[Differential diagnosis of pneumonia as a complication of nasal liquorrhea in the context of the COVID-19 pandemic: Case report].

Nasal liquorrhea the outflow of cerebrospinal fluid from the cerebrospinal fluid spaces of the cranial cavity into the nasal cavity or paranasal sinuses due to the presence of a congenital or acquired defect in the bones of the skull base and meninges of various etiologies. Nasal liquorrhea leads to potentially fatal complications: meningitis, meningoencephalitis, pneumocephalus, brain abscess. Also, with nasal liquorrhea, less dangerous complications may occur: aspiration bronchopneumonia and gastritis. The article presents a case of aspiration pneumonia in two patients with nasal liquorrhea treated at the Burdenko National Medical Research Center for Neurosurgery during the COVID-19 pandemic. Both patients noted the profuse nature of the nasal liquorrhea, complained of coughing in a horizontal position. In both cases, no RNA virus (SARS-CoV-2) was detected during the polymerase chain reaction. Antibodies (IgG, M) to coronavirus were not detected. Computed tomography of the chest organs in both cases revealed areas of frosted glass darkening. Since no data was obtained for coronavirus infection (negative tests for coronavirus, lack of antibodies), changes in the lungs were interpreted as a consequence of constant aspiration of CSF. The patients were admitted to a separate ward. Both patients underwent endoscopic endonasal plasty of the skull base defect. The postoperative period in both cases was uneventful. In both cases, the patients underwent computer tomography scan of the chest organs one month later. On the photographs, the signs of pneumonia completely regressed.

[Adipsic diabetes insipidus after transsphenoidal surgery for suprasellar intraventricular].

Presented case demonstrates a rare diencephalic pathology - adipsic diabetes insipidus (ADI) with severe hypernatremia in a 58-year-old woman after ttranssphenoidal removal of stalk intraventricular craniopharyngioma. ADI was diagnosed because of hypernatremia (150-155 mmol/L), polyuria (up to 4 liters per day) and absence of thirst. Normalization of water-electrolyte balance occurred on the background of desmopressin therapy and sufficient hydration in postoperative period. After release from the hospital, the patient independently stopped desmopressin therapy and did not consume an adequate amount of fluid of the background of polyuria. This led to severe hypernatremia (155-160 mmol/L) and rough mental disorders.Patients with ADI need closely monitoring of medical condition and water-electrolyte parameters, appointment of fixed doses of desmopressin and adequate hydration.

[Transcranial microsurgical decompression of the optic canal in surgical treatment of meningiomas of the sellar region]. / Transkranial'naya mikrokhirurgicheskaya dekompressiya kanala zritel'nogo nerva v khirurgii meningiom khiazmal'no-sellyarnoi oblasti.

