Taras Andreevich Shatokhin

Anterior clinoidectomy has a significant advantage in excluding paraclinoid aneurysms from the blood flow, but it carries a potential risk of developing postoperative cerebrospinal fluid rhinorrhoea. Development of cerebrospinal fluid rhinorrhoea can lead to various intracranial purulent-inflammatory complications. Conservative treatment of cerebrospinal fluid rhinorrhoea is not effective, and currently, there is no established surgical strategy for this complication. This article describes a successful surgical treatment of postoperative cerebrospinal fluid rhinorrhoea following resection of the anterior clinoid process using endoscopic transnasal repair of the skull base defect using autografts and xenografts.

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.

AIM . To compare the surgical treatment outcomes of patients with occlusive lesions of the extra-intracranial arteries of the brain, operated on with and without frameless neuronavigation. MATERIALS AND METHODS . The study was conducted at the bases of the Pirogov Russian National Research Medical University and the Russian Center for Neurology and Neuroscience from 2016 to 2023. The analysis included 59 patients with occlusive lesions of the extra-intracranial arteries of the brain, divided into three groups. Group 1 included 19 patients (32.2 %) (16 men and 3 women, median age 59 years) who underwent extra-intracranial arterial bypass grafting (EIABG) without the use of frameless neuronavigation. Group 2 included 19 patients (32.2 %) (12 men and 7 women, median age 58 years) who underwent EIABG with the use of frameless neuronavigation only during the access planning stage based on CT angiography (stage 1) – for marking the donor artery, skin incision, and craniotomy. Group 3 included 21 patients (35.5 %) (14 men and 7 women, median age 58 years) who underwent EIABG with the use of frameless neuronavigation at both the access planning stage and the main stage of the operation – for marking the donor artery, locating the recipient artery using CT angiography and SPECT considering the hypoperfusion area, craniotomy, and skin incision. RESULTS . The use of frameless neuronavigation significantly reduces the size of the skin incision (p1–3=0.01, p2–3=0.016), the area of craniotomy (p1–3=0.04), and the size of resection trepanation (p1–3=0.049). Frameless navigation increases the perfusion gain in the hypoperfusion area (p1–3=0.007) and allows for targeted revascularization of the hypoperfusion region (p1–3=0.003, p2–3=0.003). Frameless navigation did not significantly affect: blood loss volume (p=0.849), anastomosis functionality (p=0.161), linear blood flow velocity (p=0.066), RMC index (p=0.859), functional outcomes after surgery (p=0.42), development of new neurological deficits (p=1.0), systemic complications (p=0.833), or the number of days spent in intensive care (p=0.144) and the hospital (p=0.156). CONCLUSION . In patients with occlusive lesions of the extra-intracranial arteries of the brain, the use of frameless neuronavigation enhances the effectiveness of the main stage of the operation, allows for targeted revascularization of the hypoperfusion region, and reduces the length of the skin incision as well as the size of the cranioplasty and resection trepanation.

Background. The treatment of complex cerebral aneurysms is still remained the great challenge for neurosurgeons. There is a large choice of intravascular techniques for excluding the complex cerebral aneurysms from the blood flow: endovascular embolization with microcoils, usage of flow-diverting stents, balloon angioplasty and stenting of extra- and intracranial segments of the main cerebral arteries. At the same time, the microsurgical treatment of cerebral aneurysms has not lost its relevance and remains the most radical method of treatment. However, simple clipping or reconstruction of complex aneurysm wall is not always possible. In such cases, trapping of parent artery and revascularization of the required blood supply territory are used.Aim. To present the two clinical cases of patients with complex intracranial aneurysms without the possibility of endovascular treatment, who underwent parent artery trapping and alternative middle flow extracranial-intracranial (EC–IC) bypass as well as to conduct the literature review concerning the key aspects of this topic.Clinical cases. This article presents two patients operated on for complex intracranial aneurysms. The first patient had a complex fusiformsaccular aneurysm of the left middle cerebral artery (MCA) with a frontal M2 segment of the left MCA extending from the fusiform dome; the second patient had a giant saccular aneurysm of the supraclinoid segment of the left internal carotid artery (ICA) and a complete posterior trifurcation on the left. Endovascular treatment was considered as impossible. The trapping of the parent artery and performing of middle-flow EC–IC bypass using the distal branches of the external carotid artery (ECA) were conducted. Intraoperative frameless neuronavigation was used. Conclusion. The use of terminal branches of the ECA (maxillary artery and proximal part of superficial temporal artery) expands the possibilities of cerebral revascularization performing in cases where low- or middle-flow EC–IC bypasses are required. The relatively rare use of these arteries in practice and few publications about these types of bypasses require careful selection of patients with preoperative assessment of the brachiocephalic arteries and hemodynamic parameters.

