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Four cases of giant or large paraclinoid aneurysms of the internal carotid artery successfully trapped after assessing blood flow using a flowmeter are presented. In all cases, the initial plan for clipping was changed to aneurysm trapping due to various reasons. The collateral blood flow was assessed using the flowmetry test, the original procedure of measuring volumetric blood flow in the middle cerebral artery using an ultrasonic flowmeter. We analyze the reasons for clipping refusal, the procedure of measuring blood flow, treatment outcomes, and catamnestic data. The risks of reconstructive surgeries involving the internal carotid artery are discussed and the literature data are analyzed. Conclusions. Ultrasonic flowmetry is a simple and safe method for intraoperative control over blood circulation, which may play the key role in complicated surgical cases.

Radiation treatment techniques are essential in complex management of selected neurooncological, neurovascular and functional brain pathology. Stereotactic radiotherapy provides sufficient damage to the target (tumor, AVM, functional structures) with minimal impact on surrounding brain tissue. Development of stereotactic methods with X-ray guidance lead to expansion of indications for irradiation of intracranial and extracranial lesions. This paper represents the first experience of treating patients with AVMs using CyberKnife system in Russia. The technique of stereotactic radiotherapy (SRT) and radiosurgery (SRS) is described in details, as well as indications for SRT and SRS in different regiment of fractionation, possibilities of planning systems, with additional emphasis on specific complications, radiation-induced reactions and capabilities of neurovisualization methods in evaluation of radiation-induced damage of brain tissue.

Recently the number of AVM resections in Burdenko Neurosurgical Institute has been increased dramatically. Aim of this study was to assess the results of open surgery in our clinic in modern neurosurgical era. Consecutive series if 160 patients with AVM treated using microsurgical technique since 2009 till 2011 was analyzed. Spetzler-Martin score distribution was: grade I--29 (18.1%) cases, grade II--84 (52.5%), grade III--38 (23.8%), grade IV--9 (5.6%). Patients with grade V AVMs were not operated. Treatment options included: AVM resection in 143 (89.4%) cases, embolization followed by resection in 15 (9.3%) and clipping of afferents in 2 (1.3%). Glasgow outcome scale score distribution was the following: V (good recovery)--70 (43.7%), IV (moderate disability)--71 (44.4%), III (severe disability)--16 (10%), II (vegetative state)--1 (0.6%) and I (death)--2 (1.3%). Microsurgery remains the primary option for radical treatment of cerebral AVMs. Careful selection of patients and planning of surgery are crucial for good outcomes.

The study was performed to substantiate optimal tactics of management of patients with multiple cerebral aneurysms based on analysis of surgical results. This study included 233 (20%) patients with multiple cerebral aneurysms who were treated in Burdenko Neurosurgical Institute since 1995 till 2007. We analyzed results of single-stage (microsurgical technique) and multistage (microsurgical technique and step-by-step application of endovascular and microsurgical techniques) approaches. The following factors were investigated: severity of subarachnoid hemorrhage (Hunt-Hess scale), localization of aneurysms in different arterial systems, quantity and size of aneurysms.. Postoperative mortality was 4.7%. Poor outcomes were observed in 37 (16%) patients. In multi-stage surgical treatment the number of totally occluded aneurysms was significantly higher (92% vs. 79%, p < 0.05) as the number of palliative operations and untreated aneurysms was lower (5.8% vs. 16%, p < 0.05). The best technical and clinical results were obtained in the group of patients who were treated using step-by-step application of endovascular and microsurgical techniques. Despite coexistence of aneurysms of both carotid systems with vertebrobasilar aneurysms in 15% of this group, poor outcomes were not observed and total occlusion of aneurysms was performed in 91.4% of cases. Obtained technical and clinical results of treatment of multiple aneurysms prove that multi-stage surgical management is the therapy of choice in surgery of multiple aneurysms. Our data demonstrate high effectiveness of multimodal approach with integration of endovascular and microsurgical methods. Combination of both techniques is preferential in coexistence of aneurysms of carotid and vertebrobasilar systems.