RATIONALE: When removing the meningiomas of the sellar region, there is always a risk of visual impairment for various reasons, in particular, as a result of traction damage to the optic nerve. Decompression of the optic canal increases nerve mobility during tumor manipulation. In cases of meningioma growing into the canal, its decompression often seems necessary. AIM: Evaluation of the effectiveness and risks of performing decompression of the optic canal. MATERIALS AND METHODS: The study included patients with meningiomas of the parasellar location, who underwent surgical treatment at the Burdenko Neurosurgical Center for the period from 2001 to 2017. They were divided into two groups - main and control. The main group consisted of 129 patients who underwent decompression of the optic nerve canals when the tumor was removed. The tumor matrix in this group was most often located in the region of the tuberum sellae, supradiaphragmally, in the region of the anterior clinoid process and the optic canal. In 31 cases, decompression was bilateral - during one operation and using one access in 27 patients; in 4 cases, the decompression of the second canal was delayed for 1.5-3 months after the first operation. 160 decompressions were performed by the intradural and 7 - by extradural methods. During intradural decompression, the roof of the optic canal was resected, and during extradural decompression, the lateral wall of the canal was trephined. The control group consisted of 308 patients who did not undergo canal decompression when the tumor was removed. It included meningiomas with a predominant location of the matrix in the area of the tuberclum and diaphragm of the sella. Tumors in both groups were removed according to the same principles (matrix coagulation, mainly the gradual removal of the tumor, the use of ultrasonic aspirator, a situational decision on the radicality of the operation, etc.). The main difference between operations in these two groups was only canal related algorithms (with or without its trepanation), as well as the probable prevalence of significant lateral tumor growth in cases with canal trepanation. Visual functions in the «primary¼ group were evaluated before and after operations with trepanation of the canal depending on various factors - the initial state of vision and the radicality of the tumor excision, including removal from the canal. The differences in the postoperative dynamics of vision in the main and control groups were studied. The primary data processing was carried out using the program MSExcel. Secondary statistical processing was carried out using the program Statistica. To assess the statistical significance of differences in the results obtained in the compared patient groups, the Chi-square test was used, and in the case of small groups - the exact Fisher test was applied. RESULTS: In the main group postoperative vision improvement of varying degrees on the side of trepanation was registered in 36.9% (59 out of 160) cases, no vision changes were found in 36.9% (59 out of 160), and in 26,2% (42 out of 160) the eyesight deteriorated. If preserving vision is attributed to a satisfactory result, then in general the results of these operations should be considered good. A comparative study of the results of removal of meningiomas with trepanation of the canals (main group) or without it (control group) was carried out among patients with the most critical vision situation (visual acuity 0.1 and below, up to only light perception). These groups are comparable in the number of observations - 62 and 73 respectively. The predominance of cases with improved vision in the main group compared with the control group (50.0% versus 38.36%) and a lower incidence of vision impairment (22.58% versus 34.25%) were found. However, the revealed differences are statistically unreliable and make it possible for us to talk only about the trend. The complications associated with trepanation of the canal include mechanical damage to the nerve by the drill. In our series of observations, there was only 1 case of abrasion of the nerve surface with the burr, which did not lead to a significant visual impairment. With the intradural method of trepanation in the area of the medial wall of the canal, the sphenoid sinus may open (in our series, in 34 cases out of 160 trepanations). Immediately closure of these defects was performed by various auto- and allomaterials in various combinations (pericranium, fascia, muscle fragment, hemostatic materials, and fibrin-thrombin glue). A true complication - CSF rhinorrhea liquorrhea developed in only one case, which required transnasal plastic surgery of the CSF fistula using a mucoperiostal flap. CONCLUSIONS: 1. Trepanation of the optic canal in cases of meningiomas of parasellar localization is a relatively safe procedure in the hands of a trained neurosurgeon and does not worsen the results of operations compared with the excision of the same tumors without trepanation of the canal. 2. The literature data and the results of our study make it possible to consider the decompression of the optic canal as an optional, but in many cases, useful option that facilitates the transcranial removal of some meningiomas of the sellar region.

[Primary sellar neuroblastoma (clinical case and literature review)]. / Pervichnaya sellyarnaya neiroblastoma. Klinicheskoe nablyudenie i obzor literatury.

Neuroblastoma is a malignancy developing from the embryonic neuroblasts of sympathetic nervous system. Primary sellar neuroblastomas are extremely rare (there are currently only 11 case reports in the literature). Possible development of neuroblastoma in sellar region expands differential diagnosis of local processes due to inclusion of neuroblastoma into the spectrum of suspected tumors. We report a literature review and description of a patient with primary sellar neuroblastoma.

[Transsphenoid extirpation of pituitary adenomas in patients with McCune-Albright syndrome (two cases from practice and literature review)]. / Transsfenoidal'noe udalenie adenom gipofiza u patsientov s sindromom MakK'iuna-Olbraita (dva sluchaia iz praktiki i obzor literatury).

INTRODUCTION: McCune-Albright Syndrome is a rare genetic disease characterized by the formation of fibrous osteodysplasia foci of various localization, including the bones of skull base. Having a gross lesion of the main bone body and the simultaneous formation of the pituitary adenoma, its transnasal removal becomes very difficult. MATERIAL AND METHODS: Two clinical observations are presented where at patients with the classic manifestation of McCune-Albright syndrome we were able to successfully remove somatotropinomas with endoextrasellar growth. In both cases the presence of visual disorder was the indication for surgery. RESULTS: Despite pronounced deviations in the anatomy of the skull base bones in both cases we managed to access the Turkish saddle. Removal of the pituitary tumor did not differ from standard surgery. Improved vision after surgery was observed in two patients. Tumors were removed subtotally and clinical and biochemical remission of acromegaly was not achieved. In both cases, the tumors had morphological signs of atypia. Patients continued to receive therapy with somatostatin analogues and radiation. CONCLUSION: The possibility of performing transnasal surgery in this category of patients using specific instruments and intraoperative navigation is shown.

[Transsphenoidal surgery of suprasellar meningiomas - is there a future for the technique?] / Transsfenoidal'naia khirurgiia supraselliarnykh meningiom - est' li budushchee u metodiki?

