Ivan Mikhailovich Godkov

Introduction. Currently diagnosis of cerebrospinal fluid (CSF) leak involves the use of instrumental and laboratory techniques. Computed tomography of the brain (CT brain) is the preferred instrumental method. However, it is not always effective for visualization of skull base defects less than 2 mm in size.Aim. To confirm nasal CSF leak primarily using laboratory diagnostic methods, rather than instrumental diagnostic methods.Materials and methods. Instrumental diagnosis of nasal CSF leak (outpatient): high-resolution CT brain with subsequent image analysis in multiplanar projections. Laboratory diagnosis: quantitative test of glucose in nasal fluid using test strips (Russia) and quantitative test using hexokinase method and biochemical analyzers (Japan, USA).Results. Diagnostic tactics and types of surgical treatment for 34 patients are presented. CT brain was performed in all patients, and no bone defect was found in 5 (14.7 %) cases. However, thinning of the bone tissue in the area of the cribriform plate of the ethmoid bone with the presence of a soft tissue inclusion (meningoencephalocele), as well as a low position of the olfactory fossa (8.16 ± 0.14 mm) was observed. Through laboratory diagnostics, admixture of CSF in nasal fluid was verified in 5 (14.7 %) patients. Reconstruction of CSF fistulas was performed in all patients through endoscopic endonasal access using multilayer closure technique with allo- and autografts. In the postoperative period, no recurrence of CSF leak was observed. Follow-up period ranged from 6 months to 3 years.Discussion. In verification of CSF in nasal fluid, CSF fistula diagnosis requires CT brain; in the absence of obvious defects of the skull base according to CT results, endoscopic examination of the nasal cavity and cribriform plate of the ethmoid bone should be performed without the use of invasive diagnostic methods.Conclusion. In the context of negative CT and positive laboratory results, the area of the cribriform plate of the ethmoid bone should be regarded as the most likely source of CFS.

Background. The frequency of traumatic cerebrospinal fluid (CSF) leaks in fractures of the skull base is 33–40 %, intracranial purulent complications occur in 10–37 % of cases, and mortality rate is 30 % even with antibiotic therapy. The difficulty of diagnosing CSF leaks in patients with severe traumatic brain injury is caused by several factors: impossibility of gathering complaints from a patient with decreased alertness; difficulty to position a patient for instrumental diagnostics due to concomitant injuries; artificial ventilation; cerebrospinal fluid leak being masked by hemorrhagic secretions from the nose.Aim. To review the effectiveness of various diagnostic methods and algorithms for detection of cerebrospinal fluid leak and to access their feasibility in cases of potentially penetrating traumatic brain injury.Results. The study identified the main challenges of diagnosing cerebrospinal fluid leaks in intensive care patients, including difficulties in performing invasive neuroimaging methods, challenges in collecting nasal secretions for laboratory detection of CSF-specific markers, and the absence of fluorescein approved for intrathecal use in the Russian Federation. It was established that in severe cases, the most informative methods are brain CT and glucose oxidase test with radionuclide cisternography recommended in cases of uncertain results. Upon confirmation of cerebrospinal fluid leak, endoscopic nasal cavity revision and, if necessary, CSF fistula repair are advised.Conclusion. The findings emphasize the need for further research and refinement of diagnostic algorithms to improve the accuracy of traumatic CSF leak detection in patients with severe traumatic brain injuries.

Objective. To determine the method of prediction of postoperative mortality in patients with hemorrhagic stroke. Material and methods. The study included 264 patients who underwent surgery for a hypertensive intracerebral hematoma at the N.V. Sklifosovsky Research Institute for Emergency Medicine from 1997 to 2020. Of these, 116 (43.9%) had putamen hematomas, 107 (40.5%) had subcortical hematomas, and 41 (15.5%) had cerebellar hematomas. Results. A retrospective analysis identified risk factors affecting the disease prognosis. Univariate and multivariate Cox regression analysis yielded a statistically significant mathematical model (p, Wald <0.0001) with good consistency (concordance coefficient=0.83). A nomogram was plotted to predict the survival of patients after surgery. The final model included the following factors that increase the probability of death: deep coma (HR=542.8; 95% CI 68.2—4321.3), decompression craniotomy (HR=7.64; 95% CI 4.06—14.39), hypertension (HR=6.48; 95% CI 1.80—23.40), recurrent hemorrhage (HR=4.78; 95% CI 2.66—8.59), postoperative infection complications (HR=3.24; 95% CI 1.56—6.71), pyramidal insufficiency (HR=3.34; 95% CI 0.85—13.04), as well as factors that reduce the risk of death: moderate coma, the presence of transverse dislocation, cerebellar symptoms, and moderate severity. Conclusions. The analysis identified predictors of death in this category of patients, thus further narrowing the group of patients with hemorrhagic stroke for whom surgical treatment is indicated.

