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The relevance of this study is conditioned by the technical complexity of the design solutions for construction projects of ground-based space infrastructure. It is associated with the possibility of special loads in the form of an air shock wave in the event of a launch abort, a fall of a fragment, an emergency shutdown of engines, an air shock wave from the indirect impact of nuclear weapons, seismic loads, accidental cargo falls, terrorist attacks, etc. Such impacts with a high degree of probability lead to damage to building structures and in the future, they need to be reinforced. These building structures must have survivability under special loads and deform without collapsing. Under the dynamic loading, the energy intensity of the bendable structures is important, to determine which it is necessary to know the magnitude of the acting force and deflections. The effective load in a wide class of problems refers to the initial data, and the determination of reliable values of the dynamic deflection of the bendable structure is an actual problem. The purpose of this study is to conduct a numerical and experimental investigation of the deflection of conventional and strengthened reinforced concrete structures under short-term dynamic loading. This study used the following research methods: measurements of deflections and loads by strain measurement, graphical analytic research using Microsoft Excel, numerical calculation in the environment of the Explicit Dynamics module of the Ansys software package. As a result of the study, experimental investigation of conventional and strengthened bendable reinforced concrete elements under short-term dynamic loading was carried out, the values of the effective force and deflections were obtained. The same experiment was modelled in the environment of the Explicit Dynamics module of the Ansys software package. A comparison of the deflection parameters was made, based on the results of numerical and physical experiments on the example of a specific design, which showed satisfactory convergence.

Введение. Вопросы прочности и деформативности железобетонных перекрытий при продавливании остаются в настоящее время недостаточно изученными, несмотря на имеющиеся многочисленные публикации в технической литературе. Представлены результаты экспериментальных исследований прочности на продавливание фрагментов сопряжения плоских железобетонных монолитных плит с колонной при статическом нагружении. Цель исследования — получение экспериментальных данных о напряженно-деформированном состоянии фрагмента монолитного перекрытия при статическом продавливании и разработка пространственной модели на основе метода конечных элементов с последующими численными исследованиями. Материалы и методы. Экспериментальные исследования проводились на испытательном стенде. Даны характеристики опытных образцов: размеры, армирование, класс бетона и арматуры. Описана установка для проведения испытаний. Для численного моделирования узла сопряжения плиты с колонной применялся программный комплекс ATENA, который позволяет осуществлять физически и геометрически нелинейные расчеты железобетонных конструкций с учетом реальной работы материалов, используемых при создании экспериментальных моделей. Результаты. Выполнено сравнение результатов по разрушающей нагрузке, полученное при проведении эксперимента, с результатами численного моделирования методом конечных элементов и с результатами вычисления по методикам СП 63.13330.2018 и Еврокод 2. Получены эпюры распределения деформаций в арматуре и бетоне, разрушающие нагрузки и схемы распределения трещин образцов. Выводы. Анализ экспериментальных и численных исследований позволил сформулировать условия прочности на продавливание плоских плит с продольным армированием и дать рекомендации по расчету на прочность при центральном нагружении. Напряжения в горизонтальной арматуре и нормальные напряжения сжатия в бетоне плиты в стадии разрушения от вертикального продавливания могут не достигать расчетных предельных значений. Методика их определения является предметом дальнейших исследований.

Objective To perform a radiological analysis of the degeneration of C1-C2 joints after C1-C2 transarticular fixation (TAF) and compare the long-term results of a routine Magerl technique (RMT) to a posterior transarticular C1-C2 stand-alone screw instrumentation (SAS) application. Methods A total of 40 patients (26 men and 14 women) were included in the present retrospective observational cohort study. The mean follow-up period was 61.7 months (range, 11–118). The mean patient age at the baseline examination was 48.4 years (range, 22–82). Of the 40 patients, 11 were included in the RMT group and 29 in the SAS group. Results The structure of 80 atlantoaxial joints was analyzed, with grade 4 degenerative changes observed in 57 joints (71.3%). Of the 40 analyzed atlanto-odontoid joints, grade 4 degenerative changes were revealed in 18 joints (45%). C1-C2 bone fusion was observed in 38 patients (95%) and stable fibrous fusion in 2 patients (5%). No cases of C1-C2 nonunion were revealed. No statistically significant differences in the frequency of C1-C2 fracture consolidation or C1-C2 fusion were revealed between the RMT and SAS groups. Conclusions The application of cortical lag screws in TAF might result in stable atlantoaxial joint fusion formation without joint curettage. Atlanto-odontoid joint fusion was also observed after C1-C2 TAF. The application of cortical lag screws for bilateral fixation using the SAS technique resulted in C1-C2 fusion in 93.1% of cases, comparable to the results with the Magerl technique.

