Results of surgical treatment of cerebellar astrocytomas in young children

Objective ‒ to analyze the results of surgical treatment of cerebellar astrocytomas in young children, to establish the factors that determine the prognosis of the course of the disease.Materials and methods. The results of surgical treatment of 112 children with cerebellar astrocytoma, who were operated in Romodanov Neurosurgery Institute of NAMS of Ukraine in 1980‒2019; 59.8 % were boys, 40.2 % were girls. The age of children ‒ from 3 months to 3 years. Removal of the tumor was performed in 106 patients: in 58 ‒ totally, in 31 ‒ subtotally, in 16 ‒ partially, in 1 ‒ biopsy. Diffuse differentiated astrocytoma (low-grade (II)) was detected in 94 (83.9 %) patients, poorly differentiated diffuse astrocytoma (high-grade (III)) ‒ in 18 (16.1 %). In the cerebellum astrocytomas in 77 (68.7 %) cases were located in the midline. In 59 (52.7 %) cases astrocytomas had a cystic component, in 53 (47.3 %) cases were solid ones. Postoperative mortality over 30 years of observations was 15.2 %. Results. It was found that survival rates in the early postoperative period were statistically (p = 0.03) better in cases of total tumor resection compared with patients after with subtotal resection. In patients with diffuse differentiated astrocytoma of the cerebellum, the average duration of follow-up was 6.7 years, a good quality of life was noted in 39.4 % of patients. In the long-term follow-up period, 7.3 % of children died. In patients with poorly differentiated diffuse astrocytoma of the cerebellum, the average duration of follow-up was 4.3 years, while a satisfactory quality of life was observed in 68.0 % of patients, a poor quality in 22.0 %, and a vegetative state in 10.0 % of children. In the long-term period, 20.0 % of children died. Microscopic features of cerebellar astrocytomas are their expansive-infiltrative nature of distribution and the presence of zones of neoangiomatosis.Conclusions. It was revealed that the degree of differentiation of diffuse cerebellar astrocytomas and the radicality of their removal correlates with the quality and life expectancy of patients. The tendency of the influence of the degree of malignancy of astrocytomas on the indicators of general and reccurence-free survival of children of the younger age group was noted.

Cerebral and spinal neurological complications in patients with COVID-19: authors’ clinical experience and literature review

Objective ‒ to highlight the high probability and features of neurological complications in patients with COVID-19 pneumonia.Materials and methods. A retrospective cohort study was done of 57 patients with COVID-19 pneumonia who were treated at the COVID-location of the Department of Vascular and Minimally Invasive Neurosurgery and Neurology of the Clinical Emergency Hospital of Lviv in the period from June 29 to September 28, 2020 (91 day).Results. Out of the 57 patients 14 (24.6 %) were selected by prospective analysis that had a clear association between COVID-19 pneumonia and neurological complications. Neurological complications of COVID-19 were manifested as ischemic stroke in 57.1 % of patients, encephalopathy with convulsions and without seizures ‒ in 35.7 %, polyneuropathy with tetraparesis, secondary purulent-inflammatory lesions of the spine ‒ in 7.2 %. Neurological complications occurred on average (20. 4 ± 6.1) days after the onset of the disease.Conclusions. Lesions of the spine and structures in the spinal canal after coronavirus infection had a significant spread along the axis of the spine and severe course. The largest (57.1 %) was the proportion of ischemic stroke in the structure of neurological complications of COVID-19, which indicated the severity of the coronavirus infection and its aggressive effect on the nervous system. The effectiveness of treatment of COVID-19 neurological complications depends on the urgency of hospitalization of patients, as evidenced by the correlation between favorable treatment outcomes and the time from disease onst to admission to either therapeutic (r = + 0.37) or neurological department (r = +0.32).

The approach to the management of a patient with chronic venous insufficiency in a specialized vascular center ‒ a combination of world guidelines and personal experience

A lot of recommendations has been published regarding the treatment of chronic venous disease. At the same time, none of these documents reflects the complete «path» of the patient from the stage of the initial visit (diagnosis) to the choice of the optimal treatment option. Therefore, the creation of a protocol that would take into account on the one hand the most modern and proven effective approaches to diagnosis and treatment, and on the other hand, the individual characteristics of each clinical case is an urgent task.The main task of the publication is to create a practice-oriented instruction for the diagnosis, comprehensive treatment and prevention of chronic venous insufficiency. The management of a patient with chronic venous insufficiency is presented in the form of «AngioLife Venous Protocol®», a set of clear practical recommendations for vascular surgeon and phlebologist. This protocol is based on our own practical experience, existing protocols and guidelines for the treatment of patients with chronic venous insufficiency. The venous protocol includes four stages of a set of medical measures, the purpose of which is to form a clear program of further examination and treatment of the patient. Adherence to all the recommendations specified in the protocol allows to obtain satisfactory functional and cosmetic results of treatment of patients with chronic venous insufficiency with minimal risk of recurrence.

