[Surgical treatment of focal drug-resistant epilepsy associated with temporal lobe encephalocele]. / Khirurgicheskoe lechenie patsientov so strukturnoi fokal'noi farmakorezistentnoi epilepsiei, assotsiirovannoi s visochnymi entsefalotsele.

BACKGROUND: In recent years, temporal lobe encephalocele has become more common in patients with focal drug-resistant epilepsy. Despite available experience, there are still no clear recommendations for choosing the extent of surgery in these patients. OBJECTIVE: To evaluate the effectiveness of diagnosis and surgical treatment of focal drug-resistant epilepsy associated with temporal lobe encephalocele. MATERIAL AND METHODS: The study included 21 patients with focal temporal lobe epilepsy and temporal lobe encephalocele. All patients underwent continuous video-EEG monitoring and MRI of the brain. There were 12 (57.4%) selective encephalocele resections and 9 (42.6%) anterior temporal lobectomies. The median follow-up period was 31 months. RESULTS: The overall effectiveness of surgical treatment with postoperative Engel class I was 76% (16 cases). Selective encephalocele resection was followed by postoperative Engel class I in 10 patients (83%). There were 6 (67%) patients with similar outcomes after temporal lobectomy. Mean volume of resected tissue adjacent to encephalocele was 8.3 cm3. CONCLUSION: Surgery is a highly effective treatment for patients with epileptic seizures following temporal lobe encephalocele. In our sample, favorable postoperative outcomes were achieved in 76% of patients (Engel class I). There were no significant differences in effectiveness between selective resection and temporal lobectomy. Further research is necessary for a clear protocol of surgical treatment of focal drug-resistant epilepsy associated with encephalocele.

[Epileptic syndromes associated with focal clonic seizures]. / Epilepticheskie sindromy, assotsiirovannye s fokal'nymi klonicheskimi pristupami.

OBJECTIVE: To study clinical, electroencephalographic and neuroimaging features in children with epileptic syndromes associated with focal clonic seizures (FCS). MATERIAL AND METHODS: We examined 1258 patients with various forms of epilepsy with the onset of seizures from the first day of life to 18 years. RESULTS: FCS was identified in 263 patients (20.9%). FCS were included in the structure of 13 different epileptic syndromes: Rolandic epilepsy (28.1%), structural focal epilepsy (27.5%), structural focal epilepsy associated with benign epileptiform discharges of childhood (SFE-BEDC) (20.6%), focal epilepsy of unknown etiology (7.5%), epilepsia partialis continua (4.6%), pseudo-Lennox syndrome (3.4%), ESES syndrome (2.7%), Landau-Kleffner syndrome (1.5%), Dravet syndrome (1.1%), benign occipital epilepsy (1.1%), benign focal epilepsy in infancy (0.8%), MISF syndrome (0.8%), cognitive epileptiform disintegration (0.8%). In 50% of cases, epilepsy associated with FCS debuts before the age of 5 years (from 1 month to 18 years, average age 4.26±3.9). CONCLUSION: The groups of syndromes associated with FCS have different prognosis for remission of seizures. Prognostic predictors of seizure remission are: epileptic syndromes associated with BEDC, the presence of periventricular leukomalacia. A severe prognosis for the course of epilepsy is associated with local structural changes in the neocortex. Despite a favorable prognosis for seizures, continued diffuse interictal epileptiform activity with BEDC on the electroencephalogram is a predictor of the onset of cognitive impairment in children.

[The effectiveness of botulinum therapy of trigeminal neuralgia]. / Effektivnost' botulinoterapii pri trigeminal'noi nevralgii.

OBJECTIVE: To evaluate the treatment protocol with the use of onabotulinum toxin type A (botox) and the efficacy of a single botulinum therapy procedure for clinical manifestations in patients with trigeminal neuralgia (TN). MATERIAL AND METHODS: We studied 90 patients (57 women, 33 men), including 80 people with primary TN and 10 people with secondary TN. Then 20 patients with primary TN (11 women and 9 men, mean age 61.8 years) received local injections of onabotulinum toxin type A (botox). Clinical examination included taking anamnesis, assessment of pain on a visual analogue scale (VAS), assessment of the frequency of pain paroxysms, taking into account the average indicator (0 to 100 seizures during the day); neurosensory examination according to the developed protocol with the definition of pain, temperature, tactile sensitivity, the study of stimulus-dependent pain; MRI of the brain to diagnose neurovascular conflict. RESULTS: A month after the injections, the pain intensity practically did not change (8.5 versus 7.2 points on the VAS), but the number of paroxysms decreased (31.2 versus 22.5 seizures per day). Two months after the use of botox, the number of pain attacks continued to decrease (31.2 versus 17.7; Mann-Whitney U-test, p=0.006). At the same time, there was a decrease in pain intensity according to the VAS (8.5 versus 6.1, t-test 2.75 points; p=0.02). After three months, there was a decrease in the number of paroxysms from 31.2 to 9.2 (paired Student's test, p<0.001) and the severity of pain (8.85 versus 4.0 points on the VAS, paired t-test 3.95 points, p<0.001). There were significant differences in the average dose of carbamazepine (867.5 versus 670.8 after 3 months, t-test 196.7 mg, p=0.02). In TN patients who underwent destructive operations with exposure to the peripheral branches of the trigeminal nerve, signs of severe neurosensory deficit on the face and burning pain are added to the main symptoms, which corresponds to the clinical criteria of post-traumatic trigeminal neuropathy. CONCLUSION: Local injections of type A onabotulinum toxin (botox) are minimally invasive, safe and effective symptomatic therapy for patients with TN. Persistent sensory disturbances that develop in patients after destructive surgeries call into question the safety of these therapies for TN.

