[Venous cerebral complications after microsurgery for complex aneurysms of the middle cerebral arteries]. / Venoznye tserebral'nye oslozhneniya mikrokhirurgicheskikh operatsii po povodu slozhnykh anevrizm srednikh mozgovykh arterii.

Microsurgeries are common for complex aneurysms of the middle cerebral artery (MCA). OBJECTIVE: To evaluate the incidence and types of venous cerebral disorders after microsurgeries for complex MCA aneurysms. MATERIAL AND METHODS: A retrospective study included 285 patients with complex MCA aneurysms between 2009 and 2020. Pterional craniotomy and transsylvian approach were used in all cases. Aneurysm clipping was performed in 230 cases, revascularization - 27, trapping without bypass - 17, reinforcement - in 11 cases. Computed tomography within 1-3 days after surgery recognized venous cerebral disorders as heterogeneous foci of abnormal brain density with unclear boundaries. These foci were crescent-shaped as a rule and located in deep and basal parts of the frontal lobes. RESULTS: Venous abnormalities occurred in 76 (26.7%) patients. Thirty-five (12.3%) patients had mild venous edema of the frontal lobe alone. In 35 (12.3%) patients, we found moderate disorders with focus in the frontal lobe and compression of anterior horn of the left lateral ventricle with or without hemorrhagic imbibition. Severe disorders occurred in 6 (2.1%) patients with lesion extending to the frontal, insular and temporal lobes. These lesions were accompanied by hemorrhagic imbibition, and lateral dislocation exceeded 5 mm. CONCLUSION: Careful dissection of veins in Sylvian fissure with preservation of bridging veins is likely to reduce the risk of this complication. Cauterization of a large vein in Sylvian fissure should be followed by careful hemostasis within frontal or temporal cortex. Bleeding and cortical tension can indicate intracerebral hematoma whose likelihood is higher in patients with venous cerebral disorders.

[Comparison of polymethyl methacrylate skull implant fixation by three types of titanium fasteners]. / Sravnenie sposobov fiksatsii implantov cherepa iz polimetilmetakrilata tremya vidami titanovykh krepezhei.

OBJECTIVE: To evaluate mechanical strength of three methods of polymethyl methacrylate skull implant fixation in two experimental models. MATERIAL AND METHODS: The first experiment was performed on a plastic model that was as close as possible to bone in structural characteristics. The second experiment was performed on a biological specimen (a ram's head). We assessed the quality of implant fixation to bone window edges by craniofixes, ties and microscrews and lateral intercortical screws. RESULTS: Craniofixes are feasible for small flat flaps, but not advisable for wide highly curved implants. They are also the most expensive method of fixation. Implant fixation by ties and microscrews is a universal method comparable in price to craniofix. Lateral intercortical fixation is effective both for small flat implants and wide implants with large curvature. However, this method is not always applicable. CONCLUSION: Combined fixation by lateral intercortical screws and ties allows for the most effective fixation while reducing the overall price of consumables.

[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.

[Complicated course of the postoperative period with the development of epidural hygroma and intracranial hypotension after removal of cranio-orbital meningioma. Clinical case and literature review]. / Oslozhnennoe techenie posleoperatsionnogo perioda s razvitiem epidural'noi gigromy i vnutricherepnoi gipotenzii posle udaleniya kranioorbital'noi meningiomy. Klinicheskii primer i obzor literatury.

