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The article formulates proposals for improving the calculation methodology for punching. The methods in the current regulatory documents for assessing the tensile strength are based mainly on empirical dependencies obtained on the basis of numerous experimental studies. It should be noted that they give reliable results if certain design requirements are met (typical column sections). Along the interface line of the plate with a rectangular (square) column, supporting bending moments act in two orthogonal directions. The magnitude of these moments for the most common spans is large and, in an elastic setting, exceeds the span by two times. Taking into account the redistribution of forces and the most likely formation of cracks in the stretched zone, it can be argued that in the operational stage, the support sections of the plates have compressed and stretched zones. With such a stress-strain state, in the calculation scheme, when evaluating the tensile strength, the stretched part of the side surface of the “reduced” pyramid, bounded by the neutral axis along all faces, should be excluded. As a result, expressions are presented to determine the parameters of the reduced punching pyramid and the value of forces in concrete and reinforcement at the maximum bearing capacity stage.

The radioiodine therapy is a one of the basic elements at combined treatment of differentiated thyroid cancer and is an alternative method for patients with distant metastases and a potentially high risk of tumor recurrence. It has been used in clinical practice for more than 80 years. The first report on the phenomenon of accumulation of 130I/131I in a metastatic focus of differentiated thyroid cancer was published by A. Keston et al. in 1942, and in 1946, the production of 131I was established, and the drug became available. In our country, radioiodine therapy has been widely used for the treatment of differentiated thyroid cancer since 1982.This article presents methodological recommendations for radioiodine therapy of patients with differentiated thyroid cancer, provides a modern examination algorithm, discusses the basic principles of laboratory, instrumental diagnostics and treatment approaches treatment of this disease.

Local injection therapy (LIT) is an important component of the complex treatment of musculoskeletal disorders (MSD), which is widely used in real clinical practice. Glucocorticoids, hyaluronic acid drugs (HA), autologous cell drugs, botulinum toxin type A, radioactive isotopes, etc. are used for LIT. LIT makes it possible to achieve a pronounced symptomatic effect, while in some cases, for example, repeated HA treatments in patients with osteoarthritis, the possibility of slowing the progression of the disease and reducing the need for surgical treatment is discussed.The performance of LIT requires special skills and abilities of the physician, careful compliance with the rules of asepsis and antisepsis, and instrumental visualization. LIT can be associated with serious complications and therefore must be performed according to strict indications.The Expert Council was devoted to defining the basic principles of LIT. The indications for the use of certain types of this therapies, the evidence base for its efficacy and safety, the order of application of different drugs, and the need to combine LIT with other drug and non-drug treatments of MSD were reviewed.

Neurosurgical treatment for psychiatric disorders has a controversial history. This branch of neurosurgery called by developer of prefrontal leucotomy and Nobel prize laureate Egaz Moniz “psychosurgery”, was initially based not on scientific researches, but on enthusiasm of individuals and pressing social need. The outcome of psychosurgery regardless of its clinical benefits was the negative attitude of the broad masses and medical community, some countries have banned psychosurgery – the era of psychopharmacology has come. However, some patients suffering from severe course of the psychiatric disorder are resistant to conservative treatment.Over the last decades, the novel neuroimaging methods and neurobiological researches have considerably improved understanding of the pathogenesis of psychiatric disorders and scientific validity of the surgical intervention into the neural circuits. In this article, the main stages of the history of the psychiatric neurosurgery are briefly reviewed. Furthermore, the clinical and surgical considerations including the anatomic target localization, outcome and possible complications of the major operations which are still in practice are presented. The new neurosurgical techniques such as deep brain stimulation and gamma knife stereotactic radiosurgery were also considered. The part of the article is devoted to ethical, legal and terminological issues of psychiatric neurosurgery.