This study aimed to evaluate the impact of several factors, including patients’ intraoperative position, intraoperative visualization technique, fixation method, and type of screws and their parameters, on the frequency of intraoperative screw-associated complications in posterior transarticular C1–C2 fixation. A systematic review of the PubMed database between January 1986 and March 2018 was performed. The key inclusion criteria comprised detailed descriptions of the surgical technique and post-operative screw-associated complications. The initial search resulted in 1041 abstracts, and a total of 54 abstracts were included in the present study. The overall number of operated patients was 2306. In this group, 4439 screws were inserted. The rate of screw-associated complications during the different time periods was estimated upon meta-analysis. Statistical analysis of the screw malposition rate, vertebral artery injury rate, screw breakage rate based on patients’ intraoperative position, intraoperative visualization technique, fixation method, and type of implants and their parameters was also performed. The factors that help reduce the rate of screw-associated complications include the intraoperative application of biplanar fluoroscopy or neuronavigation system, the use of 4 mm or thicker lag screws, and screw insertion through contraincisions using cannulated ported instruments. On the other hand, the potential risk factors of screw-associated complications include inadequate intraoperative head fixation using skeletal traction, uniplanar fluoroscopy-guided screw insertion, screw insertion using the posterior midline approach, and the use of 3.5 mm or thinner full-threaded screws. These slides can be retrieved under Electronic Supplementary Material.

Background Kimmerle anomaly is characterized by ossification of the posterior atlanto-occipital membrane with formation of a complete or incomplete bony ridge in the area of the groove for the vertebral artery (VA) (ponticulus posticus [PP]). In some cases, the bony ridge may also be formed at the level of the VA emerging from the transverse process of the С1 vertebra (ponticulus lateralis [PL]). Simultaneous 1-sided formation of PL and PP is very rare. Data concerning surgical treatment for compression of the VA owing to PL are lacking. Case Description A 34-year-old woman presented with significant dizziness to the point of losing consciousness while rotating her head to the left. Computed tomography angiography of the cervical spine revealed С1 anomaly with the formation of PP and PL with acute-angled С-shaped kinking of the VA. The patient underwent resection of the bony ridges through minimally invasive lateral (PP) and far-lateral (PL) approaches. Treatment led to significant improvement in quality of life, with disappearance of the pain syndrome via the С1 spinal root and absence of bow hunter's syndrome in the postoperative period. Conclusions This is the first report to our knowledge on the surgical treatment of VA compression owing to PP and PL. VA decompression in such cases can be performed via 2 separate minimally invasive lateral and far-lateral approaches. Surgical strategies for treatment of Kimmerle anomaly may significantly improve patients' quality of life.

This review focuses on the role of mental and cognitive disorders in the prognosis for surgical treatment of pharmacoresistant epilepsy. The authors analyze historical aspects of the surgical treatment of epilepsy and present current data on the prognosis of operative intervention with respect to seizure control, cognitive functioning, and psychiatric disorders. The psychiatrist's role in the structure of preoperative and postoperative management of patients is considered.Обзор посвящен роли психических и когнитивных расстройств в прогнозе хирургического лечения фармакорезистентной эпилепсии. Дан анализ исторических аспектов хирургического лечения эпилепсии, приведены современные данные о прогнозе оперативного вмешательства в отношении контроля над приступами, когнитивного функционирования, психических расстройств. Рассмотрены вопросы роли психиатра в структуре предоперационного и послеоперационного ведения пациентов.

Anterior transarticular fixation of the C1–C2 vertebrae is a well-known technique that involves screw insertion through the body of the C2 vertebra into the lateral masses of the atlas through an anterior transcervical approach. Meanwhile, contralateral screw insertion has been previously described only in anatomical studies. We describe two case reports of the clinical application of this new technique. In Case 1, the patient was diagnosed with an unstable C1 fracture. The clinical features of the case did not allow for any type of posterior atlantoaxial fusion, Halo immobilization, or routine anterior fixation using the Reindl and Koller techniques. The possible manner of screw insertion into the anterior third of the right lateral mass was via a contralateral trajectory, which was performed in this case. Case 2 involved a patient with neglected posteriorly dislocated dens fracture who could not lie in the prone position due to concomitant cardiac pathology. Reduction of atlantoaxial dislocation was insufficient, even after scar tissue resection at the fracture, while transdental fusion was not possible. Considering the success of the previous case, atlantoaxial fixation was performed through the small approach, using the Reindl technique and contralateral screw insertion. These two cases demonstrate the potential of anterior transarticular fixation of C1–C2 vertebrae in cases where posterior atlantoaxial fusion is not achievable. This type of fixation can be performed through a single approach if one screw is inserted using the Reindl technique and another is inserted via a contralateral trajectory.

