[Surgical treatment of intracranial aneurysms in acute period of hemorrhage in Hunt-Hess grade IV-V patients at Burdenko Neurosurgical Center between 2006 and 2020]. / Analiz rezul'tatov khirurgicheskogo lecheniya tserebral'nykh anevrizm v ostrom periode krovoizliyaniya u patsientov so stepen'yu tyazhesti Hunt­Hess IV­V v FGAU «Natsional'nyi meditsinskii issledovatel'skii tsentr neirokhirurgii im. akad. N.N. Burdenko¼ za 2006­2020 gg.

BACKGROUND: Management of patients in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V is still a complex and unsolved problem, especially regarding surgical treatment and various complications. OBJECTIVE: To analyze postoperative outcomes in patients undergoing surgery in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V between 2006 and 2020, as well as to assess various factors influencing treatment outcomes. MATERIAL AND METHODS: We analyzed 163 patients who underwent surgery within 21 days after aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V. All patients were divided into 2 groups depending on the period: 2006-2011 (group 1) and 2012-2020 (group 2). RESULTS: Mortality reduced from 28.6% in group 1 to 8.3% in group 2. At the same time, incidence of vegetative state (GOS grade 2) increased from 4.8% to 17.4%. Incidence of outcomes GOS grade 3 - 5 was similar. CONCLUSION: Large or giant aneurysm, repeated preoperative subarachnoid hemorrhage, intraoperative aneurysm rupture and prolonged temporary clipping can impair postoperative outcomes in patients with hemorrhage Hunt-Hess grade IV-V. External ventricular drainage, intraarterial injection of verapamil, intracisternal administration of calcium channel blockers and active surgical tactics improve postoperative outcomes and reduce mortality.

[Unruptured asymptomatic brain aneurysms: modern approaches to the choice of surgical method and treatment outcomes]. / Nerazorvavshiesya bessimptomnye anevrizmy arterial'nykh sosudov golovnogo mozga: sovremennye podkhody k vyboru khirurgicheskogo metoda i rezul'taty lecheniya patsientov.

BACKGROUND: In recent years, significant attention has been paid to preventive vascular neurosurgery. Treatment of unruptured asymptomatic brain aneurysms is one of the sections of this surgery. OBJECTIVE: To evaluate treatment outcomes in patients with unruptured asymptomatic brain aneurysms who underwent treatment chosen on the basis of criteria adopted at the Burdenko Neurosurgery Center. MATERIAL AND METHODS: There were 2814 unruptured asymptomatic brain aneurysms in 2334 patients for the period from 1995 to 2019. RESULTS: Microsurgical operations for unruptured asymptomatic brain aneurysms were performed in 64.9% of cases, endovascular procedures - in 35.1% of patients. Endovascular operations were usually performed for ICA aneurysms and posterior aneurysms of circle of Willis. Microsurgical operations were mainly performed in patients with aneurysms of anterior and middle cerebral arteries. Favorable outcomes (GOS grade V-IV) were obtained in most patients (98.3%). Incidence of severe complications was similar in both groups, mortality rate was 0.3% and 0.4%, respectively. CONCLUSION: Currently, there is a tendency towards annual increase in the number of surgeries for unruptured brain aneurysms. Anatomical and morphological characteristics of aneurysm should be considered to achieve favorable clinical results. At the same time, comprehensive analysis of each case and identification of individual risk factors will eliminate serious complications of surgical treatment.

[Surgical treatment of vertebral artery confluence aneurysms]. / Khirurgicheskoe lechenie anevrizm v oblasti sliyaniya pozvonochnykh arterii.