Pharmacokinetic parameters are important for calculating the absorbed dose; they also provide an indirect measure of the in vivo stability of a radiopharmaceutical. The aim of the study was to determine the excretion rate of the activity of 177Lu-DOTA-PSMA-617 and MCA 5–10 microns, 188Re, from the blood and urine of patients undergoing systemic and local radiotherapy in clinical trials. Materials and methods: the study involved radiometry of blood and urine samples of 12 male patients with metastatic prostate cancer and 20 patients of both sexes with chronic synovitis, selected after radiotherapy with the experimental radiopharmaceuticals 177Lu-DOTA-PSMA-617 and MCA 5–10 microns, 188Re, respectively. The activity of the samples was measured using a dose calibrator and a gamma counter. Results: the activity of 177Lu in the blood of patients was 36.0–89.3%, 10.4–55.7%, 14.6–32.8%, 10.6–35.7%, and 7.3–25.1% at 5 minutes and at 1, 3, 6 and 8 hours after the administration of 177Lu-DOTA-PSMA-617, respectively. The 48-hour urine excretion varied within 34.4–88.8% for 177Lu-DOTA-PSMA-617 and within 0.15–2.91% for MCA 5–10 microns, 188Re. Conclusions: the maximum values of 177Lu-DOTA-PSMA-617 activity in the blood 8 hours after administration (9.6–25.1%) corresponded to the maximum injected activity of the radiopharmaceutical product. The low rate of 188Re urinary excretion after intra-articular administration of MCA 5–10 microns, 188Re, is an indirect indication of the quality of the radiopharmaceutical. The obtained pharmacokinetic parameters show high in vivo stability of the 177Lu and 188Re medicinal products. The results obtained will be used to calculate absorbed doses in patients.

Хронические нарушения сознания (ХНС) представляют собой синдромы тяжелого поражения центральной нервной системы, приводящие к длительной грубой инвалидизации и требующие значительных усилий по лечению и реабилитации, которые ложатся на медицинские учреждения и на плечи близких пациентов. ХНС развиваются у пациентов после комы и характеризуются наличием бодрствования при полном или практически полном отсутствии признаков осознанного поведения. К ХНС относятся вегетативное состояние (ВС) и состояние минимального сознания (СМС). Также для описания начальных стадий этих состояний используется термин «продленное нарушение сознания» (ПНС). Отдельно выделяют выход из СМС — состояние, которое формируется по мере восстановления когнитивных функций. Диагностика ХНС основывается на многократном структурированном клиническом осмотре с применением специализированных шкал при условии исключения обратимых причин нарушения сознания. Лечение пациентов с ХНС включает в себя поддержание жизненно важных функций, обеспечение оптимального питания и борьбу с типичными осложнениями и сопутствующими состояниями (пролежни, спастичность, боль, пароксизмальная симпатическая гиперактивность и др.). У пациентов с ХНС должна проводиться реабилитация с участием мультидисциплинарной реабилитационной команды в объеме, который определяется проблемами и возможностями конкретного пациента. Наиболее эффективной реабилитация является при условии ее раннего начала. На данный момент однозначных доказательств эффективности каких-либо специфических методов, направленных на восстановление сознания, не получено; изучается ряд соответствующих фармакологических и нефармакологических вмешательств, обязательным условием применения которых является максимально возможная коррекция соматических проблем пациента. Важную роль в ведении пациентов с ХНС играет вовлечение близких пациента, которые, в свою очередь, нуждаются в получении объективной практической информации о состоянии своего родственника и о направлениях реабилитации, а также в психологической помощи.