CSF fistulas of the lateral recess of the sphenoid sinus are a rare surgical pathology. Cerebrospinal fluid leak from lateral recess of the sphenoid sinus is observed with a frequency of 7.7% among all leakafe of the skull base. The article presents 3 clinical cases of patients with spontaneous cerebrospinal fluid leak from lateral recess of the sphenoid sinus and surgical treatments by transsphenoidal and transpterygoid (transpterygoid) endoscopic approaches with various postoperative results. The plastic surgery success of CSF fistulas from lateral recess of the sphenoid sinus doesn`t depend on the type of endonasal surgical approach, but on the plastic quality and the preoperative level of CSF pressure.

Aim: to present the experience of using the technique of endoscopic aspiration (EA) of lateral intracerebral hematomas (ICH) through the mini-supraorbital approach. Material and methods. From 2019 to 2021 at the Sklifosovsky Institute for Emergency Medicine, 12 patients with lateral ICH underwent EA of the ICH using a mini-supraorbital approach. There were 7 men (58.3 %) and 5 women (41.7 %). The mean age of the patients was 53.2±6.8 years. According to the Glasgow Coma Scale (GCS), the level of consciousness during hospitalization corresponded to 15 points in 4 (33.3 %) patients, and 11‑14 points — in 8 (66.7 %) patients. The average volume of lateral ICH was 45.3±17.4 cm3 (from 28 to 84 cm3). The average duration of the surgical intervention was within 4.2±2.1 days. The operations were performed using STORZ endoscopic equipment. Ventriculoscopes and Gaab trocars were used in 3 cases, and transparent endoscopic ports with a diameter of 8 mm and 4 mm endoscopes were applied in 9 cases. The operations were performed under the control of BrainLab frameless neuronavigation. Results. The average duration of operations was 93±18 minutes. EA through the mini-supraorbital approach provides the removal from 51 to 91 % of the intracerebral hematoma volume, 73.3±16.6 % on average. There were no complications during the operation associated with the use of the approach. The outcomes were of 0‑2 in 2 (16.7 %) patients, 3‑5 — in 8 (66.7 %), and 6 — in 2 (16.7 %) patients according to the modified Rankin Scale. Conclusion. Supraorbital approach allows efficient removal of lateral ICH. The close passage of the access trajectory to the base of the anterior cranial fossa is not an obstacle and does not reduce the radicality of blood clots removal from the ICH cavity. However, the lateral ICH removal through the supraorbital approach requires the use of frameless navigation during the entire main stage of the operation, and instead of a metal trocar, it is recommended to use a transparent endoscopic port.

Aim: to conduct a comparative analysis of the invasiveness, radicality of operations and treatment outcomes, depending on the options for the technique of endoscopic aspiration of hypertensive intracerebral hematomas (EA ICH). Material and methods. At the Sklifosovsky Institute for Emergency Medicine, EA ICH was performed in 131 patients with haemorrhagic stroke from 2006 to 2020. There were 89 men (67.9%) and 42 women (32.1%). The mean age of the patients was 55.1±12.5 years (from 20 to 87 years). According to the Glasgow Coma Scale (GCS) [28], the level of consciousness during hospitalization corresponded to 15 points in 42 (32.1%) patients, 11-14 points - in 78 (59.5%), 9-10 points - in 9 (6.9), 6-8 points - in 2 (1.5%) patients. In 124 (94.7%) patients, ICH was supratentorial, in 7 (5.3%) patients - subtentorial. The average volume of supratentorial ICH was 48.3±20.1 cm³ (from 6 to 131 cm³), subtentorial - 14.3±3.5 cm³ (from 9 to 18 cm³). The average term of performing the surgery was 5.5±7.5 days. ICH removal in the aquatic environment was performed through single-channel (6.5 mm) and multi-channel (6.0 mm) trocars of ventriculoscopes; removal of ICH in the air was achieved through a single-channel trocar (6.5 mm), wide (from 12 to 21 mm) and narrow (8.0 mm) transparent ports. CT brain scan was performed during the first day after the operation. The outcomes were assessed on the 30th day according to the modified Rankin scale. Results. The most radical ICH removal was achieved with the use of wide transparent ports, while the least number of recurrences was after operations through narrow transparent ports, and the tendency to achieve better functional outcomes was obtained when the method of ICH removing in the aquatic environment was refused in favor of EA in the air environment. Conclusion. The trend in achieving better functional outcomes can be traced in patients after surgeries in the air environment. Operations through wide ports provide a more radical removal of blood clots, while operations through a trocar and narrow ports in the air allow for the lowest rate of ICH recurrences.