BACKGROUND: Aneurysms of vertebral artery confluence and proximal parts of basilar artery are extremely rare. They are usually combined with proximal fenestration of basilar artery. No timely surgical treatment of these aneurysms is associated with high risk of adverse outcomes, and their treatment is a challenge for neurosurgeons. MATERIAL AND METHODS: We analyzed postoperative outcomes in 17 patients with 21 aneurysms of vertebral artery confluence and proximal parts of basilar artery. RESULTS: Six patients with 10 aneurysms underwent microsurgical resection, 11 patients with 11 aneurysms - endovascular procedure. Persistent postoperative deterioration was observed in 5 (29.4%) patients: severe neurological symptoms (GOS grade 3) in 1 case (5.9%), minor bulbar disorders in 4 cases (23.53%). There were no lethal outcomes. CONCLUSION: According to our own and literature data, aneurysms of vertebral artery confluence are extremely rare. The risk of rupture of these aneurysms is extremely high. Endovascular approach is preferred in these patients. Microsurgical procedure is an acceptable alternative if endovascular surgery is impossible.

Intra-arterial Administration of Verapamil for the Prevention and Treatment of Cerebral Angiospasm.

From 2013 to 2017, at the Burdenko Institute of Neurosurgery, intra-arterial verapamil for treatment of cerebral vasospasm following intracranial hemorrhage after aneurysm rupture was administered to 35 patients (total 75 procedures). The age is from 8 to 77 years. All ruptured aneurysms were treated: in 26 cases with open approach-clipping-and in 9 cases with endovascular occlusion. The procedure was carried out from 0 to 11 days after the operation. Severity of spasm was assessed by angiography and TCDU. Efficacy of the administration was assessed by TCDU 1 h after the procedure and by clinical evaluation of the patient's condition. The dose of verapamil was 15-50 mg (on average 40 mg) per procedure/per carotid pool and depended on the data of TCDU and clinical and radiological picture. The procedure was performed repeatedly (1-5 times) according to the indications and depending on the patient's condition, with an interval of 24 h. The procedure was effective as a preventive measure for care of patients in the initial stage of cerebral ischemia and was ineffective with a formed focus of ischemia. Endovascular administration of verapamil for treatment of cerebral vasospasm is a safe technique which positively affects the overall recovery of such patients.

[Surgical treatment of patients with cerebral aneurysms in the acute stage of rupture: dynamics of results during 2006-2018]. / Khirurgicheskoe lechenie bol'nykh s anevrizmami sosudov golovnogo mozga v ostroi stadii razryva: dinamika rezul'tatov za 2006-2018 gg.

Treatment of cerebral aneurysms in the acute stage of subarachnoid hemorrhage (SRH) especially on the background of cerebral vasospasm continues to be a difficult task. OBJECTIVE: Assessment of dynamics of the surgical treatment results of patients with cerebral aneurysms in acute period of SRH. MATERIAL AND METHODS: A comparative analysis of the results of patients' surgical treatment in NMRCN Burdenko about aneurysm in 1-21 days after hemorrhage was made. The following periods were selected: 2006-2014 (343 patients) and 2015-2018 (356 patients). Most patients had microsurgical operations in both periods. The tactics of choosing the surgery time was the main difference between the periods: particularly in 2015-2018 period the surgery was not postponed at patients with severe. RESULTS: Analysing the post surgical mortality, it was found that since 2006 there is a consistent trend towards a decrease in the number of patients who died after surgery. When calculating the average post surgical mortality for the studied periods this trend is confirmed - number of lethal cases in 2015-2018 reliably decreased when comparing with 2006-2014 - from 6.8 till 3.2%; p=0.03. At the same time, the number of patients with outcome of vegetative status (from 0.3 till 5%). CONCLUSION: The tactics of surgical treatment of patients with cerebral aneurysms in the acute period of SRH regardless of severity of patient's condition and time of hemorrhage did not lead to worse treatment. In contrast, post surgical mortality rates show a consistent decline. We associate this fact with a number of changes that have occurred in the management and treatment of patients. In particular, we have high hopes for developing new approaches to the treatment of vasospasm, which remains the leading cause of lethal cases. More definite conclusions will be made at the end of the treatment analysis of the respective patient groups.

[Intracisternal administration of verapamil for the prevention and treatment of vasospasm in patients after microsurgical treatment of cerebral aneurysms in the acute period of hemorrhage]. / Intratsisternal'noe vvedenie verapamila dlia profilaktiki i lecheniia vazospazma u bol'nykh posle mikrokhirurgicheskogo lecheniia anevrizm sosudov golovnogo mozga v ostrom periode krovoizliianiia.