Introduction. Current treatment of differentiated thyroid cancer includes surgical resection of the thyroid gland, radioiodine therapy (RIT) followed by hormone therapy with levothyroxine. If a patient has distant metastases, radioiodine therapy gains vital importance, becoming a non-competitive method of treatment. However, with incomplete expressed or lost ability of tumor cells to absorb radioactive iodine (131I), the effect of RIT occurs to be limited or completely lost. Radioactive iodine refractivity develops, in which the disease progresses despite ongoing therapy. Therapy with tyrosine kinase inhibitors for the progressive radioiodine-refractory thyroid cancer is currently the only recognized effective treatment. Based on the results of the SELECT study, in an indirect comparison with the data obtained earlier in the DECISION study, lenvatinib was found to be the most effective drug.The study objective is to provide a comparative analysis of response to treatment and overall survival in two groups of patients with progressive metastatic differentiated thyroid cancer. In group 1, treatment was based on continuing radioiodine therapy in combination with suppressive hormone therapy with levothyroxine; in group 2, with the development of radioiodine refractivity, lenvatinib was prescribed.Materials and methods. The study included two groups of patients treated at different times in the A.f. Tsyb medical Radiology Research Center - branch of the National medical Research Center of Radiology, ministry of Health of Russia. group 1 included patients who continued radioiodine therapy, despite disease progression on treatment (historical control group). This group (n = 191) consisted of patients with differentiated thyroid cancer who received radioiodine therapy until January 2015, when the criteria for radioactive iodine refractivity had not yet been established and there was no unified approach to such patients and no possibility of targeted therapy with tyrosine kinase inhibitors. group 2 (n =71) consisted of patients receiving lenvatinib in the 1st line targeted therapy from January 2015 to march 2022, from the time of radiographically confirmed tumor progression according to Response Evaluation Criteria in Solid Tumors 1.1 (RECIST 1.1) and establishing the fact of radioactive iodine refractivity.Results. In the historical control group (n = 19) 18 (9.4 %) patients are alive to date. It should be specifically noted that all of them had a miliary dissemination in the lungs. None of the 191 patients had a complete or partial response to treatment. All patients had either disease stabilization (83 (43.45 %) patients), or disease progression (108 (56.54 %) patients). The number of RIT courses varied from 9 to 27, 13 ± 3.4 on average. The total dose for the entire treatment period varied from 21 to 75 GBq, 39.3 ± 10 on average. Overall survival averaged 80 ± 20.3 months (min 54 months, max 162 months). patients with slow disease progression had the longest overall survival. In the lenvatinib group the median duration of therapy in patients who discontinued treatment reached 26.3 months (1-52 months). Tumor response to treatment was evaluated in 71 patients. According to the RECIST 1.1 criteria, the maximum response was regarded as complete in 1 (1.41 %) patient, as partial - in 30 (42.45 %) patients, as stable disease - in 23 (32.39 %) patients, as disease progression - in 13 (18.31 %) cases. The median time to evaluate the first response to treatment was 4 (2-8) months. PFS was 17.3 months (95 % confidence interval 15.1-19.4 months). The median PFS in the subgroup of patients who responded to lenvatinib therapy (with a complete and partial response) was 32.5 months (95 % confidence interval 30.7-37.7). The median overall survival at the time of data analysis was not reached.Conclusion. A comparative analysis showed that the approach to the treatment of patients with progressive radioyod-refracted differentiated thyroid cancer based on continued radioiodine therapy is wrong. It was the only impelled option when tyrosine kinase inhibitors therapy for differentiated thyroid cancer was unavailable. Currently, the majority of patients with progressive radioyodrefracted differentiated thyroid cancer receive lenvatinib in the first line targeted therapy. The role of this therapy in the treatment of patients with radioyodrefracted differentiated thyroid cancer is currently increasing. The promising prospects for the synthesis of new targeted drugs are becoming obvious, such as the need for further research and comparison of drugs already in use as well.

AIM OF STUDY To identify risk factors for adverse outcomes of surgical treatment of patients with HS.MATERIAL AND METHODS A retrospective analysis of the results of surgical treatment of 500 patients operated on at the N.V. Sklifosovsky Institute from 1997 to 2020 for hypertensive intracerebral hematomas. The mean age of the patients was 53.1±12.2 years. There were 335 (67%) men and 165 (33%) women.The level of consciousness before the operation was clear in 176 (35.2%), stupor (11–14 score, GCS) — in 258 (53.6%), sopor (score 9–10, GCS) — in 38 (7.6 %), moderate coma (7–8 score, GCS) — in 10 (2%) patients, deep coma (score 6) — in 7 (1.4%) patients. ICHs were lobar in 218 (43.6%) patients, lateral in 212 (42.4%) patients, thalamic in 10 (2%) patients, mixed in 10 (2%) patients, cerebellar in 50 (10% ) patients. The average volume of ICH was 46.5±25.1 cm3, supratentorial ICH – 49.6±24.5 cm3 (from 4 to 147 cm3), subtentorial — 18.7±6.4 cm3 (from 5 to 36 cm3). The average duration of the surgical intervention was 3.3±2.6 days. The following types of operations were performed: open removal of the ICH in 271 (54.2%) patients, puncture aspiration and local fibrinolysis of the ICH in 98 (19.6%) cases, endoscopic aspiration of the ICG in 131 (26.2%) patients.RESULTS The risk factors for lethal outcome in HT surgery are the age of patients older than 50 years (χ2=13.9, p