Craniocerebral trauma (CCT) is the cause of 20% ofsymptomatic and 5% of all cases of epilepsy [23]. In Russia,CCT is the main cause (27.7%) of location-dependentepilepsy in adults [1, 18].Post-traumatic epilepsy (PTE) is one of the late and mostserious complications of CCT. CCT and, hence, the possiblerisk of PTE, is most common in the age range 15–34 years,where the number of cases is about 30% [30]. The mostimportant cause of CCT consists of transport accidents (most-ly traffic accidents), as well as domestic, sporting, and indus-trial accidents, as well as military injuries.Assessment of the morbidity of PTE involves use of var-ious definitions of CCT itself and PTE [17], as well as dif-ferent durations of studies. This is because the developmentof PTE requires a stably developed focus of epileptic activityresulting from organic brain injury [1, 29]. The mechanismsof epileptogenesis are tightly linked with the course of recov-ery processes after CCT or the occurrence of aberrant plas-ticity. The most important are changes in neurotransmitterprocesses, sprouting, the various mechanisms of neurondeath, changes in membrane and receptor properties, and theformation of hyperexcitable neuronal systems [19]. Whileepileptic activity during the acute phase of traumatic braininjuries results from cortical injury and the nonspecificresponse to intense physical actions (the mechanisms of pri-mary brain damage), in the later period of trauma, the harm-ful actions of free radicals and excitotoxicity due to gluta-mate accumulation (the mechanism of delayed secondarybrain damage) are probably more important [30]. An impor-tant role here is played by impairments to cellular andhumoral immunity and disintegration of the functions ofautonomic and humoral-endocrine regulation [1]. In allcases, genetic predisposition factors are of undoubted impor-tance, though they are complex and heterogeneous [17, 21].PTE should also be discriminated from post-traumaticseizures. PTE includes repeated, late (i.e., onset more thanone week after CCT) post-traumatic seizures [15, 23, 51].Post-traumatic epileptic seizures include any epilepticseizure developing as a result of CCT [21, 34, 35]. Epilepticseizures can develop at different times after CCT. In assess-ing the periods of onset of epileptic seizures, most authorsuse the Barolin et al. classification [5], initially developedfor epileptic seizures in cerebrovascular diseases. This clas-sification identifies the following types of epileptic seizures:immediate, developing within the first 24 h; early, develop-ing at 1–7 days from onset of illness; and late, starting atseven or more days.The time of onset and the frequency of development ofepileptic seizures depend on the type, location, and volumeof the focus of brain damage and the state of the premorbidbackground of the patient (presence of cerebrovascular dis-ease, repeated CCT in the history, genetic predisposition,chronic alcoholism, etc.) [1]. The incidence of early post-traumatic seizures is 3–5%, compared with an incidence of

The pathophysiological mechanisms of brain lesions after craniocerebral trauma (CCT) are associated with the effects of primary and secondary damaging factors. Here, we studied the changes in the indices of oxidative stress, including the content of malondialdehyde (MDA), the total antioxidant activity (TAA), the MDA/TAA coefficient, albumin, and the levels of the markers of secondary damage, such as nitric oxide (NO x ) and glucose in the blood serum of patients with CCT of moderate severity. A total of 29 patients with CCT were examined on days 1, 3, and 5 of their stay in a hospital. On day 5 of the posttraumatic period, we observed the exhaustion of the antioxidant system expressed in the increased MDA/TAA coefficient and decreased TAA in patients with CCT of moderate severity. The NO x level was decreased on day 1 and on days 3 and 5 it was similar to the norm. The glucose level was normal during the entire observation period. A significant positive correlation between the MDA/TAA index and traumatic subarachnoid hemorrhage was revealed on day 5, which reflected the relationship between oxidative stress and the lesion volume. This should be taken into account for the selection of a therapeutic approach.

The development of cerebral vasoconstriction in subarachnoid hemorrhage (SAH) induced by the rupture of an aneurism of brain vessels impairs cerebral circulation. Treatment with normobaric hyperoxia may be used as an effective approach to oxygen delivery to the injured brain tissue. The purpose of the present study was to evaluate the effects of normobaric hyperoxia on oxidative stress and factors of endogenous vascular regulation in eight patients who suffered from non-traumatic SAH and remained in critical condition. The intensity of oxidative stress was assayed by measuring malonic dialdehyde and the total antioxidant activity in the blood serum. Endothelium functions were evaluated using the content of the stable metabolites of nitric oxide and the activity of angiotensin-converting enzyme in the blood serum. The data from eight patients who suffered from non-traumatic SAH showed an enhancement of oxidative stress, which influenced the functions of the vascular endothelium and resulted in an imbalance in the endogenous regulation of vascular tone. Treatment with normobaric hyperoxia was not associated with intensification of free-radical processes in patients who suffered from non-traumatic SAH and did not influence intracranial and arterial pressure.

