим снижением перфузии пораженного полушария. Выполнение симультанного клипирования интракраниальных аневризм и ЭИКМА в остром периоде САК у больных с субкомпенсированной ишемией головного мозга позволяет улучшить результаты лечения. Наиболее перспективными для использования представленной методики являются пациенты с проксимальным ангиоспазмом М1- и М2-сегментов средней мозговой артерии в первые 24 ч после развития очагового неврологического дефицита, доказанным снижением перфузии в соответствующем сосудистом бассейне.

Traumatic brain injury (TBI) is one of the major causes of death and disability in young and middle-aged people. The most problematic group is comprised of patients with severe TBI who are in a coma. The adequate diagnosis of primary brain injuries and timely prevention and treatment of the secondary injury mechanisms largely define the possibility of reducing mortality and severe disabling consequences. When developing these guidelines, we used our experience in the development of international and national recommendations for the diagnosis and treatment of mild traumatic brain injury, penetrating gunshot wounds to the skull and brain, severe traumatic brain injury, and severe consequences of brain injuries, including a vegetative state. In addition, we used international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe traumatic brain injury, which had been published in recent years. The proposed guidelines concern intensive care of severe TBI in adults and are particularly intended for neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in the treatment of these patients.Черепно-мозговая травма (ЧМТ) является одной из основных причин смертности и инвалидизации лиц молодого и среднего возраста. Наиболее сложная группа - пострадавшие с тяжелой ЧМТ, находящиеся в коме. Адекватная диагностика первичных повреждений мозга, своевременное предупреждение и лечение вторичных механизмов повреждения во многом определяют возможность снижения летальности и тяжелых инвалидизирующих последствий. При создании данных рекомендаций авторы использовали свой опыт участия в разработке международных и отечественных рекомендаций по диагностике и лечению легкой ЧМТ, проникающих огнестрельных ранений черепа и головного мозга, тяжелой ЧМТ, тяжелых последствий повреждений мозга, включая вегетативное состояние. Кроме того, были использованы материалы международных и национальных рекомендаций по диагностике, интенсивной терапии и хирургическому лечению тяжелой ЧМТ, опубликованные в последние годы. Предложенные рекомендации касаются интенсивной терапии тяжелой ЧМТ у взрослых и адресованы прежде всего нейрохирургам, неврологам, нейрорентгенологам, анестезиологам, реаниматологам, повседневно участвующим в лечении данной группы пациентов.