ABSTRACT Nowadays surgical treatment of patients with traumatic intracranial hematoma (TICH) and injuries of the brain is a very actual problem in neurosurgery.The purpose of this work was to assess of the feasibility and safety of minimally invasive endoscopic removal of TICH.MATERIAL AND METHODS In the period of 2010–2019, 2734 operations were performed on patients with traumatic brain injury in the Sklifosovsky Research Institute. There were 334 patients with TICH and the CC/BC foci, that made 12.2% of all patients. The median of hematoma volume, that did not cause a loss of consciousness was 48 cm2, and in most of the patients the hematoma volume ranged 30–35 cm2. Local fibrinolysis of TICH was performed in 14 patients with the hematoma volume of 30–50 cm2 without brain dislocation and not causing the consciousness depression more severe than sopor.Endoscopic removal of TICH was performed in 4 men at mean age of 54.8 years within 18–36 hours after trauma. Three patients had depression of consciousness to obtundation (14 by Glasgow Outcome Scale (GCS)), and one patient was in clear consciousness. The volume of the dense part of the contusion foci in the pole-basal regions of the frontal and temporal lobes was 24–40 cm3.RESULTS Among patients with TICH operated on by using the traditional technique, postoperative lethality was 13%, good outcomes were seen in 41%, and 46% had neurological disorders of varying severity. While treating the patients with TICH by using the local fibrinolysis method, 1 patient died after surgery, a good outcome was seen in 8 of 14 patients, and neurological disorders persisted in 3 patients in the postoperative period.Radicality of surgery in patients operated on by using endoscopic technique averaged 76% ranging from 41% to 91%. There were no complications during surgery nor in post-operative period. Patients were discharged from hospital after 8-21 days.

Radioiodine therapy for differentiated thyroid cancer has been used for a long time, mainly in patients of intermediate and high risk, as well as in the presence of distant metastases. However, about 30–40 % of patients are refractory to radioiodine therapy, which significantly worsens the prognosis. In patients with radioiodine-refractory differentiated thyroid cancer, therapy with targeted agents, primarily tyrosine kinase inhibitors, is indicated.This review addresses the criteria for refractoriness and criteria for prescription of targeted therapy, and presents the results of clinical studies of the targeted agents used. As of today, lenvatinib is the most well-known targeted agent. In particular. In SELECT trial lenvatinib demonstrated efficacy in terms of progression-free survival and overall survival in patients with radioiodine-refractory differentiated thyroid cancer. As a result, lenvatinib was included in the international and Russian clinical guidelines for the management of this group of patients as a drug of the 1st line of targeted therapy.

Carotid stenosis is a multidisciplinary problem that requires the involvement of a specialists’ team, including cardiovascular surgeons, neurosurgeons, endovascular surgeons, cardiologists, neurologists, and internists. In this consensus statement, a group of experts considered the main stages of diagnosing carotid stenosis, as well as discussed, the necessary prevention methods and features of choosing the optimal treatment approach. The aim was to provide concise and structured information on the management of patients with carotid stenosis. This document was developed based on the updated clinical guidelines of the European Society for Vascular Surgery and the American Association for Vascular Surgery, taking into account the consensus opinion of Russian experts.