Surgery of suprasellar meningiomas is a challenge and associated with a high risk of injury to the vascular-neural structures lying along the approach and surrounding the tumor. Currently, many foreign clinics and our Center have introduced a technique for resection of suprasellar meningiomas through the anterior extended transsphenoidal endoscopic endonasal approach. OBJECTIVE: The study objective was to evaluate the role of extended transsphenoidal endoscopic endonasal approaches in surgery of suprasellar meningiomas. MATERIAL AND METHODS: The present study is a retrospective analysis of surgical treatment outcomes in 45 patients (11 males and 34 females aged 23 to 70 years (median, 50 years) with suprasellar meningiomas who underwent surgery for skull base tumors using the anterior extended transsphenoidal endoscopic endonasal approach in the Surgery Department of the Burdenko Neurosurgical Institute in the period from 2009 to 2017. In all cases, surgery was the primary method of treatment. RESULTS: Total tumor resection (the tumor was resected completely together with an infiltrated DM - Simpson 1) was achieved in 77.8% (35/45) of cases; subtotal resection (more than 80% of the tumor was removed) was in 17.8% (8/45) of cases; in 4.4% (2/45) of cases, resection was partial (less than 80% of the tumor was resected). Worsening or development of visual impairments immediately after surgery occurred in 13 (28%) of 45 patients. In 3 of them, vision was completely recovered on conservative treatment by the time of hospital discharge. In 4 patients, vision partially improved by the time of discharge. In 6 patients, vision was not recovered by discharge (in 2 of them, vision partially improved during follow-up). Therefore, by the time of hospital discharge, deterioration in vision occurred in 10 (22%) of 45 patients. In 7 (21.2%) out of 33 patients who had visual impairments before surgery, there was an improvement in vision in the postoperative period. CONCLUSION: Analyzing the findings and generalizing our experience, we may say that, in surgery of suprasellar meningiomas, the anterior extended transsphenoidal endoscopic endonasal approach should be used for relatively small (up to 3 cm), medially located symmetrical tumors that do not involve large vessels. The efficacy of this technique for tumors extending into the optic nerve canals requires additional analysis in a larger series of cases.

[Preoperative and postoperative endocrine disorders associated with pituitary stalk injuries caused by suprasellar growing tumors]. / Éndokrinnye rasstroistva do i posle operatsii pri razlichnykh porazheniiakh steblia gipofiza supraselliarno rastushchimi opukholiami.

The pituitary stalk (PS) is a relatively thin bundle connecting the hypophyseal stalk to the pituitary gland; it consists of both axons of the hypothalamic nuclei (terminating in the neurohypophysis) and the system of portal vessels. Compression of the PS by a space-occupying lesion or its transection (forced or intended) during surgery may lead to the development of endocrine disorders: hypopituitarism, diabetes insipidus, and hyperprolactinemia. The modern literature lacks studies evaluating the severity of endocrine disorders depending on the PS condition before and after surgery. PURPOSE: The study purpose was to investigate endocrine disorders in patients with sellar region (SR) tumors and the PS that was compressed before surgery and preserved or transected during a neurosurgical intervention. MATERIAL AND METHODS: The study included 139 patients with various SR tumors. In 82 patients, a preoperatively compressed PS was preserved (41 patients with hormonal inactive adenoma (HIA) and 41 patients with suprasellar meningioma); in 57 patients, the PS was transected during surgery (46 patients with pituitary stalk craniopharyngioma and 11 patients with hormonally inactive endosuprasellar pituitary adenoma). The hormonal status (PRL, TSH, LH, FSH, fT4, cortisol, testosterone, or estradiol) was examined in all patients both before and after surgery. RESULTS: Hyperprolactinemia was preoperatively detected in 37% of patients with tumors compressing the PS. Elimination of PS compression (tumor resection) led to normalization of the PRL level in most patients and was not accompanied by aggravation of hypopituitarism symptoms. Transection of the PS caused panhypopituitarism in 100% of patients and diabetes insipidus in 93% of cases. After transection of the PS, hyperprolactinemia did not develop in 59% of patients with craniopharyngiomas (CPs) and 82% of patients with HIA. CONCLUSIONS: Given the difference in symptoms associated with compression and surgical transection of the PS, we believe that these two concepts should be clearly distinguished. The PS compression syndrome includes primarily hyperprolactinemia (37% of cases); elimination of PS compression leads to normalization of the PRL level in most patients and is not accompanied by aggravation of hypopituitarism symptoms. The PS transection syndrome in patients with CP and HIA led to the development of panhypopituitarism in all patients and permanent diabetes insipidus in most of them. The causes of the absence of hyperprolactinemia in many patients with PS transection require further research. The surgeon planning intraoperative PS transection to increase the radicality of surgery should be well informed about the consequences of this procedure for the patient's endocrine status.

[The use of platelet gel for repair of a cerebrospinal fluid fistula of the skull base (a case report and literature review)]. / Primenenie trombotsitarnogo gelia dlia plastiki likvornoi fistuly osnovaniia cherepa (sluchai iz praktiki i obzor literatury).