Since 2008 till 2010 years 22 patients with multiple aneurysms were examined in Burdenko Neurosurgical Institute (Moscow, Russia). The series included 13 female and 9 male patients, age ranged from 28 to 62 years (mean 45 years). 68 aneurysms of different localization were discovered in these 22 patients. We also analyzed results of examination of 2 patients with solitary aneurysms in which SW-MRI was performed to confirm or exclude the fact of hemorrhage due to rupture of the aneurysm. All patients were operated microsurgically. SW-MRI is effective technique for identification of source of hemorrhage in patients with multiple aneurysms thus allowing selection of correct tactics of management. Information value of the method declines with increase of time after hemorrhage (over 2 years). SW-MRI enables verification of the fact of hemorrhage due to aneurysm in disputable cases (minimal non-specific clinical presentation, absence of hemorrhage verification).

A 16-year-old boy with arteriovenous malformation (AVM) of septum pellucidum in combination with left side persistent trigeminal artery (PTA) is described. Presentation of AVM included severe intracranial hemorrhage and the lesion was removed surgically. The case deserves interest for two reasons. 1) The observation demonstrates the possibility of increased pressure in the afferent arteries of AVM. It was illustrated by distinctive displacement of the zones of the hemodynamical balance around the circle of Willis. The raised pressure in conditions of shunting can be explained using principles of the constant shear stress in the vascular system. 2) The observation of the features of venous system that may be causative for PTA. These features included presence of the large anastomotic vein between petrosal and cavernous sinuses, enlargement of petrosal sinuses and shrinking of transverse sinus ipsilateral to PTA.

Background: Intracranial aneurysms are rare lesions in children and adolescents and their epidemiology, clinical and anatomic features are poorly understood. Aim of the study was to reveal the specific features of cerebral aneurysms in children and adolescents and to develop guidelines for management of these patients., Materials and Methods: The study was performed on consecutive series of 125 patients under 18 years of age harboring 145 aneurysms. All of them were treated in Burdenko Neurosurgical Institute (Moscow, Russia) from 1987 to 2007., Results: Specific features of pediatric aneurysms include: high incidence on a background of connective tissue disorder (42%) and abnormalities of circle of Willis (20%), frequent localization in bifurcation of internal carotid artery (13.8%), its cavernous segment (17.9%), or in posterior part of circle of Willis (23.5%). In children giant aneurysms were observed in 31.7% of cases, fusiform in 19.3% and partially thrombosed in 33.8%. Complications of aneurysms in children with hemorrhagic type of course included recurrent hemorrhages (42.9%), hematomas (31%), hydrocephalus (16.7%) and seizures (33.3%). Generally, 107 pediatric patients (85.6%) with 118 aneurysm (81.4%) were operated. Microsurgical treatment was performed in 57% of patients and endovascular procedures in 43% In the series of 107 operated patients we observed excellent early postoperative results in 53 cases (49.5%), good in 45 (42.1%) and poor in 9 (8.4%). Postoperative mortality was 0.95% (1 patient)., Conclusion: Considerable proportion of complex aneurysms in children and adolescents produces certain difficulties of treatment; however, due to good functional outcomes in this age group the range of causes of denial must be minimized.

The article discusses results of surgical treatment of 82 patients with large and giant cerebral aneurysms operated in Burdenko Neurosurgical Institute (Moscow, Russia) during the recent 14 years. Special attention was given to benefits of intravascular blood aspiration (IBA) technique. This technique was proven to be very effective, allowing to clip the aneurysm in 87.8% of cases with good recovery in 41.5% and with moderate disability in 39%. Postoperative mortality was 4.9% (4 patients). The authors suggested original surgical classification of large and giant aneurysms. IBA was ineffective in cases of giant partially thrombosed aneurysms with sclerotic walls and giant aneurysms with very wide neck. These aneurysms require other surgical procedures such as embolization of ICA followed by extraintracranial bypass or high-flow bypass.

