Vladimir Viktorovich Krylov

Background. Navigation systems today have become an integral part of most neurosurgical interventions, including those on the spine. Aim. Development of a methodology for laboratory testing of the accuracy of navigation systems during surgical interventions on the spine and its evaluation for the domestic optical frameless navigation system “Multitrack”. Materials and methods. Using enbalmed human specimens, a posterior approach to the cervical, thoracic and lumbar spine was simulated. In each part of the spine, titanium miniscrews were implanted in the area of anatomical structures (target points) that were most significant when performing neurosurgical interventions on the spine. Next, a series of experimental measurements of navigation accuracy were performed to determine the system error in the axial and sagittal planes. Results. The average registration error was 0.3 [0.21; 0.43] mm. Statistical analysis showed the absence of a linear correlation between the magnitude of the registration error and the error in hitting the target points, both in the axial (r = 0.125; 95 % confidence interval 0.016–0.242; р = 0.03) and sagittal (r = 0.113; 95 % confidence interval –0.003…0.222; р = 0.051) planes. The average error in hitting the target points was 0.7 [0.4; 1.0] mm in the axial plane and 0.6 [0.3; 1.0] mm – in the sagittal. Conclusion. In a series of experiments, the Multitrack navigation system demonstrated accuracy sufficient to perform most vertebrological surgical interventions.

Background. Vagus nerve stimulation (VNS) is used in patients with drug‑resistant epilepsy, including those who have previously undergone resective surgical interventions. Aim. To evaluate the efficacy and safety of VNS in patients with persistent epileptic seizures after resective surgery, to identify the favorable predictors of treatment response as well as to determine the optimal timing for VNS device implantation following previous surgical intervention. Materials and methods. The study included 40 patients in the main group who underwent resective epilepsy surgery followed by vagus nerve stimulator implantation, and 40 patients in the control group who received only resective surgery. Outcomes were assessed using the modified J. Engel Epilepsy Surgery Outcome Scale and the McHugh Outcome Scale. Results. The analysis of VNS efficacy outcomes in the main group (n = 40) using the modified J. Engel scale in 12 months after implantation showed, that Engel class I outcomes were observed in 12.5 % of patients, Engel class II ‑ in 12.5 %, Engel class III – in 55 %, and Engel class IV – in 20 %. In 24 months after VNS implantation, Engel class I outcomes were noted in 22.5 % of patients, Engel class II – in 10 %, Engel class III – in 57.5 %, and Engel class IV – in 10 %. At 36 months of follow‑up, Engel class I outcomes were observed in – 20 % of patients, Engel class II – in 27.5 %, Engel class III – in 47.5 %, and Engel class IV – in 5 % of patients. According to the McHugh Outcome Scale, in 12 months after VNS therapy, class I outcomes were achieved in 25 % of patients, class II – in 55 %, class III – in 12.5 %, class IV – in 5 %, and class V – in 2.5 %. In 24 months after VNS implantation, class I outcomes were observed in 32.5 % of patients, class II – in 57.5 %, class III – in 5 %, class IV – in 2.5 %, and class V – in 2.5 %. At 36 months of follow‑up, class I outcomes were achieved in 47.5 % of patients, class II – in 47.5 %, class III – in 2.5 %, class IV – in 3.5 %, while no class V outcomes were observed. The most frequently reported stimulation‑related adverse events included cough (30 %), hoarseness (22.5 %), throat discomfort (12.5 %), and discomfort in the face, neck, and chest regions (5 %). Conclusion. In patients with drug‑resistant epilepsy who previously underwent resective surgery, VNS resulted in more or equal 50 % reduction in seizure frequency in 80% of patients during the first 12 months of follow‑up. With continuous stimulation, the effectiveness of the therapy increased over time. The most favorable time for VNS implantation and initiation of stimulation is within the first 16.5 months following resective epilepsy surgery.