Nasal liquorrhea is a serious problem in surgery of skull base tumors, which is associated with a high risk of purulent-septic complications. This paper presents a case of successful repair of a cerebrospinal fluid fistula with an autologous platelet gel in the postoperative period after removal of meningioma of the anterior cranial fossa base, which was accompanied by a purulent-inflammatory complication in the surgical wound area.

[Application of intraoperative electromagnetic frameless navigation in transcranial and endoscopic neurosurgical interventions]. / Primenenie bezramnoi sistemy intraoperatsionnoi élektromagnitnoi navigatsii pri transkranial'nykh i éndoskopicheskikh neirokhirurgicheskikh vmeshatel'stvakh.

The paper summarizes the experience in using a system of electromagnetic intraoperative frameless navigation in various neurosurgical pathologies of the brain. The electromagnetic navigation technique was used for 102 operations in 98 patients, including 36 transnasal endoscopic interventions. There were no intraoprtative and postoperative complications associated with the use of the system. In the process of using the system, factors influencing the accuracy of navigation and requiring additional control by the surgeon were identified. PURPOSE: The study purpose was to evaluate the use of electromagnetic navigation in surgical treatment of patients with various brain lesions. MATERIAL AND METHODS: The system of electromagnetic navigation was used for 102 operations in 98 patients (42 males and 56 females, including 18 children; median age, 34.8 years (min, 2.2 years; max, 69 years)) in the period from December 2012 to December 2016. In 36 patients, the system was used for endoscopic interventions. In 19 patients, electromagnetic navigation was used in combination with neurophysiological monitoring. RESULTS: In our series of cases, the frameless electromagnetic navigation system was used in 66 transcranial operations. The mean error of navigation was 1.9±0.5 mm. In 5 cases, we used the data of preoperative functional MRI (fMRI) and tractography for navigation. At the same time, in all 7 operations with simultaneous direct stimulation of the cortex, there was interference and significant high-frequency noise, which distorted the electrophysiological data. A navigation error of more than 3 mm was associated with the use of neuroimaging data with an increment of more than 3 mm, image artifacts from the head locks, high rate of patient registration, inconsequence of touching points on the patient's head, and unsatisfactory fixation to the skin or subsequent displacement of a non-invasive localizer of the patient. In none of the cases, there was a significant effect of standard metal surgical tools (clamps, tweezers, aspirators) located near the patient's head on the navigation system. In two cases, the use of massive retractors located near the patient's localizer caused noise in the localizer and navigation errors of more than 10 mm due to significant distortions of the electromagnetic field. Thirty-six transnasal endoscopic interventions were performed using the electromagnetic frameless navigation system. The mean navigation error was 2.5±0.8 mm. CONCLUSION: In general, electromagnetic navigation is an accurate, safe, and effective technique that can be used in surgical treatment of patients with various brain lesions. The mean navigation error in our series of cases was 1.9±0.5 mm for transcranial surgery and 2.5±0.8 mm for endoscopic surgery. Electromagnetic navigation can be used for different, both transcranial and endoscopic, neurosurgical interventions. Electromagnetic navigation is most convenient for interventions that do not require fixation of the patient's head, in particular for CSF shunting procedures, drainage of various space-occupying lesions (cysts, hematomas, and abscesses), and optimization of the size and selection of options for craniotomy. In repeated interventions, disruption of the normal anatomical relationships and landmarks necessitates application of neuronavigation systems in almost mandatory manner. The use of electromagnetic navigation does not limit application of the entire range of necessary intraoperative neurophysiological examinations at appropriate surgical stages. Succession in application of neuronavigation should be used to get adequate test results.

[Extended endoscopic endonasal posterior (transclival) approach to tumors of the clival region and ventral posterior cranial fossa. Part 1. Topographic and anatomical features of the clivus and adjacent structures]. / Éndoskopicheskii éndonazal'nyi zadnii rasshirennyi (transklival'nyi) dostup k opukholiam oblasti skata i ventral'nykh otdelov zadnei cherepnoi iamki. Chast' 1. Topografo-anatomicheskie osobennosti skata i pogranichnykh s nim obrazovanii.