Surgical removal of cranio-orbital meningiomas is an effective method of treating this pathology. Modern surgical techniques and technologies make it possible to perform operations with a low risk of complications. Lumbar drainage or repeated lumbar punctures are often used intraoperatively or in the early postoperative period to prevent nasal CSF leak; this rarely leads to the development of significant neurological symptoms. We present a case of the development of severe intracranial hypotension with the formation of a subdural hygroma in the early postoperative period after removal of a cranio-orbital meningioma in a 41-year-old patient. The operation was performed using an individual model and molds for simultaneous reconstruction of the bone defect with an implant made of polymethyl methacrylate. On the 1st and 2nd days after surgery, lumbar punctures were performed. From the 2nd day there was a progressive deterioration with the development of symptoms characteristic of intracranial hypotension. Computed tomography revealed an increasing displacement of the midline structures of the brain and an increasing volume of epidural fluid accumulation in the area of surgical intervention. Magnetic resonance imaging revealed characteristic signs of intracranial hypotension. Conservative treatment (bed rest, active hydration) had no effect. On the 6th day after surgery, an epidural blood patch procedure was performed and closed external drainage of the epidural hygroma was performed, and a rapid regression of neurological symptoms was noted. Our experience and literature data indicate that it is necessary to remember the possibility of developing clinically significant intracranial hypotension even after a single lumbar puncture. The formation of hygromas in the surgical area is characteristic of intracranial hypotension, but in most cases does not require additional surgical intervention and does not have a negative impact on the outcome of treatment. Conservative treatment of intracranial hypotension is the first choice and often sufficient. If there is no effect and the patient's condition worsens, it is necessary to perform an epidural blood patch procedure.

[Spontaneous dural CSF fistula as a cause of intracranial hypotension syndrome. Case report and literature review]. / Spontannaya dural'naya likvornaya fistula kak prichina sindroma vnutricherepnoi gipotenzii. Sluchai iz praktiki i obzor literatury.

Typical symptoms of spontaneous intracranial hypotension syndrome are severe headache, weakness, dizziness and inability to stay upright for a long time. Most often, this syndrome occurs due to CSF fistula in spinal space. Pathophysiology and diagnosis of this disease are poorly known for neurologists and neurosurgeons that can complicate timely surgical care. In case of correct diagnosis, we can identify the exact location of CSF fistula in 90% of cases. Treatment eliminates symptoms of intracranial hypotension and provides functional recovery. The purpose of this article is to describe the diagnostic algorithm and successful microsurgical treatment of a patient with spinal dural CSF fistula Th3-Th4 through posterolateral transdural approach.

[Screening of patients with cerebral aneurysms: mathematical analysis and economic justification]. / Skrining patsientov s anevrizmami golovnogo mozga: matematicheskii analiz i ekonomicheskoe obosnovanie.

Subarachnoid hemorrhages due to rupture of cerebral aneurysms have a high risk of disability and mortality. Screening of the population to detect aneurysms in patients with risk factors is currently not carried out in Russia. However, the detection of clinically silent aneurysms and their subsequent prophylactic surgical treatment are justified, according to numerous studies. BACKGROUND: Demonstrate the clinical and economic feasibility of screening the population (including first-line relatives) for cerebral aneurysms using an economic and mathematical model of the RF virtual population. MATERIAL AND METHODS: Mathematical modeling was carried out using an algorithm that implements a discrete Markov chain. The virtual population consisted of 145 million people (the population of the Russian Federation). Magnetic resonance angiography 3DTOF was chosen as a screening method. Virtual patients underwent preventive surgical treatment in case of detection of aneurysm during screening. The number of aneurysms in the population, the number of aneurysmal subarachnoid hemorrhage (aSAH), the cost and outcomes of treatment, and the risk of disability were calculated. RESULTS: In the case of screening and preventive surgical treatment of aneurysms, there is a decrease in the number of aSAH by 14.3% (37.5% in first-line relatives (RPLR), which affects the reduction in mortality due to aSAH by 14.4% (24.1% in The total number of disabled people is reduced by 1.5% (5.1% for the RPHR). A shift in the structure of disability towards greater labor and social adaptation of patients was noted. An economic analysis for the entire population showed that screening saves 7.7 billion annually rubles, including in the population consisting of RPLR - 4.9 billion rubles. CONCLUSION: The created mathematical model of the virtual population demonstrated that screening and prophylactic treatment of cerebral aneurysms makes it possible to reduce the number of aSAH and associated mortality among the entire population and in the RPLR group. The number of individuals with severe disabilities is decreasing. Thus, population screening for the detection of cerebral aneurysms may be clinically effective and cost-effective in the general population, especially in RPCR.