Stenting of ultraembolic hazardous carotid stenotic lesions using the technique of triple antiembolic protection

Objective ‒ to develop a technique of triple antiembolic protection with the simultaneous use of proximal antiembolic protection systems, distal antiembolic filters and two-layer micromesh carotid stents for carotid stenting of ultraembolic hazardous carotid stenosis. Evaluate its effectiveness and safety.Materials and methods. Since 2016, 23 carotid stenting of ultraembolic hazardous carotid stenoses has been performed using the technique of triple antiembolic protection (proximal antiembolic protection systems, distal antiembolic filters and two-layer micromesh carotid stents). All patients had symptomic stenosis: transient ischemic attacks in a certain carotid pool (n = 7), ischemic strokes (n = 16). The age of patients was from 57 to 84 years. Men prevailed among patients (n = 15). Postoperative follow-up included magnetic resonance imaging (MRI) of the brain on the first or second day after surgery with T2*, FLAIR and DWI sequences to determine the presence of «fresh» embolic ischemic foci and to exclude hemorrhagic complications. After 6 months, a control clinical examination, computed tomography or MRI of the brain, ultrasound angioscanning of the main arteries of the head were performed.Results. In all patients the patency of the carotid arteries was completely restored, and in the early postoperative period, no clinical signs of recurrent ischemic brain damage were detected in any of the cases. No signs of plaque prolapse through the stent were detected in any case. A significant amount of atheromatous debris was in 11 cases when aspirated on an external filter. In 3 cases, emboli were also detected in the distal protection filter. This fact indicates that the joint use of distal and proximal antiembolic systems reliably protects against the risk of embolism in such cases. According to MRI on the 1st or 2nd day there were no signs of «fresh» subclinical embolic ischemic foci, as well as hemorrhage. In 20 patients who underwent a follow-up examination, no signs of restenosis in the stent were recorded in any case, as well as repeated ischemic strokes. In 7 cases where the plaque had an ulcer, the ulcer resolved under the stent. Three patients are expected for a follow-up examination. According to the remote survey, these patients do not have new ischemic brain lesions. The effectiveness of the technique of triple antiembolic protection for the treatment of patients with subtotal ultraembolic hazardous carotid stenosis is indicated by the absence of clinical and neuroradiological signs of recurrent ischemic lesions.Conclusions. The technique of triple antiembolic protection for the treatment of patients with subtotal ultraembolic hazardous carotid stenoses is safe and highly effective. It is the improvement of carotid stenting results in this most dangerous group that gives reason to think about revealing the advantages of carotid stenting over carotid endarterectomy in general.

Structure and nature of hypertensive intracerebral hemorrhages of supratentorial localization

Objective ‒ to analyze data of patients with hypertensive supratentorial hemorrhages who were hospitalized in Kyiv Emergency Hospital in 2019‒2020.Materials and methods. We analyzed data of 232 patients who were treated for hypertensive intracerebral hemorrhage at the Kyiv Emergency Hospital in 2019‒2020. Patients were included regardless of admission status and chosen treatment tactics (surgical, medical). The study did not include patients with subtentorial hemorrhage, patients with tumor hemorrhage, arteriovenous malformations, aneurysms, angiomas, ischemic and mixed strokes.Results. Among patients males are predominated (149 (64 %)). The average age of patients was 60 years (group of men ‒ 56 years, group of women ‒ 69 years). 77 (33 %) patients were delivered in a comatose state (GCS ≤8 points), 36 (16 %) were in a coma (GCS 9‒12 points), 81 patients were in a state of stupor (GCS 13‒14 points), in a clear mind ‒ 31 (13 %). In 7 (3 %) cases it is impossible to determine the level of consciousness (in patients with seizures or after the introduction of sedative drugs before admission to hospital). 85 patients were operated (surgical activity ‒37 %), who underwent 97 surgical interventions. The overall mortality was 42 %, postoperative mortality ‒ 43 %. Patients who had a compression-dislocation syndrome were operated on. Mortality in the group of patients admitted in a coma mortality was 85 % regardless of the method of treatment.Conclusions. Hemorrhagic strokes predominate in men, due to lifestyle and uncontrolled hypertension in patients. The results of treatment of patients with hypertensive intracerebral hemorrhage indicate the need for early hospitalization, early CT, differentiated approache to surgical removal of hematomas (lobar, lateral with dislocation syndrome), intensive care in patients in a comatose state, even with massive hemorrhages. The results of hypertensive intracerebral hemorrhage depend on the location of the hemorrhage, the severity of the patient’s condition, the timing of hospitalization in specialized stroke departments, the dynamics of cerebrovascular disorders (completed stroke and stroke in development).