OBJECTIVE: to describe the main topographic and anatomical features of the clival region and its adjacent structures for improvement and optimization of the extended endoscopic endonasal posterior (transclival) approach for resection of tumors of the clival region and ventral posterior cranial fossa. MATERIAL AND METHODS: We performed a craniometric study of 125 human skulls and a topographic anatomical study of heads of 25 cadavers, the arterial and venous bed of which was stained with colored silicone (the staining technique was developed by the authors) to visualize bed features and individual variability. Currently, we have clinical material from more than 120 surgical patients with various skull base tumors of the clival region and ventral posterior cranial fossa (chordomas, pituitary adenomas, meningiomas, cholesteatomas, etc.) who were operated on using the endoscopic transclival approach. RESULTS: We present the main anatomical landmarks and parameters of some anatomical structures that are required for performing the endoscopic endonasal posterior approach. The anatomical landmarks, such as the intradural openings of the abducens and glossopharyngeal nerves, may be used to arbitrarily divide the clival region into the superior, middle, and inferior thirds. The anatomical landmarks important for the surgeon, which are detected during a topographic anatomical study of the skull base, facilitate identification of the boundaries between the different clival portions and the C1 segments of the internal carotid arteries. The superior, middle, and inferior transclival approaches provide an access to the ventral surface of the upper, middle, and lower neurovascular complexes in the posterior cranial fossa. CONCLUSION: The endoscopic transclival approach may be used to access midline tumors of the posterior cranial fossa. The approach is an alternative to transcranial approaches in surgical treatment of clival region lesions. This approach provides results comparable (and sometimes better) to those of the transcranial and transfacial approaches.

[The extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts of the chiasmatic region]. / Ispol'zovanie rasshirennogo transsfenoidal'nogo éndoskopicheskogo éndonazal'nogo dostupa v khirurgii épidermoidnykh kist khiazmal'noi oblasti.

Surgical treatment for epidermoid cysts of the chiasmatic region is a challenge because of the tendency to a massive spread of epidermoid masses through the cerebrospinal fluid pathways and a significant lesion deviation from the midline. PURPOSE: To analyze capabilities of the extended endoscopic endonasal transsphenoidal approach in surgery for epidermoid cysts. MATERIAL AND METHODS: The study included 6 patients with epidermoid cysts of the chiasmatic region who were operated on using the extended anterior endoscopic endonasal transsphenoidal approach at the Burdenko Neurosurgical Institute in the past 5 years. RESULTS: Epidermoid masses were completely removed in 5 patients; in none of the cases, complete removal of the epidermoid cyst capsule was achieved. There were no cases of vision deterioration and the development of new focal neurological symptoms. One female patient developed hypopituitary disorders in the postoperative period. There was no recurrence of epidermoid cysts during follow-up. CONCLUSION: Removal of epidermoid cysts of the chiasmatic region using the extended anterior endoscopic transsphenoidal approach may be an alternative to transcranial microsurgery.

[Cerebrospinal fluid rhinorrhea in primary treatment of large and giant prolactinomas with dopamine agonists]. / Nazal'naia likvoreia pri pervichnom lechenii bol'shikh i gigantskikh prolaktinom agonistami dofamina.

At present, pharmacological therapy of prolactinomas with dopamine agonists (DAs) is considered the treatment of choice. In most cases, giant prolactinomas respond to treatment with dopamine agonists and decrease in size during the first months of the treatment. One of the rare but dangerous complications of conservative treatment of prolactinomas with invasive growth is cerebrospinal fluid rhinorrhea. MATERIAL AND METHODS: We present a retrospective analysis of 15 patients with macropropactinomas who underwent surgery for cerebrospinal fluid rhinorrhea developed due to primary therapy with dopamine agonists at the Burdenko Neurosurgical Institute (BNI) in the period between 2005 and 2015. All patients had large and giant tumors (according to the classification adopted at the BNI). When cerebrospinal fluid rhinorrhea was detected, patients were hospitalized to the BNI for examination, detection of a CSF fistula, reconstruction of a defect, and resection (if possible) of the tumor. RESULTS: In the period between 2005 and 2015, 15 patients (8 males and 7 females) with prolactinomas of a large and giant size at the onset of conservative therapy underwent surgery for cerebrospinal fluid rhinorrhea at the BNI. All patients underwent transnasal reconstruction of a skull base defect, with 13 out of 15 patients undergoing simultaneous resection of the tumor. After tumor resection, reconstruction was performed using auto-fat, fascia, and glue (in 8 cases). In the remaining cases, apart from auto-fat, fascia, and glue, a mucoperiosteal flap and auto-bone were used. Fourteen patients were followe-up. In 13 cases, there was no relapse of cerebrospinal fluid rhinorrhea after skull base reconstruction. In 1 case, there was a relapse of cerebrospinal fluid rhinorrhea. CONCLUSION: Conservative treatment of patients with giant prolactinomas should be performed under regular control of ENT doctors and neurosurgeons for timely detection and surgical treatment of cerebrospinal fluid rhinorrhea.

[Endoscopic transsphenoidal resection of pituitary adenomas invading the cavernous sinus]. / Endoskopicheskoe transsfenoidal'noe udalenie adenom gipofiza, vrastayushchikh v kavernoznyi sinus.