Ischemic tolerance (preconditioning) is taken to mean a short ischemic episode subfatal to cells that activates the protective endogenous mechanisms that ensure tolerance of further longer and more severe episodes of ischemia by the organ (tissue). The present review attempts to analyze information on ischemic preconditioning in the light of the possible use for brain protection. Experimental models, temporal aspects, crossed tolerance, genomic reaction, and mechanisms are considered. There is evidence for human ischemic preconditioning.

Twenty-nine patients with basilar artery aneurysms were operated on using one of three approaches: pterional, orbitozygomatical, and subtemporal. The efficiency of surgery and the frequency of surgical complications are analyzed in detail in relation to the data of an angiographic study and the intraoperative pattern. Three (10.3%) patients died in the postoperative period. In most cases, the pterional approach is adequate for clipping almost any aneurysm of the distal portions of the basilar artery; the use of the orbitozygomatical approach in patients with aneurysm of the same location is determined by its extent and/or adhesions with the adjacent brain structures. Current neuroimaging techniques are of the most informative value in choosing a surgical treatment policy in each specific case.

A mechanical device for making arterial wide-section anastomoses was tested on a series of 15 laboratory rabbits. End-to-side anastomoses were made using a vein graft and they functioned in 93.1% of cases, as evidenced by intraoperative Doppler studies. When an anastomosis is made, the mean duration of temporary blood flow arrest in the rabbit aorta averaged 2 min. According to outcomes, the survived animals were divided into 3 groups: Group 1 comprised 2 (13.3%) rabbits that died within 10-12 hours after surgery and had significant symptoms of anastomotic dysfunction. Group 2 included 8 (53.3%) animals that died 2-3 days after surgery. They moved 5-6 hours following surgery without assistance, which was indicating of anastomotic functioning. Group 3 consisted of 3 (20%) rabbits that survived 2 weeks. Autoptic studies revealed no anastomic thrombosis in Group 2 animals. Group 3 animals were noted to have signs of allograft thrombosis and rejection. Thus, it is expedient to continue studies to make arterial wide-section anastomoses, by using the above device, in order to introduce this procedure into clinical practice.

Cerebral vasospasm and its associated ischemia are one of the main causes of death in 23% of patients with prior aneurysmal subarachnoidal hemorrhage (SAH). At present, a diversity of approaches to treating vasospasm has been developed, among them hypertensive hypervolemic hemodilution (deriving its abbreviated name 3H-therapy) offers certain advantages. At the same time a number of aspects of application of this approach remain unclear. Fifty-four patients with significant cerebral arterial spasm (elevated linear systolic blood flow velocity > or = 200 cm/s) who had been operated on in the acute period of aneurysmal SAH were selected. Of them, 18 patients had undergone hypervolemic hypertensive hemodilution (3H-therapy) under guidance of systemic hemodynamics, by using a Swan-Ganz catheter (these patients formed a study group). Thirty-six patients who had not undergone 3H-therapy under invasive monitoring of systemic hemodynamics constituted a control group. Hypervolemic hypertensive hemodilution was performed by means of continuous intravenous infusion of a combination of colloid-crystalloid solutions. The therapy was considered to be adequate by meeting the following requirements: maintenance of cardiac index not less 3.5 l/min/m2, pulmonary capillary wedge pressure below 14-16 mm Hg or central venous pressure under to 8-10 mm Hg, packed cell volume below 28-32%, and systolic blood pressure under 200 mm Hg. Hypervolemic hypertensive hemodilution (3H-therapy) applied to patients operated on in the acute period of aneurysmal SAH was effective in increasing cardiac output, central venous pressure, systemic arterial pressure and hence cerebral perfusion with the minimum number of complications unassociated with the use of this technique. This permitted a reduction in mortality rates in patients with baseline Hunt-Hess grade I-III SAH. At the same time, it should be emphasized that 3H-therapy may be used in neurosurgical patients, by thoroughly monitoring the parameters of central hemodynamics, blood coagulation system, cerebral circulation and, desirably, intracranial pressure.