Clinic and diagnostics of the non-penetrating gun-shoot craniocerebral injuries in the local war

Objective ‒ to evaluate the features of the clinical manifestations and effectiveness of multi-slice computed tomography (MSCT) of the head for the diagnosis of non-penetrating gun-shoot head injuries in the local war.Materials and methods. The medical data of 155 patients who received a non-penetrating gun-shoot head injuries during the war in the Eastern Ukraine between 2014‒2020 were analyzed. All patients were males between 18 and 60 years (average age ‒ 35.1 years). The peculiarities of clinical manifestations and results of diagnostic evaluation of non-penetrating gun-shoot head injuries during specialized neurosurgical care in medical institutions on the third and fourth levels of medical aid have been studied.Results. Wide diagnostic capabilities of MSCT were revealed for determination of the wounds localization, type of the projectile, the nature of the wound channel, gunshot skull fractures, and associated intracranial injuries. It was found that with non-penetrating bullet and shrapnel tangential cranio-cerebral wounds, incomplete and depressed fractures usually occurred, and with single and multiple shrapnel blind wounds, incomplete ‒ perforated and depressed fractures with the presence of bone fragments. The pathomorphological features of the nature of the wound channels and intracranial injuries were determined. They are always associated by traumatic subarachnoid hemorrhages and brain contusions, in most cases – focal. Intracranial hematomas were observed in 3.1 % of the patients.Conclusions. Clinical manifestations of the non-penetrating craniocerebral gunshot wounds depend not only on the type of cranial soft tissue injury, but also on the nature of the skull fracture and are mainly occurred because of the severity of the traumatic brain injury. MSCT of the head makes it possible to determine the localization of the wound, the type of the wounding projectile, the nature of the cranial soft tissues damage, wound channel, gunshot skull fractures and associated intracranial injuries.

Endovascular treatment of tandemic occlusions in acute ischemic stroke

The observation of endovascular treatment of acute tandem occlusion of internal carotid artery (ICA), anterior cerebral artery (ACA) and middle cerebral artery (MCA) in combination with the thrombosis of the right ICA and the critical stenosis of the left vertebral artery is presented.Man, 61 years old. He was delivered to the Center of endovascular neuroradiology, NAMS of Ukraine on January 15, 2021 with an ischemic stroke clinic in the left internal carotid artery basin. He fell ill acutely ‒ against the background of complete well-being, sensorimotor aphasia and right-sided hemiplegia appeared. Upon admission on the NIHSS (National Institutes of Health Stroke Scale) ‒ 18 points. On the performed initial multispiral computed tomography of the brain according to ASPECTS (Alberta Stroke Program Early CT score) ‒ 8 points. In the endovascular operating room, cerebral angiography was performed, followed by surgery aimed at restoring cerebral blood flow. The time from the onset of the disease to the puncture was 330 minutes, the duration of the operation was 135 minutes, thus the time from the onset of the disease to reperfusion was 465 minutes. Angiography revealed acute thrombosis of the left ICA starting from the orifice, M1-segment of the left MCA and A2-segment of the left ACA. Partial compensation of the basin through the supra-block anastomosis (external carotid artery ‒ ICA), as well as from the vertebro-basilar system through the network of leptomeningeal arteries. Collaterals ‒ ACG 3. Thrombosis of the right ICA and critical stenosis (95 %) of the V1-segment of the left vertebral artery were also revealed. The operation was performed ‒ recanalization of thrombosis of the left ICA orifice followed by balloon angioplasty, thrombectomy from the MCA and ACA pools. The end result is eTICI 2c reperfusion. There were no complications during this operation. The patient was discharged the next day (transferred to the neurological department at the place of residence). Control multispiral computed tomography of the brain showed positive dynamics (ASPECTS ‒ 1 point).