The first results of intracisternal administration of verapamil for the prevention and treatment of cerebral vasospasm (CVS) in patients in the acute period of subarachnoid hemorrhage (SAH) after microsurgical clipping of cerebral aneurysms are presented. OBJECTIVE: Safety assessment of the method of prolonged intracisternal infusion (PII) of verapamil. MATERIAL AND METHODS: Over the period from May 2017 to December 2018, 42 patients were included in the study, who underwent clipping of aneurysm of the anterior segments of the Willis circle. Most patients (78.6%) were operated during the first 6 days after SAH. For each patient, a thin silicone catheter was installed, through which verapamil was infused. A prerequisite was the installation of external ventricular drainage and opening of the lamina terminalis. The daily dosage of verapamil varied from 25 to 50 mg of the drug diluted in 200-400 ml of isotonic sodium chloride solution. The indication for the use of the PII method was the presence of one of the following factors: a score on the Hunt-Hess scale from III to V, 3 or 4 points on the Fisher scale, confirmed angiographically by the CVS before the operation. RESULTS: The PII procedure was performed from 2 to 5 days. The average dose of verapamil was 143.5±41.2 mg additionally, in the presence of an angiographically confirmed CVS accompanied by clinical manifestations, 14 (33.4%) patients received intra-arterial injection of verapamil in several stages, with individual selection of the drug dose. The formation of new cerebral ischemic foci of vasospastic genesis was observed in only 1 (2.4%) patient. No infectious intracranial complications were noted. The average follow-up period was 297.6±156.1 days. Long-term treatment outcomes, assessed by a modified Rankin scale from 0 to 2 points, were observed in 83.3% of patients. There were no outcomes such as vegetative status and no deaths. The frequency of liquorodynamic disorders, as well as epileptic syndrome did not exceed that among patients with SAH according to the literature. CONCLUSION: The study has confirmed the safety of prolonged PII. The efficacy of the method, compared with other methods for CVS treatment requires further investigation. The first results look quite promising: the observation shows a low percentage of new foci of cerebral ischemia and the absence of deaths associated with it. In patients with severe CVS, the efficacy of the PII method is increased when combined with intra-arterial administration of verapamil.

[Endovascular surgery of spinal dural arteriovenous fistulas]. / Éndovaskuliarnaia khirurgiia dural'nykh arteriovenoznykh fistul spinnogo mozga.

The article summarizes the experience in the treatment of spinal dural arteriovenous fistulas (SDAVFs). OBJECTIVE: To evaluate the efficacy of endovascular treatment of SDAVFs, depending on the pathophysiological mechanisms of impact on the spinal cord. MATERIAL AND METHODS: For the last 5 years (2013-2017), 302 patients with SDAVFs were diagnosed and treated at the Neurosurgical Institute. The endovascular technique was used in 295 patients with this pathology. Males accounted for 82%; females accounted for 18%; the mean age was 51 years. Magnetic resonance imaging (MRI) was used to assess the degree of spinal cord involvement. All SDAVF patients underwent total selective spinal angiography in order to study angioarchitectonics and to choose an endovascular treatment option. RESULTS AND CONCLUSION: Endovascular embolization of fistulas was performed in 295 out of 302 patients; direct surgery was used in the remaining cases. Endovascular treatment provided total SDAVF occlusion in 78% of cases and partial SDAVF occlusion in 22% of cases. Long-term outcomes were followed-up in all patients in a period of 6 to 12 months. In 90% of cases, improvement or stabilization of neurological symptoms was observed. In 60% of cases, there was a marked improvement in the neurological status in the form of rapid (within a few days) recovery of lost motor functions. The remaining patients had stabilization of clinical symptoms.

[Principles of surgical treatment for patients with asymptomatic aneurysms and cerebral aneurysms in the cold period after spontaneous intracranial hemorrhages]. / Printsipy vybora metoda khirurgicheskogo lecheniia bol'nykh s bessimptomnymi anevrizmami i anevrizmami golovnogo mozga v kholodnom periode posle spontannykh vnutricherepnykh krovoizliianii.