Vascular occlusion leading to the development of an ischemic focus or incomplete aneurysm closure is one of the main causes that deteriorate the total results of surgical treatment in patients with cerebral aneurysms. The study covering 50 patients with 54 aneurysms who were evaluated for vascular patency by contact Doppler ultrasonography (CDUS) assessed the role and reliability of this technique. In the study group, the ratio of males to females was 30:24, their mean age was 44 years (23-67 years); the ratio of patients with acute subarachnoidal hemorrhage (SAH) to those without SAH was 24:30. The functional outcomes were assessed by a modified Rankin scale and compared with those in the control group. The clip site was inspected by the results of CDUS in 19 (31.7%) cases; clip reposition was made in 16 (26.7%) cases due to vascular stenosis; an additional clip was use to exclude the aneurysmal functioning part in 1 (1.7%) case. Vascular stenosis was detected in 2 (3.3%) cases; however, the position of clips remained unchanged since aneurysm was excluded under the conditions of its rupture. According to the modified Rankin scale, good results were slightly more in the study group of "acute" patients than in the control group: 96.7% versus 90%; the similar results were obtained in non-SAH patients: 66.7% versus 62.5%; lambda < 1.36). CDUS is a noninvasive, simple, reliable, and inexpensive technique for blood flow evaluation.

The paper deals with the investigation studying the localization of a structure and showing the ways of formation of depth interarterial anastomoses of the brain. Three areas of deep interarterial anastomoses are identified, which are characterized by their symmetric pattern and formed by the arteries supplying blood to the deep cerebral structures and which create an epithalamic circle of anastomoses similar to the basal hypothalamic arterial circle of Willis. The existence of depth interarterial anastomoses points to the sole functional significance of depth structures of the brain. Depth epithalamic anastomoses are mechanisms that are responsible for the additional redistribution of blood from different vascular beds when cerebral blood flow is impaired in the depth structures and their presence should be taken into account during neurosurgical interventions.

The study included 38 patients with intracranial aneurysms, whose close relatives had experienced intracranial hemorrhages. The patients' relatives were divided into 2 groups according to the verification of the source of hemorrhage. The individuals at risk for aneurysmal disease in whom aneurysms should be sought before their rupture were examined. The patients with familial aneurysms were found to tend to rupture at younger age than those without familial aneurysms (the so-called sporadic aneurysms). The high rates of mortality due to intracranial bleeding were observed among the relatives of patients from the study group. Screening study of the first-order relatives of the patients with prior aneurysmal subarachnoidal hemorrhage is the method of choice in detecting unruptured cerebrovascular aneurysms. Early detection and switching-off of asymptomatic aneurysms may reduce mortality and disability rates in this group of patients.

The paper considers surgical treatment of patients with partially thrombotic giant and fusiform aneurysms of the posterior cerebral arteries (PCA), which is a challenge of cerebrovascular neurosurgery. Giant, fusiform aneurysms are clinically manifested themselves as a mass effect in 80% of cases and as spontaneous subarachnoidal hemorrhage in 20%. Due to their vicinity of the brain stem, giant aneurysms of PCA in any clinical course present a real threat to a patient's life. A case of clipping of partially thrombotic giant aneurysm of PCA by means of tunnel clips to form the wall of a vessel from an apron cut from the aneurysmal wall is considered in detail. Surgical treatment of partially thrombotic giant and fusiform aneurysms is identified as an individual problem of cerebrovascular neurosurgery, which awaits a sophisticated study in order to define an adequate surgical treatment.

The study was undertaken to analyze the outcomes of treatment in 37 patients with 44 non-ruptured aneurysms (NRA) at different sites. The paper presents a detailed classification of NRA, identifies individuals at risk for aneurysmal disease in whom an active search for aneurysms until they rupture is recommended to prevent aneurysmal subarachnoidal hemorrhages and their sequels. Total aneurysmal exclusion was achieved in 93.2% of the cases; the aneurysmal walls were consolidated with surgical gauze in 7.2%. There were no fatal cases. Postoperative progression of focal neurological symptoms was noted in 4 patients. In 3 patients, these symptoms were entirely reversible. All NRAs should be operated on irrespective of their size particularly in young and middle-aged patients since this is technically possible and there are no concomitant diseases that make surgery contraindicated. It is expedient to perform computed or magnetic resonance imaging in combination with angiography in risk-group patients in order to reveal or exclude aneurysm.

