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

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

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

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

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

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

[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).

[Use of the IntelliVent-ASV mode for maintaining the target EtCO2 range in patients with severe TBI]. / Ispol'zovanie rezhima IntelliVent-ASV dlia podderzhaniia tselevogo diapazona EtCO2 u patsientov s tiazheloi ChMT.

PURPOSE: the study purpose was to evaluate the efficacy of the IntelliVent-ASV mode in maintaining the target range of PaCO2 in patients with severe TBI. MATERIAL AND METHODS: The study included 12 severe TBI patients with the wakefulness level scored 4-9 (GCS). This was a crossover design study. Two ventilation modes were consecutively used: IntelliVent-ASV and P-CMV, for 12 h each. When using the P-CMV mode, the ventilation parameters were set to maintain PaCO2 in a range of 35-38 mm Hg. The IntelliVent-ASV mode involved the Brain Injury ventilation algorithm. The target range of EtCO2 was set in accordance with the delta PaCO2-EtCO2 to maintain PaCO2 in a range of 35-38. At the beginning of each ventilation period and every 3 hours, the arterial blood gas composition was analyzed. When PaCO2 occurred out of the 35-38 range, appropriate adjustments were made to the ventilation parameters. In the P-CMV mode, the Pinsp and RR parameters were adjusted to achieve the target PaCO2 range. In IntelliVent mode, a shift of the target EtCO2 range was adjusted in accordance with a changed PaCO2-EtCO2 difference. In all patients, ICP, blood pressure, and EtCO2 were monitored; the arterial blood gas composition was analyzed every 3 h; the frequency of manual settings of ventilation parameters was recorded. RESULTS: The EtCO2 and PaCO2 parameters were found not to be significantly different in the P-CMV and IntelliVent modes, but the spread in these parameters was significantly lower in the IntelliVent ventilation mode. The PaCO2 parameter occurred out of the target range significantly less often in the IntelliVent mode than in the P-CMV mode. The mean frequency of manual respirator settings needed to maintain the target EtCO2 range was significantly lower in the IntelliVent-ASV mode than in the P-CMV mode. CONCLUSION: The IntelliVent-ASV mode provides more efficient maintenance of PaCO2 in the target range compared to traditional artificial ventilation using fewer manual settings of the ventilation parameters.

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

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

[Paradoxical air embolism resulted in acute myocardial infarction and massive ischemic brain injury in a patient operated on in a sitting position].

Paradoxical air embolism (PAE) is a rare life-threatening complication when air emboli enter arteries of the systemic circulation and cause their occlusion. Here, we describe a clinical case of PAE developed during neurosurgery in a patient in the sitting position. PAE led to injuries to the cerebral blood vessels, coronary arteries, and lungs, which caused death of the patient. An effective measure for preventing PAE is abandoning surgery in the sitting position in favor of surgery in the prone position.

[Spinal stroke in a pregnant female with an endodermal cyst of the cervical spinal cord (a case report and literature review)]. / Ostroe narushenie spinal'nogo krovoobrashcheniya u beremennoi s endodermal'noi kistoi sheinogo otdela spinnogo mozga (sluchai iz praktiki i obzor literatury).

AIM: The study purpose was to present a clinical case of spinal stroke in a pregnant female, which was caused by an endodermal cyst of the cervical spinal cord, and to analyze treatment tactics. RESULTS: A 20 week pregnant female presented with acute transverse spinal cord injury at the of C3-C5 spinal segment level. CT revealed an extramedullary space-occupying lesion in the ventrolateral position, with compression of the spinal cord at this level. The patient in the state of progressive deterioration with respiratory failure was transferred to the Neurosurgical Institute on the 5th day after disease onset. The patient underwent surgery on the 7th day after disease onset. Doctors of various specialties participated in preparation for surgery. During surgery, total resection of the space-occupying lesion and spinal cord decompression were performed. An obstetrician-gynecologist conducted intraoperative fetal monitoring by ultrasound. The histological diagnosis was an endodermal cyst. There was no improvement of neurological symptoms in the early postoperative period. After stabilization of the condition, the patient was discharged for follow-up care at the place of residence. According to the follow-up report, the patient underwent the cesarean section because of exacerbation of lung infection and a significant delay in the fetal development. After a few days, the patient died due to multiple organ failure. The child was alive, in serious condition, under mechanical ventilation. CONCLUSION: In the case of spinal stroke, the decision on treatment tactics should be made no later than 12 hours after its onset; otherwise, the outcome is usually unfavorable, and a neurological deficit is irreversible. The decision about continuing pregnancy should be made individually in each case, and an approach to the choice of appropriate treatment tactics should be multi-disciplinary.