To the issue of degree of removal of gliomas of supratentorial localization

Objective ‒ to assess the possibility of increasing the time of surgical restoration of blood flow in the acute period of ischemic stroke due to occlusive lesion of the internal carotid artery (ICA).Materials and methods. Among the patients who were admitted for treatmentat in the Regional Odessa Hospital with acute ischemic stroke in the carotid region a group of 6 patients was identified in whom the cause of stroke was occlusion of the ICA by an atherosclerotic plaque. Age of patients ‒ from 54 to 71 years. Patients were hospitalized later 6 hours from the onset of stroke. The survey was carried out according to the established protocol. Neurological deficits are mild to moderate. In order to eliminate the occlusion of the ICA, all patients underwent endarterectomy.Results. Carotidendarterectomy was performed from 2 to 11 days after onset of stroke. Retrograde blood flow through the ICA was obtained in three (50 %) patients in whom surgical interventions were performed up to 4 days after the disease. In the postoperativeperiod a typical therapy was carried out. In cases with the obtained retrograde blood flowon control carotid angiograms demonstrated revascularization of the ICA basin according to mTICI-3. On the control CT of the brain in postoperative period in one case the point subarachnoid hemorrhages was determined. In the other two cases there was no evidence hemorrhagic transformation. Operated patients showed positive dynamics: a decrease hemiparesis by 1 poin and regression of mental disorders. The patients were discharged withm RS 1‒2. During the follow-up examination 90 days the neurological condition of the patients improved to mRS 1‒0.Conclusions. Results obtained in increasing the “therapeutic window” for revascularization of the occluded ICA allow to continue research in the indicated direction and improve the quality of surgical care for patients with acute stroke.

Possibility of increasing the «therapeutic window» for revascularization of the carotid arteries in the acute period of ischemic stroke

Objective ‒ to assess the possibility of increasing the time of surgical restoration of blood flow in the acute period of ischemic stroke due to occlusive lesion of the internal carotid artery (ICA).Materials and methods. Among the patients who were admitted for treatmentat in the Regional Odessa Hospital with acute ischemic stroke in the carotid region a group of 6 patients was identified in whom the cause of stroke was occlusion of the ICA by an atherosclerotic plaque. Age of patients ‒ from 54 to 71 years. Patients were hospitalized later 6 hours from the onset of stroke. The survey was carried out according to the established protocol. Neurological deficits are mild to moderate. In order to eliminate the occlusion of the ICA, all patients underwent endarterectomy.Results. Carotidendarterectomy was performed from 2 to 11 days after onset of stroke. Retrograde blood flow through the ICA was obtained in three (50 %) patients in whom surgical interventions were performed up to 4 days after the disease. In the postoperativeperiod a typical therapy was carried out. In cases with the obtained retrograde blood flowon control carotid angiograms demonstrated revascularization of the ICA basin according to mTICI-3. On the control CT of the brain in postoperative period in one case the point subarachnoid hemorrhages was determined. In the other two cases there was no evidence hemorrhagic transformation. Operated patients showed positive dynamics: a decrease hemiparesis by 1 poin and regression of mental disorders. The patients were discharged withm RS 1‒2. During the follow-up examination 90 days the neurological condition of the patients improved to mRS 1‒0.Conclusions. Results obtained in increasing the “therapeutic window” for revascularization of the occluded ICA allow to continue research in the indicated direction and improve the quality of surgical care for patients with acute stroke.

Radiosurgical treatment of residual and recurrent pituitary adenomas

Objective ‒ the treatment result estimation of subtotally removed and recurrent pituitary adenomas using different algorithms of radiotherapy and radiosurgery.Materials and methods. The retrospective analysis of 21 cases of pituitary adenomas was performed. There were 11 women and 10 men included. The average age was 45 (from 18 to 72) years. All patients had relapse or residual tumor after incomplete surgical removal. The method of irradiation was chosen by a radiologist. Tumor size control was assessed by an independent radiologist in 3 months and 1 year after treatment. Endocrine function was estimated by an independent endocrinologist in 3 months and 1 year after treatment.Results. Following transsphenoidal removal ‒ 13 patients (4 were operated twice), 5 after cranial surgery and 3 were operated sequentially transnasally and transcranially. Irradiation of 14 cases of residual tumor was performed no later than 6 months after surgery. The mean term of treatment start of recurrent adenomas was 12 months (8‒17) after surgery. VARIAN Novalis was applied in 16 cases, VARIAN Clinac iX in 4 cases and VARIAN TrueBeam STx was used once. Single and total radiation doses were determined individually. None of patients had visual impairment after treatment. The hypopituitarism deterioration was not noted as well.Conclusions. Hypofractionated stereotactic radiosurgery allows to bring a high dose of radiation to the pituitary adenomas, minimizing damage to the visual pathways, the pituitary gland and infundibulum. As the sequence, it reduces the toxicity of the technique. The application of modern radiation technologies minimize the irradiation of healthy surrounding tissues and reduce the negative effects of treatment.