Temporary clipping was used during operations in 69 patients. Of them, 51 patients underwent temporary arterial clipping, forced temporary arterial clipping was used in 18 patients. A total of 104 patients were operated on with preventive temporary clipping. Aneurysmal rupture occurred in 18 (17.3%) patients of them. The bioelectrical activity of the brain was intraoperatively monitored by using EEG and ECG in 12 patients of whom 11 felt rather well on discharge. The temporarily arterial clipping technique using EEG and ECG makes it possible to monitor the allowable time of temporary arterial clipping, which is in turn associated with a less risk for postoperative ischemic complications.

The authors studied the time course of changes in the parameters of the cerebral thyronergic system (total and free triiodthyronine (T3) and thyroxin (T4), thyroxine-binding globulin (TBG), thyroid-stimulating hormone (TSH) by radioimmunoassay (Immunotech, Czechia; CIS, France), proinflammatory cytokine of TNF-alpha by enzyme immunoassay (Innogenetic, Belgium) in the blood and cerebrospinal fluid (CSF) in 59 patients (37 males and 22 females whose age ranged from 21 to 64 years) in acute subarachnoidal hemorrhage due to arterial aneurysmal rupture. On admission, the condition of 47 (79.7%) was rated as grades III-VI according to the Hunt-Hess scale, which was responsible for high mortality rates (33.89% in the assessment of outcomes according to the Glasgow outcome scale). The causes of death were ischemic and hemorrhagic insults, edema of the brain, cerebral stem wedging. Laboratory findings were analyzed in relation to the clinical condition of patients, outcomes, and the degree of secondary vasospasm assessed by Doppler transcranial study by the average blood flow velocity in the middle cerebral artery. They revealed a significant depression of thyroidal metabolism with developed the total low T3 syndrome just before surgical treatment in patients with deterioration in the early postoperative period. The significant correlations found by the authors between the decreased blood T3 and TSH levels and 1) the severity of neurological disorders; 2) the degree of vasospasm, and 3) the outcome of disease, as well as negative correlations of elevated TNF-alpha levels not only in the blood, but also in CSF with the content of CT3, CT4 and with the severity of neurological symptomatology are indicative of the development of isolated syndrome in the brain, which is characterized by specific thyroidal metabolic disorders, which the author propose to call the cerebral low T3 syndrome (by taking into account the presence of the autonomic systems of thyroidal homeostatic provision).

A 42-year-old male patient was operated on for a giant fusiform aneurysm of the right internal carotid artery. Extracranial-intracranial bypass was first performed. Despite suction decompression, the aneurysm could not be clipped for its fusiform neck, and it was coated with surgical gauze. Before surgery, his bilateral visual acuity was 1.0; there was a complete left homonymic hemianopia, the fundus oculi was normal. On postoperative day 1, the visual functions were unchanged. Then there was a visual loss in the right eye that progressed to blindness 2 weeks after surgery. The authors consider variants of the pathogenesis of blindness: 1) development of foreign-body granuloma and surgical gauze-induced optochiasmal arachnoiditis; or 2) thrombosis of the aneurysm and thickening of its wall with compression of the right optic nerve. One-year follow-up revealed that the visual acuity of the right eye recovered (1.0), but the right optic disk became pale, the left optic disk was normal. A complete left homonymous hemianopia was unchanged. Spontaneous recovery of visual acuity makes the second hypothesis of the pathogenesis of blindness more preferable.