This consensus outlines the key information regarding the course of the disease and treatment approaches for patients with pituitary adenomas. A multidisciplinary team of specialists, including a neurosurgeon, an endocrinologist, and a radiotherapist, carries out the management of this patient group. The document details the current understanding of the course of the disease and treatment methods for somatotroph, corticotroph, prolactin-secreting, thyrotroph, and clinically non-functioning pituitary adenomas. The applied treatment modalities include surgical, medical, and radiotherapeutic approaches. The choice of strategy depends on hormonal activity, tumor size, direction of growth, the severity of mass effect, and the presence of somatoneurological complications. Patients should be followed by specialists with the appropriate expertise to diagnose and manage the full spectrum of pituitary adenomas. Upon diagnosis of a pituitary adenoma, consultation with a neurosurgeon, radiologist, and radiotherapist is recommended to exclude meningiomas, craniopharyngiomas, and other neoplasms of the sellar region. For all patients with acromegaly who are candidates for neurosurgical treatment, surgery is recommended to be performed at medical centers specializing in pituitary disorders. In the vast majority of cases, medical therapy for acromegaly is recommended as second-line therapy. Radiotherapy constitutes the third line of treatment for acromegaly. The treatment of Cushing’s disease involves surgical, medical, and radiotherapeutic interventions. First-line treatment consists of endoscopic transnasal adenomectomy performed at an expert-level center. In cases where surgery is ineffective, repeat surgery may be considered. Medical therapy or radiotherapy are used as second-line options. In life-threatening hypercortisolism, bilateral adrenalectomy is performed. The management of prolactin-secreting adenomas involves three main methods: medical, surgical, and radiotherapeutic. Medical therapy is the preferred treatment modality. Surgery is not the treatment of choice for prolactinomas. Adenomectomy is recommended for patients with intolerance or resistance to conservative therapy, or when absolute indications are present. Upon confirmation of a thyrotropinoma diagnosis, endoscopic transnasal adenomectomy is performed in a specialized medical facility. If surgery is not feasible or for preoperative preparation, somatostatin analogs are used. Thyrostatic agents are not indicated. For clinically non-functioning pituitary adenomas, surgical treatment is indicated in the presence of: visual field deficits and decreased visual acuity caused by compression of the optic chiasm and optic tracts; oculomotor disturbances such as ophthalmoplegia, diplopia, or other neurological disorders resulting from pathological compression of adjacent neural structures; pituitary apoplexy with visual disturbances; impaired cerebrospinal fluid outflow, hydrocephalus, and intracranial hypertension caused by tumor extension into the third ventricle; CSF rhinorrhea resulting from tumor-induced destruction of the diaphragm and the floor of the sella turcica.

Материалы на основе шелка паутины для регенеративной медицины

Introduction Symptomatic cerebral vasospasm (CVS) is one of the most severe complications of subarachnoid hemorrhage (SAH) due to ruptured cerebral aneurysms, leading to delayed cerebral ischemia. The pathogenesis of CVS is associated, among other factors, with a deficiency of the endothelial vasorelaxant factor — nitric oxide (NO). Administration of inhaled NO can replenish this deficit and help reduce the severity of CVS; however, clinical data remain limited. Aim To evaluate the feasibility of inhaled nitric oxide (iNO) therapy in patients with signs of symptomatic vasospasm in the acute period of non-traumatic SAH caused by ruptured cerebral aneurysms. Material and methods A case series was carried out involving 9 patients (5 women, 4 men; aged 35–74 years) admitted to the N.V. Sklifosovsky Research Institute for Emergency Medicine in 2022–2024 during the hyperacute period after cerebral aneurysm rupture. The main inclusion criterion was the development of symptomatic CVS resistant to standard therapy (calcium channel blockers, induced hypertension) for at least 1 hour. All the patients underwent microsurgical aneurysm clipping. Inhalation of NO was performed via a face mask using a “Tianox” device at a concentration of 55–80 ppm with FiO₂ 21% until regression of symptoms. Clinical neurological status, jugular venous oximetry, markers of oxidative stress (malondialdehyde (MDA), total antioxidant status (TAS)) and endogenous vascular regulation (nitric oxide metabolites (NOx), angiotensin-converting enzyme (ACE)), video-EEG monitoring and CT perfusion data were assessed. Results Inhalation therapy resulted in regression of symptomatic CVS in 8 of 9 patients, including complete neurological recovery in 5 patients. The mean time to symptom regression ranged from 3 to 21 hours. In 2 patients, premature discontinuation of therapy led to symptom recurrence, requiring resumption of inhalations. CT perfusion on day 7 revealed reversible focal cerebral perfusion deficits in 4 patients. No adverse effects (methemoglobinemia >3.5%, hypotension, toxic NO₂ concentrations) were recorded. Mortality (n=2) was due to extracranial complications. Conclusion Inhaled NO therapy in SAH patients with symptomatic CVS on spontaneous breathing is safe and potentially effective for rapid regression of neurological symptoms and improvement of cerebral perfusion.