Surgical treatment of patients with cerebral aneurysms still remains one of the most important issues of cerebrovascular neurosurgery, which is associated with both complexity of treatment and risks posed by the disease. The purpose of this publication is to discuss the recommendations and algorithms adopted at the Neurosurgical Institute for choosing surgical treatment of patients with single and multiple intracranial aneurysms based on the clinical course of disease and anatomical morphological classifications of aneurysms. The study was based on a large clinical material: we analyzed treatment outcomes in 1,621 patients (2009-2017); of these, 966 (59.5%) patients were operated on using microsurgical techniques, and 655 (40.4%) patients underwent endovascular surgery. Surgical treatment of patients with cerebral aneurysms has been performed in close cooperation between two vascular (microsurgical and endovasal) departments, using the latest technical innovations.

[Disturbances of the hemostatic system in patients with aneurysmal subarachnoid hemorrhage]. / Narusheniia sistemy gemostaza u patsientov s anevrizmaticheskim subarakhnoidal'nym krovoizliianiem.

Subarachnoid hemorrhages due to rupture of cerebral aneurysms are characterized by high mortality. More than 25% of patients who have survived the first hours after aneurysmal SAH (aSAH) develop delayed cerebral ischemia that is one of the main causes of disability. The mechanisms underlying delayed ischemia have not yet been fully understood. Previously, the development of vasospasm was believed to be the only cause for development of delayed ischemia. In recent years, there has been evidence that hemostatic system disorders typical of this category of patients are the cause of cerebral artery thrombosis, which is one of the main pathophysiological mechanisms for the development of delayed cerebral ischemia. This review presents an analysis of published papers on hemostasis disturbances in patients with aSAH, their pathophysiological mechanisms, and their role in the development of cerebral ischemia.

[Intra-arterial administration of verapamil for prevention and treatment of cerebral angiospasm after SAH due to cerebral aneurysm rupture]. / Intraarterial'noe vvedenie verapamila dlia profilaktiki i lecheniia tserebral'nogo angiospazma posle SAK vsledstvie razryva anevrizm sosudov golovnogo mozga.

AIM: The study purpose was to analyze the efficacy of intra-arterial administration of verapamil (IAV) in the treatment of angiospasm in SAH patients and to determine optimal parameters of the procedure. A number of studies demonstrated the efficacy of intra-arterial administration of vasodilators, in particular verapamil, in the treatment of angiospasm after aneurysmal SAH, which served the basis for inclusion of this method in the recommended protocol for treatment of SAH patients [1-7]. MATERIAL AND METHODS: We analyzed the efficacy of IAV in 35 patients in the acute period of SAH, with 77.2% of the patients having a Hunt-Hess score of III-V. The inclusion criteria were as follows: IAV within two weeks after SAH; excluded aneurysm; verapamil dose per administration of at least 15 mg; follow-up for at least three months. Efficacy endpoints were as follows: changes in spasm according to angiography and transcranial dopplerography (TCDG); development of ischemic lesions; clinical outcome according to the modified Rankin scale. RESULTS: A total of 76 IAV procedures were performed. The verapamil dose per procedure was 36.7±9.7 mg, on average; the number of procedures varied from 1 to 5. One arterial territory was treated in 12 cases, two arterial territories were treated in 48 cases, and three arterial territories were treated in 15 cases. Typical adverse reactions included decreased blood pressure, a reduced heart rate, and elevated ICP. In all cases, TCDG revealed signs of reduced angiospasm - a 20-40% decrease in the LBFV in the M1 MCA. Four (11.4%) patients died; of these, only one died due to angiospasm progression. On examination at 3 months or more after discharge, favorable outcomes were observed in 74.3% of cases. CONCLUSION: IAV is associated with a low risk of significant complications. IAV should be performed under control of systemic hemodynamics and ICP. The indications for IAV include signs of moderate worsening or severe angiospasm according to TCDG and/or angiography. The IAV procedure may be performed every day. Further clarification of the IAV procedure and evaluation of clinical outcomes under prospective study conditions are required.