The efficiency of a procedure of intravascular blood aspiration (IVBA) in patients with large and giant parawedge aneurysms of the internal carotid. The study was based on the analysis of clinical data and outcomes of surgical treatment in 20 patients with the aneurysms. The paper presents different procedures for IVBA, a complex of methods for preoperative examination of patients and intraoperative prediction of possible ischemic complications and defines indications for the IVBA procedure. Complete and partial aneurysm exclusion was achieved in 15 (75%) and 2 (10%) patients; the neck and walls of aneurysm were strengthened with surgical gauze in 2 (10%) patients. Incompetent clipping was observed in one case. There was recovery in 17 (85%), improvement in 2 (10%), 1 (5%) patients. No deaths occurred. The IVBA procedure for aneurysm is indicated for large and giant thin-walled non-thrombotic aneurysms of the parawedge carotid segment. It permit effective proximal monitoring of carotid blood flow and creates favourable conditions for preparing and excluding aneurysm, and, if necessary, forming a carotid lumen. Intraoperative monitoring of brain function is highly important and obligatory for early prediction and prevention of ischemic complications. Under intraoperative monitoring of brain function, fractional IVBA makes it effective even if collateral circulation is inadequate.

The authors discuss the results of pharmacological protection of the brain, consisting in intraarterial or intravenous infusion of drugs (sodium thiopental, nimodipine, ketamine) during intracranial interventions in 13 patients with giant arterial aneurysms of the anterior portions of Willis' circle. In some patients drug protection of the brain prevented the development of ischemic focus in the basin of temporarily occluded vessel. Intraarterial infusion of protector drugs is preferable because it allows decreasing the doses and severity of untoward hemodynamic effects.

The paper presents two cases of high-surgical-risk deep arteriovenous malformations (AVM) concurrent with aneurysms of the middle portion of the anterior ciliary artery (a male aged 35 years and a female aged 24 years). In the former case, aneurysm and large AVM in the left visual tuber were causes of 4 hemorrhages. In the latter, AVM of subcortical nodes and internal capsule were responsible for single hemorrhage. The patients underwent intraoperative embolization of the anterior ciliary artery followed by its clipping. This allowed the authors to exclude aneurysm and to achieve obliteration of the bulk of AVM. Operation were performed under intraoperative guidance of motor and speech functions. Residual AVM were exposed to proton beam radiation. The outcomes of treatment were good. After 4 months of surgery, the male had no neurological disorders; in the female motor and speech disorders were associated with prior hemorrhage.

A comprehensive examination was made in 39 patients with arteriovenous malformations (AVM) of hippocampus. Prior to and following surgery, all the patients underwent neuropsychological study after A. R. Luriia (1962). Mnestic disorder was found to be the most common abnormality in patients with AVM at this site. Before surgery, they were detected in 34 of 39 patients, 11 of them having severe memory disorders with the traits of the Korsakoff's syndrome. These patients were found to have mixed posthemorrhagic lesion of the hippocampus, other portions of the temporal lobe and periventricular structures. Twenty nine patients were operated on, 14 of them had progressive mnestic disorder of the modally nonspecific type irrespective the side operated on. There were no postoperative Korsakoff's syndromes. There was no progression in memory defects in patients after surgery on the brain drastically changed after hemorrhage or removal of minor malformations. Before hemorrhage, epileptic paroxysms were observed in 2 of the 39 patients only in the presence of massive AVM obligatorily involving the temporal cortex. Following surgery, there were no new epileptic paroxysms and changes in the emotional status and motivations in the patients. Thus, the hippocampal formation is involved in the primary mechanisms of fixation, retention, reproduction of a memory trace. The participation of many structures of the brain is required to form an emotional status, motivation, and clinical manifestations of epileptic activity.

Changes in intracranial pressure (ICP) and cerebral circulation were evaluated from Doppler transcranial ultrasound (DTU) in 29 patients with spontaneous aneurysmal hemorrhage in acute rupture. There is a tendency for the pulse wave amplitude (PWA) of ICP to increase concurrently with higher ICP values (r = 0.768, p < 0.01), the tendency being smoother in patients with severe diffuse spasm (r = 0.573, p < 0.01). There was also a linear correlation between the ICP values and the pulse index of blood flow velocity (r = 0.783, p < 0.01). Evidence is given for the possibility of indirect assessment of ICP from DTU data and for that of indirect evaluation of cerebral perfusion from ICP monitoring data. In the latter case, the authors used a ICP PWA ratio. The findings suggest that the decrease in PWA/ICP values by less than 0.2 during intracranial hypertension and severe diffuse arterial spasm corresponds to the reduction in cerebral blood filling beyond the critical values.