[Spinal CSF-venous fistula: case report and literature review]. / Spinal'naya likvoro-venoznaya fistula kak prichina sindroma spontannoi vnutricherepnoi gipotenzii: sluchai iz praktiki i obzor literatury.

Syndrome of spontaneous intracranial hypotension is increasingly described in the literature as a multifactorial disease with impairment of the quality of life and risk of mortality. CSF-venous fistula as a cause of intracranial hypotension syndrome is extremely rare and requires complex diagnosis and timely surgical treatment. OBJECTIVE: We present a 55-year-old patient with acute spontaneous intracranial hypotension and spinal CSF-venous fistula. Literature data are also analyzed. RESULTS: Algorithm for diagnosis and efficacy of microsurgical resection of CSF-venous fistula is demonstrated. CONCLUSION: Intracranial hypotension following spinal fistula requires careful examination. Accurate understanding of pathophysiological and anatomical features of this disease is necessary to select an effective treatment method.

[Intravascular hypothermia for cerebral ischemia after microsurgical clipping of complex MCA aneurysms]. / Vnutrisosudistaya gipotermiya pri tserebral'noi ishemii posle mikrokhirurgicheskogo klipirovaniya slozhnykh anevrizm srednei mozgovoi arterii.

Hypothermia for neuroprotection and correction of intracranial hypertension was described in both experimental and clinical studies. Effectiveness of hypothermia for improvement of functional outcomes in neurosurgical patients is still unclear despite the previous randomized trials. In available national and foreign literature, we found no trials devoted to hypothermia in patients with ischemia after surgical treatment of complex aneurysms of the middle cerebral artery (MCA). OBJECTIVE: To analyze the effectiveness of intravascular hypothermia in patients with ischemic cerebrovascular accidents in early postoperative period after microsurgical clipping of complex MCA aneurysms. MATERIAL AND METHODS: We present four patients with cerebral ischemia after microsurgical treatment of complex MCA aneurysms. In all cases, ischemic disorders developed immediately after surgery. We induced intravascular hypothermia 32-34 °C in all patients. CT-based volumetry of ischemia and edema foci was performed to objectively assess the dynamics of ischemic disorders. We carried out volumetry using segmentation of edema and ischemia foci (range 5-33 Hounsfield units). RESULTS: According to brain CT data, all four patients had enlargement of postoperative ischemic brain damage. Nevertheless, ICP was stable that made it possible to avoid decompressive craniotomy. CONCLUSION: Early hypothermia for acute ischemic injury after surgery for complex MCA aneurysms can reduce ischemic perifocal edema. This approach effectively reduces ICP and can exclude the need for decompressive craniotomy in some cases. No side effects of hypothermia justifies further research in this field.

[Features of modeling a polymer implant for closing a defect after decompressive craniotomy]. / Osobennosti modelirovaniya, izgotovleniya i ustanovki polimernykh implantatov dlya zakrytiya defekta cherepa posle dekompressivnoi trepanatsii.

BACKGROUND: Individual polymer implants are widespread for bone reconstruction after decompressive craniectomy. Despite the availability of customized titanium products, various specialists and hospitals prefer polymer implants. OBJECTIVE: To compare the methods of modeling and manufacturing the polymethylmethacrylate implants and identify the features affecting the quality of reconstruction. MATERIAL AND METHODS: We analyzed 14 patients with extensive skull defects after installation of polymethyl methacrylate implants. Software used for modeling of individual implants by different specialists was compared. RESULTS: Satisfactory reconstruction result was obtained in all cases. There were no infectious complications. The authors outlined certain important aspects for modeling of individual polymer products: local use of anatomical thickness of the implant, leaving safe spaces, prevention of temporal retraction, template-based resection before reconstruction. CONCLUSION: To date, skull defect closure with polymeric materials remains relevant, and even has certain advantages over customized titanium products.

