Remission of migraine after clipping of saccular intracranial aneurysms.

BACKGROUND: Unruptured saccular intracranial aneurysm (SIA) is associated with an increased prevalence of migraine, but it is unclear whether this is altered by clipping of the aneurysm. The aim of our study was to determine whether remission rate of migraine and other recurrent headaches was greater in patients with SIA after clipping than in controls. METHODS: We prospectively studied 87 SIA patients with migraine or other recurrent headaches. They were interviewed about headaches in the preceding year before and 1 year after clipping using a validated semi-structured neurologist conducted interview. The remission rates of migraine and tension-type headache (TTH) in these patients were compared to 92 patients from a headache center. Diagnoses were made according to the ICHD-2. RESULTS: During 1 year preceding rupture 51 patients with SIA had migraine. During the year after clipping, this was reduced by 74.5% (P < 0.0001). At first encounter, 47 control patients had migraine during the preceding year, and during 1 year of treatment, it was 41, a reduction 12.8% (P > 0.5). The decrease of migraine in SIA patients was significantly higher than in controls: 74.5% vs 12.8% (P < 0.001). A history of TTH was given by 33 patients with SIA during the year preceding rupture and by 44 during 1 year after clipping (P > 0.75). Forty-one control patients had TTH, 27 after 1 year of treatment, a reduction 34.1% (P < 0.05). No factors except clipping of the aneurysm could explain the remission of migraine. CONCLUSIONS: Migraine prevalence in patients with SIA decreases significantly after clipping. Further comparative studies of migraine after coiling vs clipping in SIA patients are needed.

Systemic connective tissue abnormalities in patients with saccular intracranial aneurysms.

OBJECTIVES: Our purpose was to identify the incidence and significance of markers of systemic connective tissue abnormalities (CTA) in patients with saccular intracranial aneurysms (SIA). MATERIALS AND METHODS: This prospective case-control study included 199 consecutive patients with SIA (103 women and 96 men, mean age - 43.2 years) and 194 control patients - blood donors (108 - men, 86 - women, mean age - 38.4 years). Aneurysms were verified by conventional cerebral angiography. All patients were examined by the first author using a specially designed questionnaire and a standardized physical examination with special emphasis on systemic CTA. RESULTS: Twelve markers of systemic CTA were significantly higher in patients with SIA than in controls: visible vessels on face and chest (59.8%), scoliosis (44.7%), varicose veins in legs (39.7%), flatfoot (34.6%), hyperextensibility of the skin (33.6%), spontaneous epistaxis (25.6%), easy bruising (20.6%), abdominal hernia (13.6%), periodontal disease (10.5%), chest deformations (7.5%), abdominal striae (3.5%), joint hypermobility (2.5%). A blinded validation study in a subset of 43 patients showed similar results. Among patients with SIA, 125 of 199 patients (62.8%) had at least three markers of systemic CTA compared with 23 (11.8%) of the controls (P < 0.0001, OR = 12.5, 95% CI 7.45-21.1). The mean number of markers of systemic CTA in patients with SIA was 3.07 and 1.17 in controls. CONCLUSION: Patients with SIA have multiple markers of systemic connective tissue abnormalities. Systemic weakness of connective tissue represents a risk factor for development of SIA. Identification of these markers may help in detection of high-risk patients.

[Vascular diseases in first-degree relatives of patients with intracranial aneurysms].

An aim of the study was to compare frequencies of vascular diseases in first-degree relatives (FDR) of patients with intracranial aneurysms (IA) and FDR of controls. Pedigrees have been selected through interviews in 194 patients with IA (96 men and 98 women) and in 193 age- and sex-matched controls. Only FDR with complete information about their disorders have been included in the study: 1011 FDR of patients with IA and 812 controls. The frequency of strokes was 2.5 times and hemorrhages --3.7 times higher in FDR of patients with IA compared to controls. Only 0.9% of FDR of patients with IA had the rupture of intracranial aneurysm. The frequency of headaches was 2.8 times, ischemic heart disease--2.7 times and arterial hypertension --2 times greater in FDR of patients with IA compared to controls. Moreover, sudden death occurred 5.8 times more often in FDR of patients with IA. The data obtained suggest that vascular defects leading to the development of IA may be, in part, genetically determined. Prevention of stroke and cardiovascular disease is necessary for FDR of patients with IA.

[The role of angiotensin-converting enzyme and apolipoprotein E in the development of intracranial aneurysms.].

The distribution of allele and genotype frequencies of the Alu-insertion polymorphism of the angiotensin-converting enzyme (ACE) gene and missence mutations leading to the substitution of arginine to cysteine in positions 112 and 158 of apolipoprotein E (APOE) has been studied in 166 patients with brain intracranial aneurysms and in 192 controls of Russian origin from Ural region. Brain vascular aneurysms with hypertension were associated with the D*D* ACE genotype in men and with the e2 allele and the e2/e3 APOE genotype in women. The association was also observed between the e2 allele and the e2/e3 APOE genotype and family history of stroke, hemorrhages and aneurysms in patients. Men with the I*D* ACE genotype and the e4 APOE allele were at lower risk.