Introduction The effectiveness of surgical treatment for cerebral aneurysms is due to the improvement of surgical and anesthetic methods that allow for the exclusion of aneurysms from the blood flow. An important condition for the safe isolation and clipping of an aneurysm is the temporary shutdown of blood flow in the artery, in particular, temporary clipping (TC) of the artery carrying the aneurysm. Intraoperative neurophysiological monitoring (IONM) was proposed to predict ischemic complications in the treatment for intracranial aneurysms using TC. However, data on the results of using IONM in clipping cerebral aneurysms are contradictory. The aim of the study was to evaluate the effectiveness of intraoperative neuromonitoring in the surgical treatment for cerebral aneurysms. Material and methods The examination and surgical treatment of 93 patients with cerebral aneurysms was performed; patients were divided into 2 groups: Group 1 (no IONM) — 48 patients who underwent open clipping of the aneurysm without the use of intraoperative neuromonitoring (control group); Group 2 (IONM) — 45 patients who underwent IONM during surgical treatment for cerebral aneurysms in the internal carotid artery and middle cerebral artery. The treatment outcomes were assessed by the indicators of the radicality of exclusion of the aneurysm from the blood flow, functional outcomes - by the Glasgow Outcome Scale and the Rankin scale. During IONM, transcranial electrical stimulation (TES) was performed, with the impulse being delivered through the bones of the skull from electrodes located on the scalp surface, and motor evoked potentials (MEP) were recorded, direct electrical stimulation of the cerebral cortex (DES-MEP) was performed using a strip electrode laid along the precentral gyrus. After isolating the parent vessel, TC was performed in order to dissect the aneurysm from the surrounding tissues. Results It was found that the use of IONM during blood flow interruption in surgical treatment for cerebral aneurysms was accompanied by a decrease (compared to the group of patients without neuromonitoring) in the number of cases of temporary clipping by 33%, an increase in the total duration of TC by 25%, a decrease in the number of reperfusions by 50%, a decrease in the total duration of reperfusions by 3 times, a decrease in the duration of one ТC session by 10%, and a decrease in the volumetric blood flow through the carrier arteries by 18.1%. At the same time, no significant intergroup differences in systemic hemodynamic parameters were observed. Also, during IONM, there was no decrease in the amplitude of the MEP-TES in 93.3% of patients, the amplitude of evoked potentials did not change in 77.8–91.2% of patients, while the course of the operation changed in 33.3% of patients. In the early postoperative period, in patients who underwent IONM during TC performance, the proportion of patients with a Glasgow Coma Scale score of 14–15 points was 51% higher, and with a score of 9–13 points 8.8 times lower (than in the group without IONM), speech disorders were detected 2.5 times less often, the presence of cerebral ischemia zones was noted 1.8 times less often. Conclusion Thanks to the feedback provided by the use of IONM in real time, the surgeon can always immediately respond to the development of structural damage to the brain, which in turn helps prevent neurological disorders during surgical treatment of cerebral aneurysms. The use of IONM during open clipping of aneurysms allows increasing the number of excellent treatment outcomes by 44%.

Ultrasound scan is a minimally invasive and highly informative method of examination of patients with atherosclerotic lesions of the brachiocephalic arteries. The article presents an algorithm of examination of patients with symptomatic occlusion of the internal carotid artery who are scheduled for revascularization interventions. The aims and capabilities of ultrasound diagnostics at various stages of treatment of the patients with this pathology are described. Special attention is paid to discussion of indicators predicting failure of extracranial-intracranial low-flow bypasses. Examples of functioning and failed anastomoses are presented.