To evaluate the results of surgical treatment of patients with pharmacoresistant epilepsy.Examination and surgical treatment of 61 patients with pharmacoresistant forms of symptomatic epilepsy were performed from 01.01.14 to 01.05.16.The results confirmed the safety and efficacy of the surgical treatment of pharmacoresistant epilepsy. After 12 months, seizures were controlled in 69% of operated patients. The necessity of complex examination of all patients with pharmacoresistant epilepsy to make a decision about possible surgery is shown.Цель исследования. Оценить результаты хирургического лечения пациентов с фармакорезистентной эпилепсией. Материал и методы. За период с 01.01.14 по 01.05.16 было проведено обследование и хирургическое лечение 61 пациента с фармакорезистентной симптоматической формой эпилепсии. Результаты и заключение. Полученные результаты подтвердили безопасность и эффективность хирургического лечения указанных форм эпилепсии. По оценке через 12 мес контроль над приступами достигнут у 69% оперированных пациентов. Показана необходимость проведения комплексного обследования пациентов с фармакорезистентной формой эпилепсии для решения вопроса о возможном хирургическом лечении.Цель исследования. Оценить результаты хирургического лечения пациентов с фармакорезистентной эпилепсией. Материал и методы. За период с 01.01.14 по 01.05.16 было проведено обследование и хирургическое лечение 61 пациента с фармакорезистентной симптоматической формой эпилепсии. Результаты и заключение. Полученные результаты подтвердили безопасность и эффективность хирургического лечения указанных форм эпилепсии. По оценке через 12 мес контроль над приступами достигнут у 69% оперированных пациентов. Показана необходимость проведения комплексного обследования пациентов с фармакорезистентной формой эпилепсии для решения вопроса о возможном хирургическом лечении.

To examine the influence of the parent artery pathology on the local hemodynamics on the level of aneurysm.Mathematical models of the arteriovenous malformation (AVM) were built on the CT-angiography data of real patients. To simulate the thrombosis, the parent artery and its branches were sequentially turned off in the model 1. In the model 2, the simulation of embolization of AVM was achieved by cutting off the exactly section of the parent artery that was involved in the arteriovenous formation.Model 1 showed that the flow redistribution did not significantly impact on the risk of rupture after the parent artery was turned off and blood pressure was increased in both aneurysms by 3 mm Hg. Model 2, in which the aneurysms were combined with a direct arteriovenous drainage with low peripheral resistance, showed that turning off the parent artery and pathological drainage led to the serious reduction in the venous drainage flow and it's increasing in the parent artery by about 60% that significantly increased the risk of rupture.Цель исследования. Изучение влияния патологии дистального отрезка несущей артерии на локальную гемодинамику на уровне аневризмы. Материал и методы. В работе был использован метод математического моделирования артериовенозной мальформации, построенный на основе данных компьютерно-томографической ангиографии пациентов. В модели 1 для имитации тромбоза несущей артерии созданы ситуации последовательного выключения из кровотока М1-М2 ветвей средней мозговой артерии. В модели 2 для имитации эмболизации АВМ моделировали выключение из кровотока отрезка несущей артерии, непосредственно участвующего в формировании артериовенозного сброса АВМ. Результаты и заключение. Модель 1 показала, что перераспределение потоков крови при выключении из кровотока ветвей средней мозговой артерии и увеличение давления в каждой из аневризм примерно на 3 мм рт.ст., что не оказывает существенного влияния на риск разрыва. Анализ данных модели 2, в которой аневризмы сочетаются с наличием прямого сброса из артерии в дренирующую вену (АВМ) со значительно меньшим периферическим сопротивлением, показал, что выключение несущей артерии и артериовенозного сброса приводит к снижению потока в дренирующей вене и увеличению его в несущей артерии на 60%, что существенно увеличивает риск разрыва аневризмы.