The influence of the consequences of aneurysmal subarachnoid hemorrhage on the human body in the long-term period has been insufficiently studied. Most studies indicate a high risk of developing cognitive impairment. Until now, there is no unified algorithm for the management of patients with aneurysmal subarachnoid hemorrhage, who need long-term comprehensive rehabilitation and supervision of specialists in various fields.Aim of study. To study the influence of the nature, severity, features of the clinical manifestation of aneurysmal subarachnoid hemorrhage, as well as the choice of the method of intervention in the acute period of the disease on the long-term results of treatment of aneurysms.Material and methods. In the presented study, the observation group included 74 patients who were operated on in the emergency neurosurgery department of the N.V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health Department from 2013 to 2019 in the acute period of subarachnoid hemorrhage (during the first 14 days after the rupture of the cerebral aneurysm). The average age of patients at the time of surgery was 47 [Me=46; min=27; max=76] years old. The ruptured aneurysm was turned off from the bloodstream by one of the following methods: microsurgical intervention with the application of a clip to the aneurysm neck (50 (67,6%) patients), the simultaneous open intervention of aneurysm clipping, and the formation of an extra-intracranial micro anastomosis from the side of the aneurysm access (8 (10,8%) patients), endovascular exclusion of the cerebral aneurysm from the bloodstream (16 (21,6%) patients). On average, after 2,4 [Me=2,5; min=1; max=6] years, patients were invited for a clinical and neurological examination, which included testing according to the Modified Rankin Scale (MRS), the Bartel Index questionnaire, the Mini-Mental Status Scale (MMSS), and the Hospital Anxiety and Depression Scale (HADS). We analysed the changes in the professional activity and habitual lifestyle of patients, as well as the influence of the most common risk factors: arterial hypertension, diabetes mellitus, smoking, on long-term outcomes.Results. In the long-term period of surgical treatment of cerebral aneurysms, on average after 2,4 [Me=2,5; min=1; max=6] years after subarachnoid hemorrhage, 30 (40,5%) patients scored 0 points on the Modified Rankin Scale, 27 (36,5%) patients — 1 point, 6 (8,1%) patients — 2 points, in 6 (8,1%) patients — 3 points, in 4 (5,4%) patients — 4 points and in 1 (1,4%) patient — 5 points. A significant dependence of the degree of disability according to the modified Rankin scale in the long-term period of subarachnoid hemorrhage on the severity of the patient’s condition at discharge from the hospital was revealed according to the Glasgow Outcome Scale (p˂ 0,001). The patient’s age at the time of rupture of the aneurysm independently influenced cognitive functions and the ability to self-care in the long-term period. With an increase in age by 1 year, the score on the short scale of mental status and on the Bartel questionnaire decreased by 0,08 (p=0,03) and by 0,3 (p=0,04), respectively. With the simultaneous presence of intracerebral hemorrhage and the severity of subarachnoid hemorrhage corresponding to grade III according to the Fisher classification, the likelihood of developing anxiety and depressive mental disorders according to the hospital scale of anxiety and depression increased significantly (p˂ 0,01). The development of intracerebral hematoma with aneurysmal hemorrhage contributed to the appearance of hypertension (p˂ 0,01). The development of intracerebral hematoma with aneurysmal hemorrhage contributed to the appearance of hypertension (p˂ 0,05).Conclusion. The revealed disorders that persist for several years after the intervention indicate the need for long-term follow-up of patients who underwent intervention for subarachnoid hemorrhage, the development of individual programs for physical and psychological rehabilitation, and clinical examination of persons at high risk.

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.

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.

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.

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 correlation 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.

Lateral approaches (standard subtemporal and a number of lateral and combination basal approaches) ensure access to the clivus, petroclival area, cerebellopontine angle (CPA), and lateral and posterolateral portions of the cavernous sinus. The complexity of surgeries performed via lateral approaches is attributed to the topography of the skull base, location of the sites where the vein of Labbe unites with large veins of the mediobasal surface of the brain, draining the lateral and basal surface of the temporal lobe into major venous collectors. The vein of Labbe and veins draining the temporal lobe are located in the area of operational axis and significantly limit or hinder active traction of the brain. Therefore, preservation of these veins is crucial in surgeries via lateral approaches. The location of sites where the veins draining the temporal lobe and lower anastomotic vein of Labbe unite with sinuses may vary. Therefore, the study of microsurgical anatomy of the veins draining the temporal lobe and vein of Labbe is an important aspect of skull base surgery.

Surgical treatment of craniospinal disorders and craniovertebral junction disorders is one of the most challenging problems in neurosurgery, because the pathological process involves the brain stem, cerebellum, cranial nerves of the cerebellopontine angle (CPA), spinal nerves, vertebral artery (VA) and its branches, basilar artery (BA) and its branches, bone structures, as well as joints and ligaments of the craniovertebral junction. Various approaches are used to get the access to the craniovertebral junction and foramen magnum, including the far-lateral approach analyzed in this article. The choice of surgical approach depends on the spread of pathological process.

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.

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.

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.

This article devoted to the diagnosis of intracranial hypertensionin patients with intracranial hemorrhages. The persistentincrease of intracranial pressure leads to disruption of cerebralperfusion, brain edema and ischemia. In this regard, fast correctionof intracranial hypertension is one of the importanttasks of intensive care patients with intracranial hemorrhages.The paper details the modern principles of measuring intracranialpressure.

The review is dedicated to the problem of secondary brain injurymanagement in patients with severe traumatic brain injury andnontraumatic intracerebral hemorrhage. Literature data on secondaryischemic factors impact on the cerebral blood flow, cerebraloxygenation and metabolism was analized. Special attentionwas spared on the different methods of intensive care in secondarybrain injury management.

