[Repeated tracheal resection for non-neoplastic restenosis].

Treatment of patients with recurrent cicatrical tracheal stenosis after previous circular tracheal resection is one of the most difficult problems in thoracic surgery at present time. In most cases repeated radical surgery as new resection is declined in favour of palliative treatment. It is often associated with lingering or perpetual preserving of T-shape or tracheostomy tube and respiratory tract stenting. Development of thoracic surgery last years permits to perform repeated tracheal resections with restoration of respiratory tract integrity by using of new tracheal anastomosis. For the last 4 years 6 such operations were performed with satisfactory immediate and remote results. Diagnostic algorithm before repeated surgery is similar to those before primary intervention. Special attention should be attended to state of remained parts of respiratory tract, degree and length of stenosis and tracheomalacia which may be result of divergence of edges of the primary anastomosis. Preserving of not less than 1/4 primary length of intact trachea with its satisfactory mobility is main condition for this surgery because it will permit to perform new anastomosis without high tension. Risk of postoperative complications after repeated operations is not higher than those after primary resection. But at present time these operations are in competence of small number of specialists and medical institutions with serious experience in thoracic surgery.

[Venous thromboembolic complications in patients with intracranial hemorrhage and tumors of the central nervous system].

It was analyzed the results of diagnosis and prevention of venous thromboembolic complications in 248 patients with intracranial hemorrhages of different etiology (hemorrhagic stroke, subarachnoid hemorrhage, craniocerebral injury, hemorrhages in the tumors of brain and spinal cord). The overall frequency of venous thrombosis in the vessels of the inferior vena cava pool was 24.6% (in 61 patients), the majority of patients had the asymptomatic thrombosis. The crural veins were the main localization of venous thrombosis. Also it was the main origin of thromboembolic complications (60.7%). Surgical treatment in different amount was an independent predictor of venous thromboembolic complications in neurosurgical patients according to the multivariate variance analysis. The frequency of thrombosis was significantly higher in the group of operated patients in comparison with non-operated group (37.1 vs. 17.6% (p=0.008). Early prevention by geparin (the use of direct anticoagulants for 2-4-th day of the founding of an intracranial hematoma) did not reduce the frequency of venous thrombosis in operated patients, but significantly reduced the frequency of fatal pulmonary embolism: 0 vs. 9.1% (p=0.002). Patients with intracranial hemorrhage are the one of the most unfavorable groups in terms of their venous thromboembolic complications.

[Dynamics of intracranial pressure in patients with massive ischemic stroke after decompressive craniotomy].

The goal of the study was assessment of the value of ICP monitoring in patients with massive ischemic stroke after decompressive craniotomy. 12 patients with massive ischemic stroke were performed ICP monitoring after decompressive craniotomy. We identified 3 types of ICP dynamics: a) normal ICP, which no need to treat; b) ICP elevation to 20 mm Hg and more in postoperative period, which can be treated by nonsurgical therapy; c) refractory to therapy ICP elevation to 20 mm Hg and more with development of intracranial hypertension. We consider that ICP monitoring in patients with massive ischemic stroke after decompressive craniotomy can be useful for optimization of the therapy and correction of intracranial hypertension.

[Severe thrombotic complications in the postoperative period in a child after removal of craneopharyngeoma].

The paper describes a rare clinical case of severe thrombotic complications (thrombosis of the subclavian, superior vena cava and femoral veins) of the child in the postoperative period, after removal of craniopharyngeoma. The development of complications was diagnosed based on clinical symptoms and results of ultrasound. Genesis of thrombotic complications has been clarified with the help of special hemostasiological studies that confirmed the presence of acquired protein S deficiency. The matters of discussion are the problems of diagnosis and therapy of this complication.

[Assessment of brain neural pathways in diffuse axonal injuries using diffusion-tensor magnetic resonance tomography].

BACKGROUND: Aim of this study was to assess the role of diffusion-tensor magnetic resonance imaging (DT-MRI) in diagnosis and prognosis in severe diffuse axonal injury (DAI). MATERIALS AND METHODS: The studies using 1.5 Tesla MR tomograph were performed on 2nd-17th days after injury in 22 patients with DAI and in 8 healthy volunteers. All patients were comatose in acute period (GCS 4-8), 11 had hemiparesis and in 4 had tetraparesis. Outcomes were evaluated after 6 months using GOS. Indices of diffusion coefficient (DCI) and fraction anisotropy (FA) were assessed bilaterally: in genu and splenium of corpus callosum, posterior limb of internal capsule (PLIC), cerebral peduncles, at the level of pons (along corticospinal tracts (CST). RESULTS: Significant decrease of FA (p < 0.05) along CST bilaterally was found in 7 patients without movement disorders comparing to analogous indices in the control group. Also statistically significant decrease of FA at the level of PLIC and cerebral peduncles was observed on the contralateral side in patients with hemiparesis (p < 0.01). In patients with tetraparesis FA was significantly decreased along CST bilaterally (p < 0.00001). Indices of FA in corpus callosum and along pyramidal tracts significantly correlated with outcomes in patients examined on 10th-17th day after injury (p < 0.01). In the whole group of patients mean indices of FA and DCI in the splenium of corpus callosum were significantly decreased (p < 0.01 and p < 0.05, respectively). 3D reconstruction of CST allowed to discover asymmetry of CST in 3 of 9 patients with hemiparesis on 1st-9th day after injury and in all 6 patients examined on 10th-17th day. CONCLUSION: Indices of FA reflect the degree of integrity of white matter pathways with significant accuracy. Application of DT-MRI allows to reveal quantitative and qualitative alterations in white matter tracts and to assess their clinical and prognostic value in DAI.