INTRODUCTION: Pituitary adenomas are benign growths that invade the cavernous sinus (CS) in 10-15% of cases. There are different types of microsurgical and endoscopic approaches enabling resection of tumors from the CS cavity that is a relatively small and hard to reach anatomical structure comprising eloquent neurovascular structures. MATERIAL AND METHODS: A study group included 97 patients with pituitary adenomas (PAs) invading the CS. PAs were resected using an endoscopic technique: adenomas were resected from the CS cavity through a standard endoscopic endonasal transsphenoidal approach in 62 cases; a lateral extended transsphenoidal endoscopic approach was used in 35 cases. A control group included patients with PAs spreading into the laterosellar region who were operated on using microsurgical extra-intradural (n=14) and transsphenoidal (n=149) approaches. In the study group, the degree of PA invasion into the CS cavity was determined using the Knosp scale. RESULTS: In the study group, total tumor resection was achieved in 49 (50.5%) cases, subtotal resection in 39 (40.2%) cases, and partial resection in 9 (9.3%) patients. In the case of visual disorders (n=70), vision improvement was achieved in 41.4% of cases. Vision deterioration was detected in 11.4% of cases; no vision changes were in 47.1% of cases. Patients (27.8%) who had not had visual impairments before surgery had no negative changes in vision in the postoperative period. The development/augmentation of oculomotor disorders in the study group occurred in 14 (14.4%) cases. In the study group, hormonal remission of the disease in patients with hormone-active PAs was in 26.7% of cases (n=12). There were no cases of nasal liquorrhea, meningitis, and death in the study group. CONCLUSION: Endoscopic endonasal transsphenoidal resection of PAs invading the CS is a more efficient and safer surgical technique compared to microsurgical techniques (transsphenoidal and extra-intradural approach). The lateral extended transsphenoidal endoscopic approach enables resection of PAs with massive invasion into the CS (Grade III and Grade IV, Knosp scale) and has less postoperative complications compared to the extra-intradural approach (p<0.05).

[The use of intraoperative Doppler ultrasound in endoscopic transsphenoidal surgery].

INTRODUCTION: Doppler ultrasound (DUS) has been widely used in neurosurgical practice to diagnose various cerebrovascular diseases. This technique is used in transsphenoidal surgery to identify the localization of intracranial arteries when making an approach or during tumor resection. MATERIAL AND METHODS: To identify the cavernous segment of the internal carotid artery (ICA) and/or basilar artery during endoscopic transsphenoidal surgery, we used a combined device on the basis of a click line curette («Karl Storz¼) and a 16 MHz Doppler probe (Lassamed). The technique was used in 51 patients during both standard transsphenoidal surgery (23 cases) and transsphenoidal tumor resection through an extended approach (28 cases). RESULTS AND DISCUSSION: Doppler ultrasound was used in different situations: to determine a trajectory of the endonasal transsphenoidal approach in the absence of the normal anatomical landmarks (16 cases), to define the limits of safe resection of a tumor located in the laterosellar region (7), and to implement an extended transsphenoidal endoscopic approach (28). Intraoperative Doppler ultrasound enabled identification of the cavernous segment of the internal carotid artery in 45 cases and the basilar artery in 2 cases; a blood vessel was not found in 4 cases. Injury to the cavernous segment of the internal carotid artery was observed only in 1 case. CONCLUSION: The use of the described combined device in transsphenoidal surgery turned Doppler ultrasound into an important and useful technique for visualization of the ICA within the tumor stroma as well as in the case of the changed skull base anatomy. Its use facilitates manipulations in a deep and narrow wound and enables inspection of the entire surface of the operative field in various planes, thereby surgery becomes safer due to the possibility of maximum investigation of the operative field.

[Clinical and morphological characteristics, diagnostic criteria, and outcomes of surgical treatment of TSH-secreting pituitary adenomas]. / Kliniko-morfologicheskie kharakteristiki, diagnosticheskie kriterii i rezul'taty khirurgicheskogo lecheniya TTG-sekretiruyushchikh adenom gipofiza.