Aim. To compare results of surgical treatment of patients with distal aneurysms of the middle cerebral and pericallosal arteries who underwent surgery with frameless neuronavigation and without it. Materials and methods. The study was performed at the N. V. Sklifosovsky Research Institute for Emergency Medicine, Russian Сenter of Neurology and Neurosciences, Moscow City Hospital named after S. S. Yudin between January 1st 2009 and December 31st 2023. Analysis included 45 patients with distal aneurysms of the pericallosal and middle cerebral arteries. Taking into account surgical technique, the patients were divided into 2 groups: the 1st group (n = 21) included patients who underwent surgery with frameless neuronavigation; among them 10 (47.6 %) patients had distal aneurysms of the middle cerebral artery, 11 (52.4 %) patients had distal aneurysms of the pericallosal artery. The 2nd group (n = 24) included patients who underwent surgery without frameless neuronavigation; among them 10 (41.7 %) patients had distal aneurysms of the middle cerebral artery, 14 (58.3 %) patients had distal aneurysms of the pericallosal artery. Results. The use of frameless neuronavigation helps in the search for distal aneurysms during the main stage of the surgery, decreases time between dissection and clipping of a distal aneurysm (p = 0.0001), decreases operative time (р = 0.0001) but requires more time for access planning (p = 0.008). Frameless neuronavigation helps to determine optimal size and location of craniotomy for the most direct and safe trajectory to the distal aneurysm (p = 0.008), decreases the risk of intraoperative injury of the frontal sinus (p = 0.025). Patients, in whom distal aneurysm clipping was performed using frameless navigation, had lower rate of neurologic deficit (p = 0.0001), postoperative (p = 0.025) and systemic (p = 0.005) complications, repeat surgeries (p = 0.002). Conclusion. The use of frameless neuronavigation decreases search time for distal aneurysms and operative time, allows to decrease craniotomy area and prevent intraoperative injury of the frontal sinus, statistically significantly decreases the risk of postoperative neurologic deficit, and improves clinical outcomes.

Hereditary spastic paraplegia is a diverse group of inherited neurodegenerative diseases characterized by spasticity and weakness in the lower extremities. Treatment is comprehensive and includes pharmacotherapy and physical therapy. If these approaches are ineffective, neurosurgical methods such as rhizotomy or intrathecal baclofen therapy are applied. Epidural spinal cord stimulation is still poorly studied. Objective. To evaluate safety and efficacy of epidural spinal cord stimulation in patients with hereditary spastic paraplegia. Material and methods. The study (2015—2024) included patients with hereditary spastic paraplegia refractory to conservative treatment. After test stimulation, permanent spinal stimulation systems (classic generator-based and wireless external) were implanted in 18 patients. The modified Ashworth scale, the Spastic Paraplegia Rating Scale (SPRS), the Timed Up and Go Test (TUG), the Ten-Meters Walk Test (10MWT), and the SF-36 questionnaire were used to assess neurological status preoperatively and six months after surgery. The study was approved by local ethics committee. Results. Implantation of permanent stimulation system (electrodes at the level of Th10-Th12) was performed in 18 patients (13 men, 5 women). Of these, 7 patients received wireless systems with external energy source, while 11 ones received classic generator systems. Six months after the intervention, we observed improvements in the following parameters compared to pre-implantation state: MAS score from 3 to 1.5—1 (18 patients); TUG test by 11.2—19.7% (17 patients); 10MWT test by 12.6—20.5% (17 patients); SPRS score by 27.9% (17 patients); SF-36 score 30—66% (16 patients). Conclusion. Epidural spinal cord stimulation may be considered for hereditary spastic paraplegia, but further research is needed to clarify its role in symptomatic treatment of spastic paraplegia.

This review examines the use of spider-silk-based materials in regenerative medicine. Spider silk possesses a unique combination of mechanical and biological properties, making it a promising biomaterial for tissue engineering. An analysis of in vivo studies in animal models and the first clinical trials is presented, demonstrating the ability of spider silk to direct cell growth, accelerate wound healing, and promote peripheral nerve regeneration. The prospects for large-scale production of spider silk and its medical applications are discussed.