Results of treatment of 54 patients: 43 female with breast cancer and 11 males with prostatic cancer with metastatic bone disease treated with using Sm-153 are assessed. According to semi-quantitative analyze of WB bone scans the most effects results were found in a group of patients who received combined therapy and there where regression of osteoblastic bone metastases in 84,2% of cases, progression is in 7,8%, the same number of patients had simultaneous process: progression and regression. However in patients who were treated with using Sm-153 oxabifore as mono therapy regression of bone metastases was found in 68% of cases, progression is in 25% of the patients and stabilization of metastatic bone disease is in 6,25% of cases.

The paper deals with the assessment of cerebral perfusion in patients in the acute period of acute cerebrovascular accident before and after revascularization surgery. It gives a clinical example of using contrast-free perfusion magnetic resonance imaging (MRI) in a patient with hemodynamic ischemic stroke. The use of this technique made it possible to determine indications for early carotid endarterectomy for the contralateral internal carotid artery and to evaluate positive postoperative changes in cerebral perfusion and the patient’s neurological status. The authors analyzed the current literature on this problem with a particular emphasis on the possibilities of using dynamic susceptibility contrast-enhanced and arterial spin-labeling contrast-free perfusion MRI in this category of patients. Carotid endarterectomy in the acute period of acute cerebrovascular accident can improve cerebral hemodynamics and the patient’s neurological status and prevent recurrent cerebral circulatory disorders. Indications for this surgery should be determined by taking into consideration the results of perfusion MRI techniques (single-photon computed tomography contrastenhanced and contrast-free perfusion MRI).

ABSTRACT. Cerebral vasospasm (CV) is an urgent issue in the treatment of patients with severe traumatic brain injury (STBI).OBJECTIVES. The aim of this study was to evaluate the effect of cerebral vasospasm on outcomes of STBI.MATERIAL AND METHODS. The study included 43 patients with isolated and assocoated STBI. The depression of consciousness in patients upon admission was 8 or less according to the Glasgow Coma Scale (GCS).RESULTS. Cerebral vasospasm was revealed in 33 (77%) patients. Groups were comparable according to age, type of TBI, GCS and average AP upon admission to hospital. The analysis of the disease outcomes according to GOS revealed significant between-group differences in the assessment of favorable outсomes (score 4–5, GOS), unfavorable outcomes (score 2–3, GOS) and deaths. In patients without CV and with moderate CV, the rate of cases with GOS 1 and GOS 2–3 was 30% (n=3) and 31% (n=5), respectively, and in patients with significant CV it was 82% (n=14).CONCLUSION. The development of significant cerebral vasospasm in patients with severe traumatic brain injury results in increased mortality by 21% and recovery with adverse neurological outcomes by 31%. The post-traumatic CV may cause secondary ischemic brain damage, resulting in considerable disturbance of cerebral oxygenation.

Abstract. Increased intracranial pressure results in cerebral blood flow decrease and cerebral edema formation. Correction of intracranial hypertension is one of the most important goals of intensive care in patients with severe traumatic brain injury. Objectives To determine the effects of L-lysine aescinat on ICP in patients with severe TBI.Material and methods. Twenty patients with TBI and Glasgow coma scale below 9 enrolled in the study. All patients were operated: 6 patients underwent craniotomy and intracranial hematoma removing; 11 — decompressive craniotomy and intracranial hematoma removing. In 3 patients only ICP-sensor was implanted. ICP-monitoring was used in all patients. Ten patients were randomized to L-lysine aescinat treatment (daily dose of 20 ml for 7 days after surgery) (study group), 10 — to standard therapy (control group). We perfomed a comparative analysis of the mean ICP and the incidence of ICH within 7 days after surgery in the study and control groups.Results. The length of ICP monitoring was 6.4±3.7 days: in the control group — 7.6±4.9 days, in the study group — 5.2±1.4 days. Mean intracranial pressure was less in the study group as compared to patients in the control group. The number of intracranial hypertension episodes was higher in the control group compared with patients who received L-lysine aescinat.Conclusion. L-lysine aescinat treatment in patients with severe traumatic brain injury is accompanied by reduction of mean intracranial pressure and the number of intracranial hypertension episodes.