Thyrotropinomas (TSH-secreting tumors) are a rare type of pituitary adenomas, which account for about 0.5-2.0% of all pituitary tumors. The criterion of thyrotropinoma is visualization of the tumor in the presence of a normal or elevated level of the thyroid-stimulating hormone (TSH) in the blood and elevated concentrations of free T4 (fT4) and free T3 (fT3). OBJECTIVE: To study the clinical, diagnostic, and morphological characteristics and treatment outcomes of TSH-secreting pituitary tumors. MATERIAL AND METHODS: The study included 21 patients aged from 15 to 67 years with pituitary adenoma and a normal or elevated blood TSH level combined with elevated fT4 and fT3 levels who were operated on at the Neurosurgical Institute in the period between 2002 and 2015. Before surgery, in the early postoperative period, and 6 months after surgery, the patients were tested for levels of TSH, fT4, fT3, prolactin, cortisol, the luteinizing hormone (LH), the follicle-stimulating hormone (FSH), estradiol/testosterone, and the insulin-like growth factor (IGF-1). The thyroid status was evaluated using the following reference values: TSH, 0.4-4.0 mIU/L; fT4, 11.5-22.7 pmol/L; fT3, 3.5-6.5 pmol/L. An immunohistochemical study of material was performed with antibodies to TSH, PRL, GH, ACTH, LH, FSH, and Ki-67 (MiB-1 clone); in 13 cases, we used tests with antibodies to somatostatin receptors type 2 and 5 and to D2 subtype dopamine receptors. RESULTS: Thyrotropinomas were detected in patients aged from 15 to 67 years (median, 39 years), with an equal rate in males (48%) and females (52%). Before admission to the Neurosurgical Institute, 11 (52%) patients were erroneously diagnosed with primary hyperthyroidism; based on the diagnosis, 7 of these patients underwent surgery on the thyroid gland and/or received thyrostatics (4 cases). Hyperthyroidism symptoms were observed in 16 (76%) patients. The blood level of TSH was 2.47-38.4 mIU/L (median, 6.56); fT4, 22.8-54.8 nmol/L (median, 36); fT3, 4.24-12.9 pmol/L (median, 9.66). Tumors had the endosellar localization in 4 (19%) cases and the endo-extrasellar localization in 17 (91%) cases. Total tumor resection was performed in 7 (33%) patients. All these tumors had the endosellar and endo-suprasellar localization. No total resection was performed in patients with infiltrative growth of adenoma (invading the skull base structures). An immunohistochemical study of tumor resection specimens detected only TSH expression in 3 (14%) cases; 18 (86%) tumors were plurihormonal and secreted TSH and GH and/or PRL. Of 13 tumors, expression of the type 2 dopamine receptor was detected in 9 (69%) cases; expression of somatostatin receptors type 5 and type 2 was found in 6 (46%) and 2 (15%) cases, respectively. CONCLUSION: The criterion for total tumor resection was a postoperative decrease in the TSH level to 0.1 mIU/L or less. Total resection was performed in 33% of patients with tumors of only the endosellar and endo-suprasellar localization. In most cases, tumors were plurihormonal and secreted TSH and GH and/or PRL.

[SCT perfusion in the diagnosis of sellar and parasellar tumors].

UNLABELLED: The study is devoted to the use of a minimally invasive method of SCT perfusion for the differential diagnosis of sellar and pаrаsellar tumors. Given a wide differential diagnostic range of tumors occurring in this area, the tumor perfusion indicators were used as an auxiliary diagnostic criterion. MATERIAL AND METHODS: The study analyzed outcomes in 115 patients with various tumors of the sellar area who underwent surgery or biopsy for histological verification of the diagnosis. RESULTS: The statistically significant differences were obtained for certain groups of tumors based on the values of hemodynamic parameters (p<0.05) that enable, with a high confidence, making a conclusion on the histologic type of most tumors. CONCLUSION: These findings demonstrated that SCT perfusion is a highly informative method of the preoperative differential diagnosis of these tumors. The sensitivity and specificity of SCT perfusion in the study were 100% and 81.2%, respectively.

[The effectiveness of using HyperHAES hypertonic isooncotic plasma solution to achieve stable intracranial hypotension in endoscopic endonasal transsphenoidal adenomectomy as an alternative to the invasive external lumbar drainage].

The structure of surgery of pituitary adenomas has been fundamentally changed over the past decade. The transnasal transsphenoidal approach is currently used to resect more than 95% of adenomas. The wide use of endoscopy has changed the need for perioperative control of intracranial pressure. While controlled intracranial hypertension was previously used during microscopically controlled transnasal surgery to bring the suprasellar capsule and tumor remnants to the field of vision, endoscopically controlled tumor resection implies that controlled intracranial hypotension is required to achieve complete spreading of the suprasellar capsule. External lumbar drains inserted at least for the entire surgery duration are conventionally used to control intracranial pressure. We present the results of the study proving the effectiveness and safety of the HyperHAES hypertonic isooncotic plasma substitute in achieving stable intracranial hypotension according to a large body of clinical data. Our findings give grounds for claiming that the use of the HyperHAES hypertonic isooncotic plasma substitute during the standard adenomectomy allows one to abandon the use of invasive external lumbar drainage, while the surgery quality and risks remain at the same level.

[Assessment of optic nerve decompression efficiency in resection of sellar region meningiomas via intradural subfrontal approach].