[Treatment and prevention of thromboembolism in patients with intracranial hemorrhage].

Frequency of venous thromboses and thromboembolic complications was retrospectively analyzed in 95 patients with intracranial hemorrhage of various etiology. Thrombosis of inferior caval vessels was registered in 19 (20%) patients; of them 3 patients had thromboembolism of a pulmonary artery, lethal in one case. The high frequency of venous thromboses indicates the necessity of early use of anticoagulants in treatment dosages and importance of the prophylaxis measures. Cava-filter implantation for pulmonary artery thromboembolism prevention should be considered only in patients with strong contraindications for anticoagulant therapy.

[A case of early postoperative posttransfusion-associated lung injury (TRALI) in a female patient with giant intracranial meningioma and massive intraoperative blood loss].

The paper describes a case of the relatively rare complication transfusion-associated lung injury (TRALI) in the early postoperative period in a female patient who has experienced intraoperative massive blood loss and blood transfusion. It also considers the causes of this complication, its clinical symptoms and differential diagnosis, as well as a package of therapeutic measures and possible lines of prevention.

[Intraoperative and early postoperative complications of puncture-dilation tracheostomy in neurosurgical patients].

The paper provides a detailed analysis of the most common and clinically significant complications due to percutaneous dilation tracheostomy performed in 479 patients with neurosurgical diseases in 2002-2007. It also considers such complication of the technique, which is specific to neurosurgical patients, as elevated intracranial pressure (ICP), and describes a procedure of tracheostomy in patients with elevated ICP. Percutaneous dilation tracheostomy made by a skilled surgeon is shown to be effective and safe.

[Transcutaneous dilation tracheostomy in children].

The paper presents the experience of transcutaneous dilatation tracheostomy (TDT) in 16 children. Up to date, childhood has been a contraindication for TDT. The experience gained at the Department of Resuscitation, Institute of Neurosurgery, in performing TDT in more than 300 adult patients has permitted this procedure to be also used in childhood. Based on the analysis of the outcome of 16 TDTs, the authors have posed indications for TDT, its performance modification, approaches to preventing perioperative complications, by taking into account the anatomic and physiological characteristics of childhood.

[Transcutaneous dilation tracheostomy in the acute period in patients with penetrating craniofacial injury complicated by intracranial hypertension].

Early tracheotomy is well founded in severe brain injury involving the facial skeleton and skull case. Intracranial hypertension interferes with the safe performance of an operation. The authors developed a procedure for safe paracentetic dilatation tracheostomy (PDT) in the acute phase of severe brain injury. The study covered 15 patients with severe brain craniofacial injury. Surgery was made under intravenous anesthesia (with hypnotics, myorelaxants, narcotic analgesics, and cholinolytic agents). PDT was performed by the combined procedure developed by Sigley and Griegse ("Portex and COOK") under endoscopic guidance (Karl Storz 11001 BN1), by displaying the images. The patient is put to bed, without placing a bolster under the shoulders, the bed head end being elevated at an angle of 30 degrees. Bronchoscopic monitoring was made discretely (20-60 sec) under artificial ventilation through a special connector. There were 3-6 sessions of bronchoscopies. Tracheostomy lasted as long as 24 hours in 5 patients, 48 hours in 12 patients; surgery was made in 7 patients on day 3 after injury. Prior to tracheostomy, a horizontalization test was conducted, which revealed an elevation of intracranial pressure (> or = 20 mm Hg). There were no episodes of intracranial hypertension during tracheostomy. PDT can be safely made in patients with intracranial hypertension when they are put to bed, without placing a bolster under the shoulder, the bed head end being elevated at an angle of 30 degrees under discrete bronchoscopic guidance.

[Early tracheostomy in patients with tumors in the posterior cranial fossa during postoperative period]. / Ranniaia trkheostomiia u bol'nykh s opukholiami zadnei cherepnoi iamki v posleoperatsionnom periode.

Analyzed in the paper is the early postoperative management of 50 neurosurgery patients operated on the structures of the posterior cranial fossa, primarily, in as far as the respiratory problems and their solution by early tracheostomy are concerned. A classification of indications for early tracheostomy as well as an algorithm of the management of such patients are described.