[Resection and correction of the common carotid artery to enable an endovascular approach for treatment of a giant ICA aneurysm (a case report and literature review)]. / Rezektsiia i redressatsiia obshchei sonnoi arterii dlia obespecheniia éndovaskuliarnogo dostupa pri lechenii gigantskoi anevrizmy VSA (klinicheskoe nabliudenie i obzor literatury).

The article reports a clinical case of endovascular treatment of a female patient with a giant aneurysm of the cavernous internal carotid artery complicated by gross ipsilateral bending of the proximal third of the common carotid artery. To ensure an adequate endovascular approach to the aneurysm, open repair of the common carotid artery and elimination of its bending were performed at the first stage. This enabled successful placement of a flow-diverting stent into the internal carotid artery at the aneurysm level at the second stage, resulting in good technical and clinical outcomes. We discuss the technical aspects of performed interventions and the opportunity of using this approach in patients who need endovascular interventions that are complicated by anatomical-morphological changes in the brachiocephalic arteries.

[Treatment of postoperative vasospasm after insular tumor removal by intra-arterial administration of verapamil (analysis of two clinical cases and a literature review)]. / Lechenie posleoperatsionnogo vazospazma posle udaleniia opukholi ostrovkovoi doli s pomoshch'iu intraarterial'nogo vvedeniia verapamila (analiz dvukh klinicheskikh nabliudenii i obzor literatury).

PURPOSE: We describe our experience of using intra-arterial administration of Verapamil to resolve vasospasm in two patients who underwent surgery for insular glial tumors. MATERIAL AND METHODS: Severe vasospasm (an increased systolic LBFV in the M1 MCA, more than 250 cm/s, and a Lindegaard index of 4.1) was observed in 2 (3.2%) of 62 patients in the early postoperative period after removal of intracerebral insular tumors. In both cases, vasospasm was confirmed by angiography, was clinically significant, and manifested by the development of pyramidal hemisyndrome. RESULTS: Intra-arterial administration of Verapamil led to relief of angiospasm, which was confirmed by angiographic data, and complete regression of neurological symptoms. CONCLUSION: Vasospasm symptoms in patients after removal of insular tumors largely resemble those after aneurysm hemorrhage. An increase in the LBFV in the MCA and related neurological symptoms develop lately and persists for up to 2 weeks after surgery. LBFV values are similar to those in patients after SAH and reach 250-300 cm/s. Among the causes of focal symptoms developed after removal of insular tumors, injury to the inner capsule structures, injury to arteries of the MCA territory (especially perforators), and angiospasm should be differentiated.

[Tactics of surgical treatment of patients with unruptured asymptomatic cerebral aneurysms]. / Taktika khirurgicheskogo lecheniya bol'nykh s nerazorvavshimisya bessimptomnymi anevrizmami tserebral'nykh sosudov.

AIM: To clarify the indications for surgical treatment and the principles for choosing a surgical technique for patients with unruptured asymptomatic aneurysms (UAAs) based on the results of direct and endovasal operations performed at the Burdenko Neurosurgical Institute and on the literature data. MATERIAL AND METHODS: The study included 694 UAA patients (481 females (69.3%) and 213 males (30.7%)) operated on at the Burdenko Neurosurgical Institute from 1997 to 2013. The patients' age ranged from 1 to 74 years (mean age, 48.3 years). Multiple aneurysms were in 126 (18.2%) patients. Anterior circle of Willis aneurysms were in 92.8% of cases. Among these, internal carotid artery (ICA) aneurysms (46.3%) and middle cerebral artery (MCA) aneurysms (30.8%) were predominant. Microsurgical and endovascular interventions on aneurysms were performed in 665 patients (95.8%). RESULTS: Complete aneurysm exclusion was achieved in 94.8% of cases. A pronounced neurological deficit developed in 8 (1.2%) patients, and a moderate neurological deficit developed in 62 (9.3%) patients. Postoperative mortality was 0.5%. CONCLUSION: Surgical treatment of UAAs is associated with low disability and mortality rates. All UAAs need to be operated on, especially in young and middle age patients, if surgery is technically possible, and there are no concomitant diseases contraindicating the intervention. The choice of an UAA exclusion technique is made based on the general principles of surgical treatment of cerebral aneurysms. At present, the method of choice is endovascular surgery for most cases of vertebrobasilar basin and ICA aneurysms and a microsurgical intervention for anterior cerebral artery and MCA aneurysms.