In this article we analyze results of the different variants of the optic nerve transcranial decompression in cases with different chiasmal region tumors. We operate 70 patient with different type meningioma (tuberculum sella, shenoid wings, anterior clinoid, optic canal), pituitary adenoma and one case with tuberculoma (we operate it thinking on meningioma, but histology was unexpected). Groups of the patients. Group1. 20 patients with pituitary adenoma with cavernous sinus invasion. It was our "pre-endoscopic" period when we frequently operated adenomas by transcranial approach. In this 20 patients we used intra-extradural Dolenc approach to cavernous sinus. In that cases we removed anterior clinoid process and decompressed optic canal. Here we use the results of surgery in this group for showing the possibility of using high speed drill for the optic canal decompression - for showing it safety. On our opinion this type of optic canal decompression is radical and safe but superfluous for the optic canal invasion by the meningioma. Group 2. 19 patients with meningioma. In that cases we partially unroofed optic canal by Kerrison and additionally we cut the falciform ligament. Group 3. 31 patients with meningioma. It's our "main" group. Here we made intradural wide unroofing the optic canal by high speed drill. Additionaly we cut the falciform ligament and open the dural sheet of the optic nerve. We propose this methodic like sufficient, safe and useful. In this cases we frequently saw the tumor spread inside the dural sheet of the optic nerve, without seeing it on the MRI. A lot of cases in this group was a recurrent after previous meningioma removal. Like a control groups we use two. Group 4. 11 cases with meningioma. In that cases we removed tumor from optic canal without any decompression. It was our archive group - we made this type of surgery before starting optic canal decompression. This group shows the risks of any manipulation with fixed optic nerves without optic canal decompression. Group 5. 31 case with meningioma. In this cases we saw the optic canal invasion by the tumor but we didn't try to decompress it. It was our archive group - we made this type of surgery before starting optic canal decompression. We use this group for found out the risks of canal decompression. This group shows the poor perspectives for the vision in optic canal invasion by the tumor without it decompression. We analyze the results of surgery on the day of discharge and on catamnesis - we decide that the optic nerves need time to recovery. We analyzed the results of surgery in patients with 3 types of the visual dysfunction: moderate (1.0-0.5), hard (0.5-0.1), decompensating (0.1-0). For showing the real risks and effectivety of any type of decompression and surgery without decompression we look for results in patients with decompensating of visual functions. For statistical analyses we use Fisher criteria which used in small series. We statistically showed that any attempts of tumor removal form the optic canal is more risky than decompression. Also we found a tendency that wide intradural decompresstion made by high speed drill with additional falciform ligament cutting and the dural sheet opening is more effective and safe than opening the optic canal by Kerrisson. This technique also could be used during the transcranial surgery for the other type of pathology particularly in cases with short optic nerves and prefixed chiasm - it gives the mobility for the nervesand decreased the nerve damaging.

[Experience of surgical management of trigeminal schwannomas that simultaneously spread to the middle and posterior cranial fossae].

INTRODUCTION: trigeminal schwannomas account for 0.07-0.36% of all intracranial tumors and 0.8-8% of all intracranial schwannomas. Different surgical approaches are used depending on the topographic anatomical variant of the tumor. Dumbbell-shaped tumors that spread both to the middle and posterior cranial fossae are the most challenging ones in terms of their resection. MATERIAL AND METHODS: Five patients with dumbbell-shaped trigeminal schwannomas were operated on at the Burdenko Neurosurgical Institute in 2011-2013. In four cases, tumor resection comprised two stages using the retrosigmoid suboccipital approach (RSA) and lateral extended transsphenoidal endoscopic approach (LETEA); in one case, the tumor was resected in a single session through the LETEA. If there were pronounced symptoms affecting the brainstem and/or cerebellum, tumor resection from the posterior cranial fossa through RSA was resected at the first stage (3 cases). If no symptoms were observed, tumor resection from the middle cranial fossa through LETEA was used as the first stage (2 cases). RESULTS: After two surgical stages, total, subtotal, and partial tumor resection was performed (one case each). Total tumor resection from the middle cranial fossa was achieved through LETEA in two cases. Aggravation of ipsilateral paresis of the craniocerebral nerve VI was observed after the surgery in two cases. No cases of nasal liquorrhea were observed after transnasal surgery. In one case, the cavernous segment of the internal carotid artery was damaged during LETEA, thus requiring endovascular occlusion of the damaged vessel to be performed. CONCLUSION: LETEA is an effective approach that allows resection of tumors from the middle cranial fossa and the cavernous sinus. Combined with RSA, this approach can be used for two-stage resection of dumbbell-shaped trigeminal schwannomas.