Nowadays treatment methods of severe traumatic brain injury - state of the problem in the neurosurgery department of the Sklifosovsky Research Institute for Emergency Medicine.Surgery of traumatic brain injury (TBI) is the principal direction of research activities in the neurosurgery department of the Sklifosovsky Research Institute for Emergency Medicine.With a view to produce an unified approach in treatment patients with TBI, in the neurosurgery department brain injury practical classifications have been designed. Using neurological examination and CT data they allow to diagnose and determine a severity of TBI.The conducted at the department researches allowed to clarify the indications to surgery and nonoperative treatment in patients with posterior cranial fossa injury and small intracranial hematomas. For the first time in Russia there was organized and carried out the randomized trial which was dedicated to the choice of surgery (decompressive craniectomy or craniotomy) in severe TBI. There were identified risk factors of adverse outcomes in patients with severe TBI.There was worked out and embedded in daily practice the new original minimally invasive method of TBI surgery — the puncture aspiration and local fibrinolysis of traumatic intracranial hematomas. In surgery of subacute and chronic hematomas as well as in surgery of traumatic intracranial hematomas which are located in functionally significant regions of the brain, the endoscopy is being used actively. This method allows to reduce damages of surgical approach and keep its radicality. At the present time the researches is being conducted which are dedicated to surgery of acute brain herniation syndrome. Using original tools the minimally traumatic methods of tentorium and falx cerebri incisions were designed as well as the decompressive craniectomy in combination with lower medial temporal resection were developed.Application of new technologies in diagnosis and treatment in patients with TBI as well as introduction in routine practice new types of surgery allowed to decrease noticeably postoperative mortality in operated patients with severe TBI.

ABSTRACT. The paper presents the modern principles of intensive care of patients with subarachnoid hemorrhage after cerebral aneurysms ruptures focusing on neuromonitoring, mechanical ventilation, intracranial pressure and hemodynamic correction, calcium antagonists prescription, hyperbaric oxygen therapy, nutritional support, thromboembolic complications prevention and infection complications management.

ABSTRACT. This article describes the current trends concerning diagnostics and treatment of spinal trauma as well as tumors and diseases of vertebra column and spinal cord. The assessment of computer tomography and magnetic resonance imaging capabilities to reveal various pathologies of vertebra column and spinal cord is given. The clinical cases of usage the minimally invasive, endoscopic and transcutaneous technologies for treatment of various spinal pathologies are presented.

ABSTRACT. The article is dedicated to the problem of nontraumatic intracranial hemorrhage surgery. Principal concern was given to the contemporary aspects of target and urgent diagnostics of vascular pathology of the brain, being the cause of hemorrhage, and ischemic complications detection. Modern surgical technologies applied for surgical treatment of patients with intracranial hemorrhages are described and surgical results achieved in Sklifosovsky Research Institute are represented.

BACKGROUND The hypercatabolism syndrome may occur in critically ill patients after the intracranial hemorrhage. Mixed enteral and parenteral nutrition is used to provide nutrition support.MATERIAL AND METHODS We observed 20 patients with intracranial hemorrhage and consciousness score up to 13 (the Glasgow Coma Scale) in the early postoperative period.RESULTS Administration of parenteral mixture (“three-in-one”) was followed by the progressive growth of transferrin concentration and did not lead to the signifi cant increase of triglycerides concentration in the blood serum. We also noted that the parenteral nutrition lead to the increase of malonedialdehyde (MDA) in the blood serum above normal levels, but the total serum antioxidant activity was normal.CONCLUSION The 3-component mixture that contains polyunsaturated fatty acids omega 6/omega 3 — 2.5:1 and olive oil, administered to critically ill patients after intracranial hemorrhage, improves protein metabolism indicators and sustains lipid peroxidation and antioxidant activity in the blood serum.