[The principles for choosing a surgical technique for patients with acute cerebral aneurysm rupture]. / Printsipy vybora metoda khirurgicheskogo lecheniya bol'nykh v ostrom periode razryva tserebral'nykh anevrizm.

The article describes the principles for choosing a surgical technique for patients with cerebral aneurysms in acute subarachnoid hemorrhage. The principles were developed based on the experience gained at the Burdenko Neurosurgical Institute. Microsurgical and endovascular treatment options are considered.

[Combined treatment of cerebral arteriovenous malformations. Experience of the Burdenko Neurosurgical Institute].

OBJECTIVE: Despite the achievements of recent years, cerebral AVMs continue to pose a challenge to treatment. The objective of this work was the development of recommendations for combined treatment of AVMs based on analysis of the available material and published data. MATERIAL AND METHODS: The study included 93 patients hospitalized at the Neurosurgical Institute for combined treatment of cerebral AVMs in 2010-2014. A group of combined surgery (removal of an AVM with preoperative embolization) consisted of 40 patients, and a group of combined radiotherapy (radiation after partial embolization or partial removal of an AVM) included 53 patients. 36 patients underwent radiosurgery, and 17 patients received stereotactic radiation therapy. Both groups were analyzed in terms of outcomes, complications, and follow-up results. RESULTS: In the group of combined surgery, according to the Glasgow outcome scale, good results (grade 4-5) were achieved in 35 (87.5%) patients at discharge and in 27 (90%) patients during follow-up. Treatment outcomes, surgery duration, and the amount of blood loss were not significantly different from those in the control group. Complete AVM obliteration was achieved in 29 (80.6%) patients 3 years after radiosurgery and in 8 (47%) patients after stereotactic radiotherapy. In discussion, these findings are compared to the published data, and recommendations for AVM treatment are suggested. CONCLUSION: The combined treatment of AVMs is effective management for patients with complex AVMs (Spetzler-Martin grade III-IV AVMs). Successful treatment of AVMs requires careful planning and teamwork of vascular and endovascular neurosurgeons, radiologists, and neurologists.

[Endovascular treatment of large and giant intracranial aneurysms using stent assistance].

OBJECTIVE: The study objective was to evaluate the efficacy of occlusions of large and giant intracranial aneurysms with microcoils using stent assistance (SA). MATERIAL AND METHODS: The study is based on analysis of treatment outcomes in 37 patients with large (15-25mm) and giant (more than 25mm) intracranial aneurysms, aged 18 to 72 years, who were hospitalized at the Burdenko Neurosurgical Institute in the period between 2004 and 2014. Selection of patients for endovascular treatment using SA was based on the anatomical parameters of the aneurysm and carrier vessel. The main determining factor was the index of the aneurysm body to neck size ratio. Occlusion of aneurysms was performed with microcoils of different configurations, including those with a biologically active coating. Self-expanding stents with both an open-cell and closed-cell design were used for SA. The results of intervention for large and giant aneurysms were evaluated using control angiography immediately after occlusion of the aneurysm. The condition of patients with unruptured aneurysms as well as with ruptured aneurysms in the "cold" period was evaluated using the modified Rankin scale. The condition of patients in the acute period of SAH was evaluated on the Hunt and Hess scale. RESULTS: The technical success (successful implantation of stents and coils with total or subtotal aneurysm occlusion) was 94.5%. The postoperative disability was 2.7%; mortality was 2.7%. 28 patients were followed up for the period of 5 to 84 months (the mean was 20 months.). In the long-term period, the total and subtotal occlusion rate, including the results of re-operations, amounted to 90%. Delayed disability was 10.7%, and mortality was 3.5%. CONCLUSION: Stent assistance enables achieving total or subtotal occlusion of large and giant aneurysms in 90% of cases. In certain clinical situations, it is an alternative to other existing methods.

[The analysis of complications of surgical treatment of brain aneurysms in patients operated on in the late posthemorrhagic period].