This paper presents 12 cases of the persistent trigeminal artery (PTA) concurrent with cerebrovascular diseases. In 7 patients, PTA was accompanied by cerebral aneurysms, 2 had prior subarachnoidal hemorrhage (SAH) of unknown origin, other 2 patients had acute transient ischemic attacks. In one case, PTA was concomitant with arteriovenous malformation. Clinical features and hemodynamic variants of PTA are described. Diagnostic modalities and surgical management of combinations of PTA and aneurysms in the presence of SAH are discussed.

Clinical and neuropsychological studies of the outcomes of surgical treatment in patients with arteriovenous malformations (AVM) of the gyrus cinguli were conducted. Preoperative examination revealed predominantly memory disorders in 38 cases. Of them 5 cases had amnestic disturbances similar to those of the Korsakoff syndrome. Autonomic and epileptic seizures were not common. Thirty eight patients underwent surgery. Memory deterioration was recorded in 23 cases postoperatively. Three patients developed a "new" Korsakoff syndrome. The rate of deterioration of memory disorders showed a clear correlation with the extent of gyrus cinguli destruction and degree of corpus callosum integration to AVM nidus. The qualitative analysis of amnestic syndromes demonstrated that the majority of patients developed pre- and postoperative disorders of trace selectivity, the insight incontinence of the story essence accompanied by diminished critical attitude towards their condition. This pattern of defects was similar to the clinical features of the amnestic syndrome in patients with frontal lobe lesions. Combined damage of frontal lobes and their connections (with gyrus cinguli in this case) is of great importance in the formation of a clinical picture in man. The findings should be taken into consideration when surgical policy is to be analyzed.

The paper presents a 36-year-old patient in whom giant fusiform aneurysm of the M1 segment of the MCA was successfully clipped using intravascular aspiration technique. EEG was intraoperatively monitored. At surgery, the lumen of the deformed M1 segment was newly shaped by a series of 3 fenestrated clips. Intravascular aspiration of blood from the ipsilateral ICA significantly helped decrease blood volumes within the aneurysm and its size which facilitated dissection and clipping of the aneurysm. Since intravascular aspiration have been previously used during surgery of giant and large paraclinoidal aneurysms, this case demonstrates the benefits of the technique in the surgery of aneurysms located in the areas other than paraclinoid one.

To choose the optimal surgical treatment, the follow-ups of 25 patients with arteriovenous malformations (AVMs) concurrent with arterial aneurysms who had been surgically treated were considered. Twenty four patients experienced spontaneous subarachnoidal hemorrhage, 16 of them were repeated and multiple. The accurate diagnosis of the source of bleeding was associated with objective difficulties. With allowance for intraoperative findings. AVMs caused hemorrhage in 14 (58%) cases, aneurysms in 6 (25%). AVMs and aneurysms in 4 (17%). Thirteen (52%) patients were operated on AVMs and aneurysms in one or two steps, 5 had operations only on aneurysms, 7, on AVMs alone. Taking into account ruptures and higher sizes of aneurysms after AVM dissection, it is concluded that it is necessary to immediately exclude saccular bifurcating aneurysms irrespective of the cause of bleeding. Possible variants of policy decisions are dealt with, by taking into account the specific features of the location of AVMs and aneurysms-the sources of hemorrhage. One-stage surgical interventions into AVMs and aneurysms are recognized to be optimal.

Internal carotid aneurysms in the ophthalmic area presents a challenge in cerebrovascular neurosurgery. The study was undertaken to provide evidence for the application of intravascular aspiration during direct surgical interventions and to outline their variants used at the N. N. Burdenko Institute of Neurosurgery. The study included 4 (3 females and 1 male) patients with large and giant internal carotid aneurysms of parasphenoidal site who were treated at the Institute. Clipping of the aneurysmal neck was made by employing intravascular blood aspiration from the aneurysm. The technique proved to be effective in proximal monitoring the carotid artery at surgery. It substantially reduced aneurysmal blood flow and wall tension, thus favouring aneurysmal dissection to make clipping.