Objective: to determine the impact of aneurysm of intracranial arteries on cerebral collateral circulation and to assess the relationship between these changes and the site of the aneurysm.Material and methods. CT perfusion and CT angiography were performed in 41 patients with 47 unruptured intracranial aneurysms of different sites and sizes.Results. Impaired perfusion was not found in the majority of the patients with intracranial aneurysms less than 15 mm in diameter. Hypoperfusion in the respective temporal and occipital lobes was noted in 70% of patients with aneurysms greater than 16–25 mm. Generalized hypoperfusion was diagnosed in 100% of patients with aneurysms more than 25 mm, with the partially thrombosed aneurysms accompanied by the severer, irreversible deficit immediately around the aneurysmal sac, which was induced by the effect of volumetric exposure while in the presence of unthrombosed aneurysm, hypoperfusion occasionally involved the cortex of the entire hemisphere. In this investigation, the extent and depth of hypoperfusion depended on the thrombosis of the lumen and the size of an aneurysm rather than the site of the latter.Conclusion. CT perfusion may be recommended as a standard examination of patients with detected intracranial aneurysm that is 16 mm or more in size for the timely diagnosis of cortical microcirculatory disorders and collateral circulatory insufficiency, which can affect the choice of a treatment option for the patient

INTRODUCTION. The development of prognostic criteria in brain trauma associated with extracranial injuries is necessary for treatment results definition, getting of priority rating, establishment time and volume of care, for active management of clinical process and timely complications warning.PURPOSE. To determine outcomes and predictive value of risk factors in patients with brain trauma associated with extracranial injuries in-hospital stage of medical care.MATERIAL AND METHODS. Retrospective analysis was performed in 1634 patients who were underwent surgery due to severe traumatic brain injury (TBI). There were 22,1% patients with brain trauma associated with extracranial injuries. Using statistical analysis we determined relationships between outcomes and clinical and instrumental signs, obtained during the examination of patients.RESULTS. The extracranial risk factors in patients with brain trauma associated with extracranial injuries were: ISS 40 and over, multiple extracranial injuries, spinal or abdominal injury, age 70 and over, arterial hypoxemia and hypotension, complications in postoperative period. The intracranial risk factors were: GCS score 12 and less, oculomotor nerve dysfunction, abnormal pupil reactivity, pathological motor responses or diffuse muscular tone reducing, brain herniation at the stage of midbrain or pons clinically, brain lesions volume over 90 cm3 , lateral dislocation over 10 mm, absence of basal cisterns on CT scan, VCC-2 less than 8%, brain expansion during surgery.CONCLUSION. Prognostic criteria identified by statistical analysis can be used to assess outcome prognosis at the early stages of medical care in patients with brain trauma associated with extracranial injuries.

Scales have been developed for determination of size of austenite grain of high carbon patented steel, austenite graine sizes have been researched.

The results on investigations on the problems of metal cord production are given. The matters connected with generation of single-phase corrosion-resistant brass covering, breakages at laying and plasticity after low-temperature processing are considered.

Coronary angiography was performed in 90 patients with acute non-Q wave myocardial infarction (non-Q MI) - 68 men and 22 women aged 32-78 years (mean age 64,5±2,2 years). Endovascular intervention included transluminal angioplasty and/or coronary artery stenting, with balloon catheters and B x Sonic stents (Johnson and Johnson Corp.). All patients received standard therapy of aspirin, beta-blockers, ACE inhibitors, anticoagulants, and clopidogrel. For patients with non-Q MI, one-vessel coronary artery pathology was most typical; two- and three-vessel pathology prevalence was similar. In 8,9 % of the cases, no hemodynamically significant coronary artery pathology was observed.

No abstract.

Objective: to assess the time course of changes in the parameters of cerebral oxygenation and metabolism in the correction of intracranial hypertension with hyperosmolar solutions. Material and methods. 39 episodes of elevated intracranial pressure correction with 15% mannitol solution and HyperHAES solution were analyzed in 9 patients with intracranial hemorrhages. Changes in intracranial pressure and systemic hemodynamic, cerebral oxygenation, and metabolic parameters were studied. Results: A great difference was found in the effects of the test solutions on intracranial, cerebral perfusion pressure, and cerebral metabolism. Administration of 15% mannitol solution caused no cerebral metabolic changes. Infusion of HyperHAES solution induced a significant elevation in the concentrations of glucose and pyruvate in the interstitial fluid of both the arbitrarily intact and afflicted cerebral matter. Conclusion: The administration of 15% mannitol solution and HyperHAES solution is an effective method for correcting intracranial hypertension; however, the use of HyperHAES solution results in a more prolonged decrease in intracranial pressure, an increase in cerebral perfusion pressure, and an improvement of cerebral metabolism. Brain lesion due to intracranial hemorrhage may be accompanied by the development of mitochondrial dysfunction. Key words: intracranial hypertension, intracranial pressure, hyperosmolar solutions, tissue microdialysis.