[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 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.

[Successful combination treatment of giant bicameral fusiform partially thrombosed vertebral artery aneurysm at 12-year-old patient (practical case and literature review)]. / Uspeshnoe kombinirovannoe lechenie gigantskoi dvukhkamernoi fuziformnoi chastichno trombirovannoi anevrizmy pozvonochnoi arterii u patsienta 12 let (sluchai iz praktiki i obzor literatury).

Giant cerebral aneurysms are diagnosed more often in children than in adults. Treatment of giant aneurysms is carried out both by endovascular and microsurgical methods. Literature information on combination of microsurgical and endovascular operations of cerebral aneurysms at children is little. A clinical case of the combined treatment of a giant bicameral fusiform partially thrombosed aneurysm of the right vertebral artery at a 12-year-old patient and a literature review on this topic are presented. The patient underwent several complex neurosurgical interventions during two operations: 1) microsurgery including revascularization of the right posterior lower cerebellar artery, thrombectomy and trapping of the larger chamber of fusiform aneurysm of the right vertebral artery, and 2) endovascular, which consists in the installation of redirecting stent from the left vertebral artery to main artery. The uniqueness of the case which we presented lies in the fact that the tactics of stage combined treatment for a complex aneurysm at child was originally planned and successfully implemented. The treatment allowed to ensure a complete shutdown of aneurysm and to exclude postoperative cerebral complications.

[Microsurgical treatment of aneurysms of vertebral and posterior-lower cerebellar arteries: surgical approaches, exclusion options, treatment results]. / Mikrokhirurgicheskoe lechenie anevrizm pozvonochnykh i zadnikh nizhnikh mozzhechkovykh arterii: khirurgicheskie dostupy, varianty vykliucheniia, rezul'taty lecheniia.

Aneurysms of vertebral (VA) and posterior inferior cerebellar arteries (PICA) are relatively rare pathologies and account for 3.4% of the total number of intracranial aneurysms. MATERIAL AND METHODS: The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented. RESULTS: Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes. CONCLUSION: Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.

[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.

[Individual preoperative 3D modeling of vascular brain pathology]. / Individual'noe predoperatsionnoe 3D-modelirovanie sosudistoi patologii golovnogo mozga.

The possibility of segmenting three-dimensional objects by DICOM-series is well known and available both on specialized workstations and on personal computers. The technique, however, is relatively rarely used in clinical practice, and we believe that the benefits of preoperative preparation using segmented 3D models are underestimated. The article is devoted to our experience in using segmentation of anatomical structures based on CT and MRI for preoperative preparation for surgical operations performed in neurosurgical departments on patients with vascular pathology. The paper discusses the types and possibilities of segmentation, provides some examples describing the clinical use of the technique.

[Technical features and complications of cranioplasty in patients after decompressive craniectomy in the acute period of subarachnoid hemorrhage]. / Tekhnicheskie osobennosti i oslozhneniia kranioplastiki u patsientov posle dekompressivnoi trepanatsii cherepa v ostrom periode subarakhnoidal'nogo krovoizliianiia.

Decompressive craniectomy is used for arresting hypertension-dislocation syndrome developing in seriuos patients in the acute period of subarachnoid hemorrhage. After stabilization of the patient's neurological and somatic status, cranioplasty is performed for protective, cosmetic, and therapeutic purposes. The most common surgery in these patients is skull repair using an autologous bone graft. Before cranioplasty, the patient's bone is preserved in two ways: cryopreservation or subcutaneous implantation to the anterior abdominal wall area. Recently, there have been numerous reports of early and delayed complications of cranioplasty with autologous bone grafts. The use of artificial grafts may reduce the risk of postoperative complications compared to an autologous bone graft. Previously, 'freely' or 'manually' simulated biopolymers were used. At present, they are rarely used for repair of extensive defects due to a poor cosmetic result. However, the advent of stereolithographic modeling and computer modeling of artificial grafts has improved the cosmetic result of this surgery. The purpose of this study is to assess the risk of postoperative complications of cranioplasty as well as to define the criteria for choosing a cranioplasty technique.