[Vascular pathology in first-degree relatives of patients with intracranial aneurysms].

An aim of the study was to compare by the analysis of pedigrees the frequency of vascular pathology in first-degree relatives (FDR) of patients with intracranial aneurysms (IA) and controls. Pedigrees were selected by interviewing 194 patients with IA (94 men and 100 women) and 193 age- and sex-matched control patients. Only FDR with complete information about their health status were included: 1011 FDR of patients with IA and 812 FDR of controls. The results of the study revealed that the frequency of strokes was 2.5 times higher in FDR of patients with IA than in those of controls: 6.5% and 2.6%, respectively (RR = 2.52, 95% CI = 1.56-4.09). Hemorrhages occurred 3.7 times more often in FDR of patients with IA than in FDR of controls: 3.4% versus 0.9% (RR = 3.90, 95% CI = 1.74-8.75). Only 0.9% of FDR of patients with IA had the rupture of intracranial aneurysm compared with nobody in FDR of controls. The frequency of headaches was 2.8 times greater in FDR of patients with IA than in those of controls: 19.6% versus 7.1% (RR = 2.74, 95% CI = 2.08-3.62). FDR of patients with IA suffered from arterial hypertension 2 times more often than FDR of controls: 24.9% and 11.6%, respectively (RR = 2.15, 95% CI = 1.73-2.68). Coronary heart disease was 2.7 times more frequent in FDR of patients with IA than in controls: 8.9% and 3.3%, respectively (RR = 2.68, 95% CI = 1.76-4.07). Sudden death occurred in FDR of patients with IA 5.8 times more often than FDR of controls: 11.1% and 1.9%, respectively (RR = 5.68, 95% CI = 1.37-23.39). Thus, vascular pathology occurs relatively often in FDR of patients with IA implying that vascular defects which cause the development of IA may be, at least in part, genetically determined. Prevention of stroke and cardiovascular disease is necessary for FDR of patients with IA.

[The first experience in interstitial brachytherapy for primary and metastatic tumors of the brain].

In 2001-2002, the authors performed a course of brachytherapy in 15 patients with inoperable primary, recurrent, and metastatic brain tumors. The histostructural distribution was as follows: low-grade astrocytoma (grade II according to the WHO classification) in 2 patients, anaplastic astrocytoma (AA) in 3, glioblastoma multiforme (GBM) in 5. Five patients had solid tumor deposits in the brain. Computer tomographic (CT) and magnetic resonance imaging (MRI) data were used to define a path for forthcoming biopsy and implantation at a "Stryker" navigation station, by taking into account the anatomy of the brain, vessels, and functionally significant areas. After having histological findings, plastic intrastats whose number had been determined by the volume of a target were implanted into a tumor by the predetermined path. Dosimetric planning was accomplished by using CT and MRI images on an "Abacus" system. The final stage involved irradiation on a "GammaMed plus" with a source of 192Ir. Irradiation was given, by hyperfractionating its dose (3-4 Gy twice daily at an interval of 4-5 hours) to the total focal dose (TFD) of 36-44 Gy. Patients with gliomas untreated with radiation also underwent external radiation in a TFD of 54-56 Gy and patients with brain metastases received total external irradiation of the brain in a TFD of 36-40 Gy. The tolerance of a course of irradiation was fair. In patients with AA and GBM, one-year survival was observed in 66 and 60%, respectively; in those having metastasis, it was in 20%. Six patients died from progressive disease. All patients with low-grade astrocytoma and one patient with anaplastic astrocytoma were alive at month 24 after treatment termination. The mean lifespan of patients with malignant gliomas and solid tumor metastasis was 11.5 and 5.8 months, respectively. Brachytherapy is a noninvasive and tolerable mode of radiotherapy that increases survival in some groups of patients with inoperable brain tumors.

[The surgical treatment of intracranial aneurysms from the pterion approach using small trephining openings]. / Khirurgicheskoe lechenie intrakranial'nykh anevrizm iz pterional'nogo dostupa s primeneniem malykh trepanatsionnykh otverstii.

In the past decade, there has been a clear trend for the use of low-invasive surgical interventions in many divisions of neurosurgery. Since each operation is bound to be followed by tissue traumatization, a decrease in the sizes of skull trepanation should be regarded as a way of reducing the incidence of intra- and extracranial complications. The proposed variant of a pterion access to intracranial aneurysms by using small trepanation holes may substantially decrease the duration of surgical interventions and to avoid postoperative epidural and subdural hematomas without preventing the visualization of arteries in both anterior and posterior Willis' circle and at the same time the variant exerts no negative effect on the possibilities of hemostasis in intraoperative aneurysm rupture. The operation yields a good cosmetic effect.