A comprehensive clinical and neuropsychological study was made of 34 patients with thalamic arteriovenous malformations. In the thalamus. Memory disorders were a common abnormality (in 31 of 34 patients). They were modally nonspecific and depended on the site of arteriovenous malformations. With the prevalent ventricular pattern of hemorrhages, memory disorders were accompanied by disorientation and emotional and volitional impairments. Arteriovenous malformation was removed in 12 patients (on the left side in 7 patients and on the right in 5). After surgery there was virtually progression of memory defects in all patients. Speech disorders combining the specific features of lesions in various cortical regions were detected in 5 of 7 patients with left thalamic arteriovenous malformations.

The clinical and neuropsychological signs were studied in 32 patients with arteriovenous malformations of various site who had sustained hemorrhages into the cerebral ventricles. The studies allowed the authors to identify the neuropsychological syndrome which involved the following signs: disorientation, chiefly in time, marked inertia in various scopes of activities, emotional and volitional disorders, and dysmnesia. Memory defects were seen in all spheres of mnestic activity: there were abnormalities in the actualization of consolidated knowledge, modal non-specific memory disorders in the experiment, defects in memory for current events. The degree of defect severity was found to be directly proportional to that of prior hemorrhages. In the absence of hydrocephalus, the disorders were regressive. The authors discuss what topical belonging of the detected syndrome is and how it is related to the phase of consciousness restoration.

The article analyzes the clinical data of 48 patients with arteriovenous malformations of the thalamus, who were examined at the Burdenko Institute of Neurosurgery, AMS USSR, from 1970 to 1989. The experience in surgical treatment is based on 25 cases. The authors describe in detail the indications for surgical treatment, adequate surgical approaches, and the method for removal of the malformations. Neuropsychological and electrophysiological methods of examination of patients in dynamics were applied to evaluate the results of surgery.

Experience in microsurgical treatment of 23 patients with aneurysms of the vertebrobasilar bed at the Institute of Neurosurgery, AMS USSR, is discussed. Some aspects of surgical approaches and the method of removal of the aneurysms are described. Particular attention is focussed on complicated surgical situations which needed non-standard solutions (division of the A1 segment of the anterior cerebral artery and the posterior communicating artery). All patients were operated on in the "cold" period after spontaneous intracranial hemorrhages. The postoperative mortality (one patient) is analysed.

The article analyses the clinical data in 56 patients with hippocampal arteriovenous malformations who underwent complex clinical examination in the course of the disease by means of neurological, neuropsychological, and electrophysiological methods. Cerebral angiography and computerized tomography were the main methods of topical diagnosis. Thirty-nine patients were subjected to total removal of the malformations. The authors substantiate the indications for surgical treatment. Adequate surgical approaches and the methods of removal of the malformations are described.

An anatomo-surgical classification of arteriovenous malformations of the posterior cranial fossa (PCF) is suggested, based on angiography and computer-aided tomography findings with due consideration for adequate surgical approaches to the defect. Conditions of blood supply and drainage are described with regard to localization of the malformation in the PCF structures. Analysis of the neurologic symptoms in PCF arteriovenous malformations permitted a conclusion on a comparatively rare correlation between the symptoms and the localization of the malformation in a certain PCF structure.

The work is based on analysis of the results of complex clinical examination of 70 patients (48 males and 22 females) treated at the Burdenko Institute of Neurosurgery, Academy of Medical Sciences of the USSR, for arteriovenous malformations in the posterior cranial fossa (AVM PCF). The patients' age ranged from 8 to 50 years. Various types of surgical interventions were performed on 26 patients. The authors suggest an anatomo-surgical principle of grouping AVM PCF, which is based on the findings of radiocontrast diagnostic methods. Problems of the clinical picture and topical diagnosis of AVM PCF are discussed. The indications for surgical treatment of AVM PCF, the surgical approaches to them, and the techniques of total extirpation (16 cases) are determined. The results of palliative operations (6 cases) are analysed. The microsurgical anatomy of anastomoses between AVM and PCF and their importance in surgery for these conditions are described.