[A comparative study of the efficacy and safety of the eyebrow supraorbital approach in cerebral aneurysm surgery]. / Sravnitel'noe issledovanie éffektivnosti i bezopasnosti transbrovnogo supraorbital'nogo dostupa v khirurgii anevrizm golovnogo mozga.

OBJECTIVE: The study objective was to compare the efficacy and safety of supraorbital eyebrow (SEA) and pterional (PA) approaches in surgery of anterior circle of Willis (ACW) aneurysms and to determine the advantages and disadvantages of SEA in aneurysm clipping. MATERIAL AND METHODS: The analysis included 166 patients with ACW aneurysms aged 18 to 70 years who were treated in the Neurosurgery Department of the Interregional Clinical Diagnostic Center (Kazan) in the period from 2013 to 2016. At the first stage of the study, factors affecting surgical outcomes were compared (by using the Glasgow outcome scale (GOS)) in subpopulations of patients operated on using SEA (n=49) and PA (n=117). At the second stage, we compared the efficacy and safety of approaches using a case-control subanalysis in appropriate subgroups of the SEA (n=37) and PA (n=37) groups. The subgroups were comparable in the following factors: gender, age, severity of subarachnoid hemorrhage (SAH) on (Fisher scale), severity of the patient's condition (Hunt-Hess scale), size and location of the aneurysm, surgery duration, intraoperative aneurysm rupture (IOAR), amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, rate of intraoperative and postoperative complications, hemorrhagic and ischemic complications according to postoperative CT, patient's satisfaction with the cosmetic result of surgery (visual analogue scale - VAS), and treatment outcomes (GOS). Treatment outcomes (GOS) and patient's satisfaction with the cosmetic result of surgery (VAS) were considered as the efficacy parameters. The safety parameters included the amount of blood loss, rate of frontal sinus surgery, rate of nasal CSF leak, and rate of intraoperative and postoperative (hemorrhagic and ischemic) complications. RESULTS: At the first stage of the study, we found that the amount of intraoperative blood loss in the subpopulation of patients with ACW aneurysms who were operated on using SEA was statistically significantly less than that in the PA group (p=0.0000002). In the postoperative period, patients who underwent surgery using SEA less frequently experienced neurological deficit (p=0.003), less frequently developed first epileptic seizures (p=0.035), and had a lower rate of hemorrhagic complications (p=0.003) and better treatment outcomes (GOS) (p=0.01). Comparison of appropriate subgroups in the SEA and PA groups, which were selected according to the case-control methodology and were comparable in the main factors affecting treatment outcomes, confirmed statistically significantly lower blood loss for SEA (p=0.0000002) than for PA. Compared to the SEA group, the PA group was characterized by more frequent, but not statistically significantly different, IOAR (p=1), postoperative worsening of neurological deficit (p=0.115), newly developed epileptic seizures (p=0.493), and hemorrhagic complications (p=0.0557). There were no deaths in both groups. In the SEA group, the treatment outcome was scored 4 and 5 (GOS, favorable outcome); in the PA group, the treatment outcome was scored 3 (GOS) in 2 (5.4%) patients and 4 or 5 in 35 (94.6%) patients (p=0.063). The mean subjective score of satisfaction with the treatment result (VAS) in the SEA group was significantly higher (9.4±1) than in the PA group (8.8±1; p=0.01). CONCLUSION: SEA is an adequate approach for clipping ACW aneurysms, in particular ACA-AComA and MCA aneurysms, which is as effective and safe as the pterional approach.

[A supraorbital trans-eyebrow approach in surgery of chiasmatic-sellar and anterior cranial fossa tumors]. / Supraorbital'nyi transbrovnyi dostup v khirurgii opukholei khiazmal'no-selliarnoi oblasti i perednei cherepnoi iamki.

OBJECTIVE: to analyze 31 resections of chiasmatic-sellar region (CSR) and anterior cranial fossa (ACF) tumors using the supraorbital trans-eyebrow approach (STA). MATERIAL AND METHODS: We analyzed medical histories of 31 patients who underwent tumor resection using STA in the period between October 2013 and April 2017. We analyzed the age and gender of patients, size and location of the tumor, presence of a neurological deficit, vision and olfactory functions before and after surgery, surgery duration, amount of intraoperative blood loss, rate of frontal sinus trephination and nasal liquorrhea, hemorrhagic and ischemic complications after surgery, Simpson grade of tumor resection, patient's condition before and after surgery (Glasgow Outcome Scale and Karnofsky Scale), and degree of patient satisfaction with the cosmetic result of surgery. A total of 26 meningiomas (20 sphenoid plate, tubercle, and diaphragm tumors, 3 lesser sphenoid wing meningiomas, 2 orbital roof tumors, and 1 anterior clinoid process meningioma), 3 frontal lobe gliomas, and 2 pituitary adenomas were resected. RESULTS: In all 31 operations, the approach was adequate and enabled tumor resection without lethal outcomes. The mean surgery duration was 174.6±64.4 min. The mean blood loss was 190±96.6 mL (50-380 mL). After surgery, none of the patients developed motor deficits and new epileptic seizures. Neurological deficit aggravation in the form of impaired vision and mental disorders occurred in 8 (25.8%) patients. Vision impaired in 4 (12.9%) patients, improved in 6 (19.3%) patients, and remained unchanged in 21 (67.7%) patients. An endocrinological deficit in the form of partial hypopituitarism developed in 3 (9.6%) patients; in 4 (12.9%) patients, there were mental disorders that regressed by the end of the first month of therapy. There were no intracerebral and subarachnoid hemorrhages. In 2 (6.4%) patients, small epidural hematomas were diagnosed, which did not require surgical treatment. There were only good outcomes (a GOS score of 4 or 5). After surgery, the median Karnofsky index in the STA group was 90±7. In all 31 (100%) patients, the postoperative wound healed by primary intention, without infectious complications and wound liquorrhea. One (4%) patient developed eyebrow palsy; 3 (12%) patients had hypoesthesia in the supraorbital region. The mean VAS score of patient satisfaction with the cosmetic result was 9.36 (median 10±1). The mean follow-up period was 16.2±13.5 months (2-38 months). CONCLUSION: The STA is adequate for removal of CSR and ACF tumors under proper selection of patients. It provides an adequate view of anatomical structures and enables successful tumor resection through a less traumatic access.

["Low infusion resuscitation" in the treatment of wounded and injured with acute massive blood loss].

Acute massive blood loss (AMBL) of severe and extremely severe degree is still one of the leading causes of unfavourable traumatic disease. 95% of potentially preventable lethal outcomes in severe gunshot trauma is reported to depend largely on the adequacy of AMBL correction (Howard P., 2003). An alternate approach to the issue studied was the development of preparations of hyperosmotic saline solutions (7.5% sodium chloride) combined with hyperoncotic colloid solutions (dextrans, hetastarch). As a result, solutions were developed (so-called, hyperosmotic hyperoncotic volume expanders) allowing to achieve rapid and stable volemic and hemodynamic effect in case of low volume infusion (usually, 4 ml/kg of body weight). The present study allowed to conclude that "low infusion resuscitation" technique in patients with multiple trauma accompanied by acute massive blood loss of extremely severe degree enables to reduce lethality, to achieve early subcompesatory hemodynamic state in acute traumatic disease.