[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.

[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.

[A favorable outcome of surgical treatment and intensive care in a child admitted in a severe condition in the setting of aneurysmal subarachnoid hemorrhage (a clinical case and literature review)]. / Blagopriiatnyi iskhod khirurgicheskogo lecheniia i intensivnoi terapii u rebenka, postupivshego v tiazhelom sostoianii na fone anevrizmaticheskogo subarakhnoidal'nogo krovoizliianiia (klinicheskoe nabliudenie i obzor literatury).

Treatment of children in the acute stage of hemorrhage from cerebral aneurysms is based on clinical cases reported in the literature and descriptions of small series of observations. There are no studies that enable the development of evidence-based approaches to intensive care in treatment of children with aSAH. We present a clinical case with a favorable outcome of complex treatment in a child admitted to the Burdenko Neurosurgical Institute at an extremely severe condition. The efficacy of treatment was based on a timely urgent neurosurgical intervention and adequate intensive therapy in the form of extended neuromonitoring with continuous measurement of intracranial pressure, which enabled using the whole complex of measures for timely management of intracranial hypertension. A favorable outcome (a GOS score IV) after this severe aneurysmal SAH indicates that there are no absolute contraindications for neurosurgical treatment of children with cerebral aneurysms.

[Reasonability and efficacy of decompressive craniectomy in patients with subarachnoid hemorrhage after microsurgical aneurysm exclusion]. / Opredelenie opravdannosti i éffektivnosti dekompressivnoi trepanatsii cherepa u bol'nykh s subarakhnoidal'nym krovoizliianiem posle mikrokhirurgicheskogo vykliucheniia anevrizm.

In recent years, the so-called primary or preventive decompressive craniectomy (DC) has been increasingly used in patients with aneurysmal subarachnoid hemorrhage (SAH). The main goal of the technique is prevention of refractory intracranial hypertension (ICH) and its consequences. PURPOSE: The study purpose was to define the CT criteria for reasonability and efficacy of DC as well as clarification of the indications for preventive DC in patients with SAH after microsurgical aneurysm exclusion. MATERIAL AND METHODS: The study included 46 patients who underwent microsurgical clipping of aneurysms and DC in the period between 2010 and 2016. All patients underwent surgery in the period of 1 to 12 days after SAH. Preventive DC (imultaneously with clipping of aneurysms) was performed in 38 patients. Secondary (delayed) DC was performed in 8 patients. RESULTS: Mortality in a group of all patients with DC was 15.2%. Preventive DC was considered as 'reasonable' when the patient had signs of cerebral edema in the postoperative period. The X-ray criteria of reasonable DC included a more than 5 mm brain prolapse into the trephination defect or a lateral dislocation of more than 5 mm. If the patient had no prolapse and dislocation in the postoperative period, DC was considered 'unreasonable'. Among patients with ICH in the postoperative period, including 20 patients with reasonable preventive DC and 8 patients with delayed DC, mortality was 25%. The CT signs of efficient DC were found to be a more than 5 mm brain prolapse into the trephination defect in combination with a decrease in the lateral dislocation less than 5 mm. All seven patients with inefficient DC in our group died. To clarify the indications for preventive DC, we analyzed various preoperative factors in patients with reasonable and unreasonable DC. CONCLUSION: In most cases, preventive DC in microsurgical aneurysm exclusion is indicated for patients in an extremely grave condition (Hunt-Hess Grade V), a lateral displacement of the mline structures of more than 5 mm, an intracranial hematoma of over 30 mL, and symptoms of acute cerebral ischemia (pronounced cerebral vasospasm and emerging ischemic foci).