Background. The comparison of external ventricular drainage and endoscopic surgery in patients with intraventricular hemorrhages is carried out.The aim of the study is to perform comparative analysis of external ventricular drainage and endoscopic surgery results in patients with intraventricular hemorrhage.Materials and methods. A retrospective analysis was performed in 29 patients with intraventricular hemorrhage who underwent surgery at the N. V. Sklifosovsky Research Institute for Emergency Medicine, Moscow, and the Yaroslavl Regional Clinical Hospital. Endoscopic surgery for intraventricular hemorrhage was performed in 15 cases (treatment group), and in 3 cases endoscopic removal was accompanied by external ventricular drainage. External ventricular drainage without endoscopic surgery was performed in 14 cases (control group), and in 3 of these cases local fibrinolysis was also performed. In the treatment group, mean age was 59.6 ± 16.7 years, level of consciousness per the Glasgow Coma Scale prior to surgery was 9.9 ± 3.3, severity of intraventricular hemorrhage per the Graeb Scale was 7.3 ± 2.5. In the control group, mean age was 52.8 ± 9.6 years, level of consciousness per the Glasgow Coma Scale prior to surgery was 10.7 ± 3.2, severity of intraventricular hemorrhage per the Graeb Scale was 5.0 ± 2.6. Outcomes were assessed on the 30^th day after hemorrhage using the modified Rankin Scale.Results. Endoscopic method allows to effectively remove clots from the lateral and III ventricles, decreasing the volume of intraventricular hemorrhage from 7.3 ± 2.5 to 3.9 ± 2.5 points per the Graeb Scale. Comparative analysis showed no difference in hydrocephalus resolution in the treatment and control groups. There were no intracranial infectious complications in the treatment group, but in the control group bacterial meningitis was diagnosed in 2 (14.3 %) of the 14 patients. Favorable outcome (score 0–2 per the modified Rankin Scale) was observed in 40.0 % of patients in the treatment group and 28.6 % in the control group. Mortality was 13.3 % in the treatment group and 57.1 % in the control group (χ² = 8.6, p Conclusion. Endoscopic surgery is an effective and safe method for intraventricular hemorrhage management and third ventriculostomy for occlusive hydrocephalus resolution, allowing to achieve better functional results and decrease mortality in patients with nontraumatic intraventricular hemorrhage.

Nowadays surgical treatment of patients with traumatic intracranial hematoma (TICH) and injuries of the brain is a very actual problem in neurosurgery.The purpose of this work was to assess of the feasibility and safety of minimally invasive endoscopic removal of TICH.MATERIAL AND METHODS In the period of 2010–2019, 2734 operations were performed on patients with traumatic brain injury in the Sklifosovsky Research Institute. There were 334 patients with TICH and the CC/BC foci, that made 12.2% of all patients. The median of hematoma volume, that did not cause a loss of consciousness was 48 cm2, and in most of the patients the hematoma volume ranged 30–35 cm2. Local fibrinolysis of TICH was performed in 14 patients with the hematoma volume of 30–50 cm2 without brain dislocation and not causing the consciousness depression more severe than sopor.Endoscopic removal of TICH was performed in 4 men at mean age of 54.8 years within 18–36 hours after trauma. Three patients had depression of consciousness to obtundation (14 by Glasgow Outcome Scale (GCS)), and one patient was in clear consciousness. The volume of the dense part of the contusion foci in the pole-basal regions of the frontal and temporal lobes was 24–40 cm3.RESULTS Among patients with TICH operated on by using the traditional technique, postoperative lethality was 13%, good outcomes were seen in 41%, and 46% had neurological disorders of varying severity. While treating the patients with TICH by using the local fibrinolysis method, 1 patient died after surgery, a good outcome was seen in 8 of 14 patients, and neurological disorders persisted in 3 patients in the postoperative period.Radicality of surgery in patients operated on by using endoscopic technique averaged 76% ranging from 41% to 91%. There were no complications during surgery nor in post-operative period. Patients were discharged from hospital after 8-21 days.