Postmortem MRI Characterization of Cadaveric Hypostases in Deceased Newborns.

Using postmortem MRI, we studied the features of the development of internal cadaveric hypostasis in dead newborns. Postmortem radiological and pathoanatomical examination of 62 bodies of newborns and infants who died at the age of 1.5 h to 49 days was carried out. After the death was ascertained, prior to MRI, the bodies were stored in a refrigerator at 4°C in the supine position. Depending on the duration of the postmortem period (2-72 h), all observations were divided into eight groups. Prior to autopsy, an MRI scan was performed in T1 and T2 standard modes, followed by analysis of the presence and severity of the gradient line of the intensity of the MR signal in the liver and lung tissue in the ventral (overlying) and dorsal (underlying) areas, as well as the presence of a gradient of the intensity of the blood signal in the heart cavity and in the aortic lumen. The main manifestations of cadaveric hypostasis in the liver and lungs are changes of the MR signal intensity in the ventral and dorsal regions with the appearance of a horizontal gradient of the MR signal intensity, which reflects the location of the body after death. In the heart cavity and in the aortic lumen, there is also a gradient of the blood signal intensity of various severity with the visualization of two or three of its layers. The revealed features of the MRI signal intensity and, accordingly, the presence of its horizontal gradient depended not only on the MRI mode of the study, but also on the studied organ and the duration of the postmortem period. This should be taken into account when analyzing the results of virtopsy and determining the links of thanatogenesis of dead newborns and infants.

Postmortem Computed Tomography Angiography of Newborns.

We propose an original method of postmortem computed tomography angiography of the body of a deceased newborn. The work is based on the analysis of the results of comprehensive postmortem computed tomography and pathological examination of 30 newborns, who died from congenital malformations. The key to a full-fledged postmortem radiation study using intravascular contrasting of deceased newborns and infants is the presence of vascular catheters established during life, as well as conducting it no earlier than 12 h and no later than 48 h after death. As a contrast agent, we recommend to use an iodine-containing water-soluble radiopaque drug containing at least 250 mg of iodine per 1 ml. The volume of contrast agent is calculated based on body weight, taking into account the general edema syndrome. The introduction of a contrast agent is carried out through vascular catheters in 3 stages in various positions of the body. The analysis of tomograms and 3D-reconstruction of blood vessels using their pseudocoloring allows accurate assessment of the topography of blood vessels with the possibility of separate study of the arterial and venous vessels, and to identify both congenital abnormalities of the heart and blood vessels, and their acquired pathology. CT angiography in some cases is superior to traditional autopsy in the diagnosis of blood vessel pathology. Postmortem CT angiography should be considered as an important stage of postmortem radiology in the structure of comprehensive pathological analysis of newborns and infants.

Postmortem MRI Evaluation of Maceration Degree of Deceased Fetus.

We studied the possibilities of postmortem MRI for assessing the degree of maceration and determining the duration of intrauterine fetal death. Postmortem radiological and pathoanatomic study of the bodies of 38 stillbirths who died antenatally (main group, n=31) and intranatally (control group, n=5), who were born at gestational periods of 22-40 weeks was performed. Before the autopsy, MRI was performed in standard T1 and T2 modes. The tissue of the liver, kidney, brain, femoral muscle, lung, and skin in the hip, abdomen, and skull were studied on T1- and T2-weighted images (WI), followed by calculation of the of MR signal intensity ratio in T2- and T1-WI (SIR). The duration of intrauterine fetal death was determined based on the results of autopsy and analysis of histological preparations. It was found that the calculated values of SIR depended on the evaluated organ and the duration of intrauterine fetal death. Unfortunately, the revealed dynamics of changes in SIR does not allow unambiguous assessment of the severity of maceration processes and, accordingly, the time of fetal death due to its non-linear nature. Nevertheless, the use of SIR indicators of several organs and areas of the body makes it easier to determine the duration of intrauterine fetal death and, hence, to clarify the links of thanatogenesis of the stillborn. The advantages of post-mortem MRI compared to autopsy include non-invasive nature of the study, the possibility of archiving and subsequent multiple delayed analysis of tomograms, as well as the speed of MRI analysis, in contrast to microscopic stage of pathological examination associated with the need to prepare histological preparations.

Complex Method of CT and Morphological Examination of Placental Angioarchitechtonics.