The article presents a clinical observation of a patient with nasal liquorea, which developed as a result of a defect in the posterior wall of the frontal sinus after cranial trepanation for a meningioma of the olfactory fossa. Observation demonstrates the possibilities of endoscopic endonasal access in reconstruction of such defects using multi-layer plasty and the need for combined intervention or a transcranial approach in some cases. The article also provides the literature review covering current trends on this issue. It is noted that despite the development of endoscopic rhinosinusosurgery, the problem remains complex, ambiguous and requires further research.

Aneurysmal subarachnoid haemorrhage is one of the most severe forms of cerebral stroke, associated with a high mortality and disability rate. Development of emotional disorders (anxiety and depression), as well as functional and cognitive deficits, interfere with resocialisation of patients who have undergone surgery for a cerebral aneurysm, and impair quality of life and exacerbate cognitive impairment.Objective: to investigate the prevalence of emotional disturbances in the remote postoperative period after surgical treatment of cerebral aneurysms (CA).Material and methods. The prevalence and severity of emotional disturbances in the remote postoperative period after surgical treatment of CA was analysed, mean time after surgery was 3.5 years. Two hundred and one patients underwent surgery for a CA rupture, 110 for a non-ruptured aneurysm. On admission to hospital for surgical treatment, patients underwent a clinical and diagnostic examination to confirm the diagnosis and determine the extent, timing and type of intervention. In the remote postoperative period, the degree of limitation of self-care and functional capacity (using the Barthel Index and the modified Rankin Scale), cognitive functioning (using the MoCA test) and emotional domain (using the HADS scale) were assessed.Results. In the remote postoperative period following surgical treatment of CA, subclinical and clinically significant anxiety was found in 110 (36.3%) patients and depression – in 117 (38.6%). The severity of anxiety and depressive disorders did not decrease over time. The mean score on the HADS anxiety scale during the first year after surgery was 5.9±2.8; after 5 years and more – 6.1±3.4. The mean score on the depression scale in patients tested within 1 year after surgery was 7.3±3.3; after 5 years and more – 6.7±3.5. A correlation was found between the severity of vasospasm and anxiety disorders in the remote postoperative period: anxiety symptoms predominated in patients with normal linear blood flow velocity compared to patients diagnosed with vasospasm (p=0.03). The condition of patients at hospital discharge was also associated with the severity of anxiety symptoms in the remote postoperative period: as the Glasgow Outcome Scale (GOS) score increased, so did the severity of anxiety disorders. A statistically significant correlation was found between the groups of patients with a GOS score of 3 and 5 points (p=0.016). A significant predominance of anxiety and depressive disturbances was found in female patients in the remote postoperative phase of surgical treatment (pConclusion. Emotional disturbances in patients who underwent surgery for CA persist for a long time, with anxiety disorders predominating in patients without overt neurological disorders during hospitalization. Both anxiety disorders and depressive disorders occur most frequently in female patients. The persistence of emotional disturbances over a long period of time after the exclusion of the aneurysm from the circulation shows the need for their correction in terms of patient's social adaptation.

AIM OF THE STUDY was to present a case of combined, staged surgical treatment for locally advanced cardioesophageal cancer complicated by esophageal stenosis in a comorbid patient with a significant lesion of the internal carotid artery, and to summarize the data of scientific literature on the methods for its diagnosis and treatment.MATERIAL AND METHODS A 65-year-old patient came to the Moscow Clinical Research and Practice Center named after A.S. Loginov in August 2020 with complaints of difficulty in passing solid food through the esophagus. During the examination at the Center, Siewert II cType 3 T4bN2M0 G3 cardioesophageal junction cancer was diagnosed. Taking into account the results of comprehensive diagnostics, the patient was found to have asymptomatic stenosis of the internal carotid artery up to 75%. Step-by-step surgical treatment of the patient was performed.DISCUSSION In the presented clinical observation for prevention of intraand postoperative ischemic complications, at the first stage the patient underwent carotid endarterectomy followed by surgical treatment for the underlying pathology. The presented observation is of interest due to the rare occurrence of such a combination of surgical interventions and the lack of consensus regarding the treatment tactics for this category of patients.CONCLUSION Combined staged treatment of a patient with cardioesophageal cancer and internal carotid artery stenosis reduces the risk of perioperative complications and improves the prognosis of further treatment for the underlying disease.