AIM OF STUDY To identify risk factors for adverse outcomes of surgical treatment of patients with HS.MATERIAL AND METHODS A retrospective analysis of the results of surgical treatment of 500 patients operated on at the N.V. Sklifosovsky Institute from 1997 to 2020 for hypertensive intracerebral hematomas. The mean age of the patients was 53.1±12.2 years. There were 335 (67%) men and 165 (33%) women.The level of consciousness before the operation was clear in 176 (35.2%), stupor (11–14 score, GCS) — in 258 (53.6%), sopor (score 9–10, GCS) — in 38 (7.6 %), moderate coma (7–8 score, GCS) — in 10 (2%) patients, deep coma (score 6) — in 7 (1.4%) patients. ICHs were lobar in 218 (43.6%) patients, lateral in 212 (42.4%) patients, thalamic in 10 (2%) patients, mixed in 10 (2%) patients, cerebellar in 50 (10% ) patients. The average volume of ICH was 46.5±25.1 cm3, supratentorial ICH – 49.6±24.5 cm3 (from 4 to 147 cm3), subtentorial — 18.7±6.4 cm3 (from 5 to 36 cm3). The average duration of the surgical intervention was 3.3±2.6 days. The following types of operations were performed: open removal of the ICH in 271 (54.2%) patients, puncture aspiration and local fibrinolysis of the ICH in 98 (19.6%) cases, endoscopic aspiration of the ICG in 131 (26.2%) patients.RESULTS The risk factors for lethal outcome in HT surgery are the age of patients older than 50 years (χ²=13.9, p3 (χ²=7.8, p2=9.1, p2=32.2, p2=16 ,1, p2=21.9, p2=36.9, p2=28.0, p2=64.4, p3 (χ²=4.0, p2=33.1, p2=97.2, pCONCLUSION Assessment of risk factors can help clarify the prognosis of the outcomes of surgical treatment and optimize the treatment tactics of patients.

The objective of the research: to compare the outcomes of three surgical methods used in a large cohort of patients with hemorrhagic stroke.Materials and methods. We performed a retrospective analysis of surgery outcomes in 500 patients with hypertensive intracranial hemorrhages (ICHs) operated on in N.V. Sklifosovskiy Research Institute of Emergency Medicine between 1997 and 2020. Mean patients’ age was 53.1 ± 12.2 years. The sample included 335 men (67 %) and 165 women (33 %). Mean time to surgery was 3.3 ± 2.6 days. More than half of the patients underwent open surgeries (n = 271; 54.2 %); 98 patients (19.6 %) had puncture aspiration and local fibrinolysis of intracranial hemorrhages; 131 patients (26.2 %) had endoscopic aspiration. Radicality of ICH removal was evaluated using brain computed tomography performed within 24 h postoperatively. Outcomes were assessed 30 days postoperatively using the Modified Rankin Scale (mRS).Results. Open surgery had the highest radicality (94.0 % [range: 79 %; 100 %]), whereas the radicality of endoscopic aspiration and puncture aspiration with local fibrinolysis was 80.0 % [range: 58 %;95 %] and 72.0 % [range: 58 %; 84 %], respectively (K.-W. = 52.7, p < 0.0001). The highest ICH recurrence rate (27.6 %) was observed after puncture aspiration and local fibrinolysis. Endoscopic aspiration and open surgery resulted in relapses in 16.8 % and 9.2 % of individuals, respectively (χ² = 19.7, p = 0.00005). The mRS outcomes were as follows: type 0 in 84 patients (16.8 %); type 1 in 37 patients (7.4 %); type 2 in 46 patients (9.2 %); type 3 in 38 patients (7.6 %); type 4 in 43 patients (8.6 %); type 5 in 142 patients (28.4 %); type 6 in 110 patients (22.0 %). The outcomes depended on ICH location and surgical method. Patients with lobar ICHs had better outcomes after open surgery, while patients with lateral and cerebellar ICH had better outcomes after puncture aspiration, local fibrinolysis, and endoscopic aspiration (χ² = 8.1, p < 0.02).Conclusion. Each surgical technique (open surgery, puncture aspiration, local fibrinolysis, and endoscopic aspiration) has its advantages and disadvantages depending on ICH location. Open surgery ensured better outcomes in patients with lobar ICHs, while individuals with deep ICH and cerebellar ICH demonstrated better outcomes after puncture aspiration, local fibrinolysis, and endoscopic aspiration.