UNLABELLED: Most patients with brain aneurisms were operated on in the late posthemorrhagic period at the Burdenko Neurosurgical Institute. OBJECTIVE: To investigate the rate and structure of complications of microsurgical and endovascular surgery for different topographic anatomic variants of cerebral aneurysms in patients operated on in the late posthemorrhagic period in order to assess the risk of intervention in these patients. MATERIAL AND METHODS: The study group comprised 1074 patients with single brain aneurysms who had been treated at the Burdenko Neurosurgical Institute (Russian Academy of Medical Sciences) for the period from 2005 to 2012. The exclusion criterion for the study was the acute stage--21 days after the date of hemorrhage. Age of patients ranged from 18 to 75 years, with the mean of 45.3 years. The number of female patients was 552 (51.4%); the number of male patients was 522 (48.6%). Microsurgical operations were performed in 887 (82.6%) patients, endovascular--in 187 (17.4%). RESULTS: Postoperative complications were observed in 163 (15.2%) patients. Most of the complications (14.2%) were associated with cerebral disorders. Pronounced deterioration was noted in 6% of cases, death--in 0.9%. Cerebral complications were revealed in 13.8% of the patients after microsurgery and in 16% after endovascular treatment; mortality was observed in 1% and 0.5%, respectively. CONCLUSION: The overall risk of disability and death associated with recurrent hemorrhage from the aneurysm, especially at young age, is significantly higher than risks of surgical intervention in patients in the late posthemorrhagic period. Thus, the presence of a brain aneurysm that caused hemorrhage is an indication for surgical treatment, regardless of the time of its rupture.

[Intra-arterial injection of verapamil in treatment of cerebral vasospasm in a patient with acute subarachnoid hemorrhage from an aneurysm: case report].

Cerebral vasospasm is a major cause of cerebral ischemia and neurological deficits in patients after SAH from the aneurysm. According to angiorraphy cerebral vasospasm in acute rupture of an aneurysm is detected in 50-70% of cases, and the risk of ischemia on it's background is 19-46%. One of the new trends of treatment of cerebral vasospasm is the intra-arterial injection of calcium channel blockers. The article presents a case of selective intra-arterial injection of verapamil for the treatment of cerebral vasospasm in patient after severe subarachnoid and parenchymal hemorrhage of the internal carotid artery bifurcation aneurysm with a good clinical outcome.

[Stepwise treatment of multiple cerebral aneurysms utilizing surgical and endovascular techniques].

To evaluate results of combined treatment of multiple intracranial aneurysms utilizing microsurgical clipping with endovascular techniques. Study group comprised 60 patients with 230 multiple aneurysms (MA) of different location. Most common were aneurysms of ICA--49% and MCA--24%. Single-side ICA aneurysms were found in 11 (18.3%) patients, two-sides ICA lesions in 25 (41.7%); single-side ICA aneurysm with posterior circulation aneurysm--11 (18.3%) and two-sides ICA aneurysm with posterior circulation aneurysm in 13 (21.7%). All patients were treated with endovascular coiling followed by direct surgery. Eight patients treated in acute stage of SAH. Two-stage surgery was performed in 49 cases, three-stage treatment--in 11 cases yielding 131 operations total. Time break between surgeries was 1 day to 4 month. Total occlusion was achieved in 95.3% cases, 98 aneurysms were clipped, 64 (33.4%) coiled. In 15 (7.8%) patients aneurysms were excluded with stent or balloon assisting techniques. Six aneurysms were treated with flow diverters (Pipeline Embolisation Device). Palliative treatment (ICA occlusion with balloon or coils and aneuryms wrapping) were performed in 4.7%. There were no fatal outcomes or complications required repeated surgery in the group. Multimodal approach that combines endovascular techniques with microsurgery is an effective option in multiple aneurysm treatment. Updated endovascular modalities and direct surgery together become a treatment of choice for MA patient improving radical exclusion rate and outcomes. Combined treatment is specifically indicated for elaborate MA cases requiring multiple approaches.

[Substantiation of differentiated management of patients with multiple cerebral aneurysms].

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.