We propose an original method of complex assessment of the placental angioarchitechtonics based on computed tomography (CT) and morphological examination. A prerequisite condition of successful examination and assessment of the placental angioarchitechtonics is the pre-preparative stage including clearing of the placental and umbilical cord vessels from blood clots by placement of placenta into 10% hypertonic NaCl solution and then on a hygroscopic substrate. The major stage of this method is injection of contrast staining mixtures into the umbilical vessels followed by CT. The concentration of radiocontrast agent in water solution of gouache should be 70% for arteries and 15% for veins. The volumes of mixtures for contrast staining should be calculated according to the weight of the placenta. The contrast staining mixture was first injected into the catheterized unpaired umbilical vein, and then into both umbilical arteries. Each injection of the contrast staining mixture was visually inspected; then branching of the stained vessel was photographed and scanned by CT. The CT scans were used to construct 3D models of placental vessels and spectral color maps, which made it possible to examine the peculiarities of placental angioarchitechtonics, to identify and evaluate anastomoses of placental vessels, and to establish the type of these anastomoses.

Potentialities of Postmortem Magnetic Resonance Imaging for Identification of Live Birth and Stillbirth.

The potentialities of postmortem MRI for differential diagnosis of stillbirth and death of a live newborn are studied. The results of MRI and pathomorphological studies of autopsy material from 20 stillborns dead at weeks 22-40 of gestation (group 1) and 19 newborns dead at the age of 2 h to 36 days (group 2) are analyzed. Control group has been formed from 7 live newborns aged 1-7 days. Postmortem MRI provides an objective quantitative evaluation of the intensity of MR signal in various tissues and regions. Calculation of the proportions of MR signal intensities in the lung tissue and environmental air and/or pleural fluid and the respiration values promotes an objective differential diagnosis of stillbirth and death of a live newborn. These data are expected to facilitate clearing out the circumstances and the direct cause of death. However, postmortem MRI cannot completely replace autopsy with complex macroscopic and microscopic studies of organs and tissues.

Possibilities of Postmortem Magnetic Resonance Imaging for Evaluation of Anasarca in Newborns.

We studied the possibilities of postmortem magnetic resonance imaging (MRI) for evaluation of anasarca in newborns. Before the autopsy, MRI in T1 and T2 standard modes was performed, signal intensity tomograms in the subcutaneous tissue were analyzed, and tissue hydration index was calculated. Using 3D reconstruction, we determined the values of hydrothorax, hydropericardium, and ascites, as well as specific volumes of fluid in the abdominal and thoracic cavities. It has been established that postmortem MRI of deceased newborns provides objective quantitative assessment of anasarca, as well as absolute and relative volumes of hydrothorax and ascites, which improves the diagnostic capacities of pathoanatomical autopsy or forensic examination of a corpse and contributes to the determination of tanatogenesis. However, postmortem MRI cannot fully replace traditional autopsy that allows conducting complex macroscopic and microscopic analysis of organs and tissues.

[Hippocampal sclerosis: pathogenesis, clinical features, diagnosis, and treatment]. / Skleroz gippokampa: patogenez, klinika, diagnostika, lechenie.

Hippocampal sclerosis, also known as Ammon horn sclerosis or mesial temporal sclerosis, is usually associated with intractable epilepsy and characterized by specific patterns of neuronal loss and gliosis in the medial temporal lobe structures. Hippocampal sclerosis manifests clinically as epilepsy, often intractable epilepsy; in most cases, this condition is surgically treatable. As the most common histological diagnosis in adult patients subjected to epilepsy surgery, hippocampal sclerosis is characterized by complex pathogenesis and requires a multidisciplinary approach to its diagnosis and treatment. This article reviews the pathologic features, natural history, pathogenesis, and electroclinical and MRI signs of hippocampal sclerosis.

[Diagnostic approach in mechanical jaundice, complicated by purulent cholangitis]. / Diagnosticheskii podkhod pri mekhanicheskoi zheltukhe, oslozhnennoi gnoinym kholangitom.

Up-to-date high-informative non-invasive diagnostic methods were used in 54 patients with obstructive jaundice (OJ) complicated by purulent cholangitis (PC). Treatment-diagnostic algorithm can to improve results of diagnosis. This algorithm is the following: ultrasonic examination as a screening method; if a case of jaundice is unclear and obturation is prolonged magnetic-resonance tomography and magnetic-resonance cholangiopancreaticography are carried out; in block of a distal part of the common bile duct--spiral computed tomography with bolus amplification and duodenoscopy. Invasive diagnostic methods--endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography (PTCG) are performed in buit indications in possibility to perform lithextraction and effective endoscopic decompression or in the tumor of Vater's papilla in case of low block. PTCG is used in high block and finished by percutaneous transhepatic bile outflow. General diagnostic efficacy of the complex in OJ was 97.8%. Diagnostic algorithm permitted us to make diagnosis and to start treatment in 85% during 1-2 days after hospitalization. Bile ducts decompression as a main stage of PC treatment was performed in the first 2 days after hospitalization. Diagnostic quest was performed at the same time with therapy after detoxication and correction of hemostasis disturbances.