AIM. To describe the clinical observation of a rare complication in the form of the formation of a decompensated form of subdural hygroma in a patient after decompressive stabilizing intervention at the L4-L5 level.CLINICAL CASE. Patient N., 63 years old, complained of pain in the posterolateral surface of the right lower limb. History of endoscopic decompression of the spinal canal at the place of residence for spinal canal stenosis at the L4-L5 level in 2021 and 2022. According to the Lumbosacral Spine MRI: multifactorial stenosis of the spinal canal at the L4-L5 level with compression of the L5 root by the discosteophyte complex.Intraoperatively, a defect of the dura mater was obtained without damage to the arachnoid membrane and there was no leakage of cerebrospinal fluid.On the 3rd day after surgery, the patient began to complain of an intense headache, on the 5th day during verticalization, an episode of loss of consciousness was noted. A CT scan of the brain was performed, according to the results of which pneumocephaly is determined subdurally and along the sickle of the brain. On the 14th day, the patient showed decreased alertness to moderate stupor, and hypertensive dislocation symptoms. According to CT of the brain, a subdural hygroma of the left frontal region with a volume of 150 cm3 and a transverse dislocation to the right by 13 mm was detected. The following surgical intervention was performed: microsurgical removal of the subdural hygroma in the left frontal region with a volume of 1, Stuckey ventriculocisternostomy 1. After 1 day, negative dynamics were noted: according to CT of the brain, an increase in the subdural hygroma to 120 cm3 with a transverse dislocation of up to 16 mm. A repeated surgical intervention was performed in the volume of subdural-peritoneal shunting. The postoperative period was satisfactory. On the control CT of the brain the volume of subdural contents decreased to 10 cm3, transverse dislocation to the right to 3 mm. The patient was discharged in satisfactory condition on the 21st day.CONCLUSION. The present clinical observation is of great interest due to rare formation of this complication during decompressive-stabilizing interventions on the spinal column. When clinical symptoms of intracranial hypotension appear, it is necessary to stay alert and conduct clinical and instrumental diagnostics to exclude the formation of this complication.

In large internal carotid artery (ICA) aneurysms, the angle of the mandible becomes an anatomical obstacle to creating an adequate access. Widening the access can be achieved by performing a mandibular osteotomy.Case report. A 70-year-old female patient was admitted to hospital with complaints of hoarseness of voice, dyspnoea and congestion of the right ear. Objective examination revealed nasal respiratory distress due to nasopharyngeal compression by a voluminous mass, mild dysarthria, dysphonia, tongue deviation to the right, paresis of the right soft palate and right vocal cord. Computed tomography and magnetic resonance imaging showed a 50×49×60 mm thrombosed ICA aneurysm in the carotid space. Surgical management was performed by a multidisciplinary team including neurosurgeons, otolaryngologists and maxillofacial surgeons. Extended access was achieved by intraoral mandibular osteotomy followed by mobilization. Early postoperative resolution of neurological symptoms was observed.Discussion. To gain access to giant aneurysms of the cervical branch of the ICA, it is possible to use the technique of intraoral osteotomy of the mandible. This reduces trauma and the risk of complications, while increasing the radicality of the main stage.

Intracranial germ cell tumors(GCTs) are rare and heterogeneous group of primary brain tumors, mainly affecting pediatric population and young adults. The current understanding of the etiology of intracranial GCTs and their optimal management strategies remain controversial. Treatment plans differ depending on the subtype GCT and may vary among physicians and institutions. Central nervous system non-germinomatous germ cell tumor (NGGCT) usually requires surgical resection with histological verification, chemotherapy, and radiation. The extent of surgical resection is an important prognostic factor alongside the etiology and genetics of NGGCT. This article presents a rare clinical case of a rapidly growing teratoma located in the posterior part of third ventricle of a 17-year-old male presenting with symptoms of intracranial hypertension. Surgical total resection was preceded by endoscopic third ventriculostomy. Immunohistochemistry revealed the presence of embryonal carcinoma and immature teratoma cells turning the tumor into mixed type NGGCT with unfavorable prognosis. Despite the complete resection of the tumor and the timely initiation of adjuvant therapy, a rapid progression of the disease with subsequent unfavorable outcome was observed 3.6 months after the surgical treatment.