[The current neurosurgical resources on the Internet]. / Sovremennye neirokhirurgicheskie resursy v Internet.

Progress of information and telecommunication technologies, rapid development of local computer networks and their incorporation into the global computer network Internet are of great importance for the development of modern civilization. Internet presents all spheres of human activities, including medicine, neurosurgery in particular. It is the most available resource that has an unlimited amount of information, expands and is supplemented in geometric progression. A great deal of specialized neurosurgical information has been accumulated in the network that may be available to any neurosurgeon irrespective of the geographical region. There has come a time when information can be obtained through progress in telecommunication technologies that accelerate this process by hundreds of times, there has come a time when colleagues can actively contact with each other by transmitting not only verbal and textual information, but also graphic and video information. The present paper presents a review of currently available Internet neurosurgical resources by showing the benefits of this information source and the possibilities of its use in neurosurgery for both educational and scientific purposes.

[The formation of true saccular aneurysms from diverticula of the cerebral arterial walls]. / Obrazovanie istinnykh meshotchatykh anevrizm iz vypiachivanii stenok arterii mozga.

The authors show that aneurysmic diverticula of cerebral vascular walls cam grow in size and to develop, with time, into true saccular aneurysms. Cases of aneurysmic diverticula transformation into aneurysms illustrate dynamic pattern of aneurysmogenesis and formation of this pathology during life. Feasibility of the growth and rupture of the aneurysm in intracranial hemorrhage dictates necessity of follow-up visualizations of cerebral vessels in such patients (contrast angiography, NMR angiography).

[Heredity in intracranial aneurysms (a study of identical twins)]. / K voprosu o nasledstvennosti pri intrakranial'nykh anevrizmakh (issledovanie identichnykh bliznetsov).

The study of identical twins revealed an important role of hereditary factors in the development of cerebral aneurysms. The "weakness" of connective tissue, caused by some genetic (or polygenic) defects, concurrent with several acquired conditions (essential hypertension, connective tissue disorders) leads to the development and rupture of cerebral aneurysms.

[The surgical correction of traumatic deformities of the orbit in naso-fronto-orbito-cribriform fractures]. / Khirurgicheskaia korrektsiia travmaticheskikh deformatsi orbity pri noso-lobno-orbito-reshetchatykh perelomakh.

J. Raven's (1992) classification was used in the treatment of patients with multiple fractures of the face associated with contusions, brain concussions, and injuries to the skull vault and base. According to this classification, all injuries of the cerebral and facial skull are classified as types I, II, and subtype Ia. Use of this classification became possible due to introduction of computer-aided tomography. A clinical example of a possible surgical correction of the orbit in a patient with type II fracture is presented.

[Phonoangiography in aneurysms of the cerebral vessels]. / Fonoangiografiia pri anevrizmakh sosudov golovnogo mozga.

Phonoangiography was conducted in 113 patients with various diseases of the brain. From comparison of the findings of clinical and angiographic examination the authors defined typical phonoangiographic criteria for the diagnosis of arterial and arteriovenous aneurysms of the brain which can be used in out- and inpatient practice.

[Polarographic evaluation of extra-intracranial microvascular anastomoses in the early postoperative period]. / Poliarograficheskaia otsenka ékstra-intrakranial'nykh mikrososudistykh anastomozov v rannem posleoperatsionnom periode.

Dynamic recording of the brain oxygen level by means of polarography during test with clamping of the superficial temporal artery in the early postoperative period in patients with an extra-intracranial microvascular anastomosis (EICMA) makes it possible to judge whether the anastomosis in patient or occluded. Patent anastomoses were marked by two types of changes occurring on the polarograms in clamping of the donor artery of the anastomosis. They reflect the relations between the EICMA and the natural channels of the collateral blood supply of the brain, correlate to a great measure with the localization of the occluding lesions in the cerebral vessels, and allow the efficacy of the operative intervention to be predicted.

[Extra-intracranial anastomosis in the surgical treatment of arterial aneurysms of the brain]. / Ekstra-intrakranial'nyi anastomoz v khirurgii arterial'nykh anevrizm golovnogo mozga.

Appraisal of the results of surgical treatment of 7 patients with arterial aneurysms of the carotid channel convinced the authors of the useful applicability of extra-intracranial anastomosis in occlusion of the cerebral arteries. The anastomosis provides for adequate compensation of circulation in the brain in occlusion of not only the internal carotid artery but also the middle cerebral artery. Depending on the surgical situation, extra-intracranial anastomosis can be performed both as a planned procedure and as an emergency measure. Emergency establishment of the anastomosis is useful in all cases of complications of the operations terminating in occlusion of the internal carotid or middle cerebral artery.