Traumatic brain injury is one of the main causes of mortality and disability in young and middle-aged individuals. The patients with severe traumatic brain injury who are in coma are the most difficult to deal with. Appropriate diagnosis of the primary brain injuries and early prevention and treatment of secondary damage mechanisms largely determine the possibility of reducing mortality and severe disabling consequences. The authors compiled these guidelines based on their experience in development of international and Russian recommendations on the diagnosis and treatment of mild traumatic brain injury, penetrating gunshot injury of the skull and brain, severe traumatic brain injury, and severe consequences of brain injuries, including a vegetative state. In addition, we used the materials of international and Russian recommendations on the diagnosis, intensive care, and surgical treatment of severe traumatic brain injury published in recent years. The proposed recommendations are related to organization of medical care and diagnosis of severe traumatic brain injury in adults and are primarily addressed to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and emergency room doctors, who are routinely involved in management of these patients.Черепно-мозговая травма является одной из основных причин смертности и инвалидизации среди лиц молодого и среднего возраста. Наиболее сложной группой являются пострадавшие с тяжелой черепно-мозговой травмой, находящиеся в коме. Адекватная диагностика первичных повреждений мозга, своевременное предупреждение и лечение вторичных механизмов повреждения во многом определяют возможность снижения летальности и тяжелых инвалидизирующих последствий. При создании данных рекомендаций авторы использовали свой опыт участия в разработке международных и отечественных рекомендаций по диагностике и лечению легкой черепно-мозговой травмы, проникающих огнестрельных ранений черепа и головного мозга, тяжелой черепно-мозговой травмы, тяжелых последствий повреждений мозга, включая вегетативное состояние. Кроме того, были использованы материалы международных и национальных рекомендаций по диагностике, интенсивной терапии и хирургическому лечению тяжелой черепно-мозговой травмы, опубликованные в последние годы. Предложенные рекомендации касаются организации медицинской помощи и диагностики тяжелой черепно-мозговой травмы у взрослых и адресованы прежде всего нейрохирургам, неврологам, нейрорентгенологам, анестезиологам, реаниматологам, повседневно участвующим в лечении данной группы пациентов.

We report here a retrospective analysis of the results of treatment of 89 patients with giant aneurysms (GA) of the brain vessels. A total of 67 patients underwent surgery, with open surgery performed in 49 cases and endovascular procedures in 18. The severity of patients’ status was assessed on the Hunt–Hess scale, levels of consciousness on the Glasgow Coma Scale, and treatment results on the Glasgow Outcomes Scale. Four types of course were identified for aneurysm: apoplectiform in 64 patients (72.0%), pseudotumorous in 18 patients (20.2%), embolic in three patients (3.4%), and asymptomatic in four patients (4.4%). Excellent and good results from surgery were obtained in 79.1% of patients; post-operative lethality was 13.4%. Among unoperated patients with symptomatic GA, lethality was 47.4%. These results lead to the conclusion that although open and endovascular interventions for GA represent highrisk surgery, surgery is preferable to conservative treatment, as it decreases lethality and leads to better functional outcomes.

According to B. Nordenstrom's concept, homeostasis is controlled by biologically closed electrical circuits in the organism. Therefore, a wide application of implanted platinum electrodes in medicine for diagnostics and treatment is not surprising. Open circuit potentials of platinum electrodes in biological media, termed redox potentials, reflect the level of pro- and antioxidant activities in the organism. The dynamics of redox shifts towards negative potentials in patients with acute cerebral pathology as a result of the treatment by hyperbaric oxygenation was investigated. It was suggested that an increase in antioxidant activity occurs. Thus, redox potential measurements can be used to elucidate certain mechanisms of the effect of hyperbaric oxygenation procedure in patients with acute cerebral pathology. Correlation between redox values and toxicity or quantity of "middle molecule" was found.

Purpose: To estimate the dynamics of cerebral oxygenation and metabolism during intracranial pressure (ICP) correction with 15% Mannitol and 7,2% saline in 6% HES 200/0,5. Methods: We analyzed 39 episodes of ICP correction with 15% Mannitol or 7,2% NaCl in 6% HES 200/0,5 ("Hyper- HAES") in 9 patients with intracranial hemorrhage (GCS 4-8). Monitoring of ICP, systemic hemodynamics, SvjO2 and cerebral microdialysis was used in all patients. Brain temperature (Tbr) and brain oxygen tension (PbrO2) were investi- gated in 5 patients. ICP > 20 mmHg was the indication for treatment. Results: The duration of ICP reduction below 20 mmHg was 121 ± 58 min for 15% Mannitol and 258 ± 122 min for "Hy- perHAES" (p

To evaluate the incidence and risk factors for posttraumatic seizures (PTS).The authors conducted a prospective study of 237 patients with TBI of varying severity. The patients were hospitalized and examined in Moscow neurosurgery departments. Then they participated in the follow-up observation for 2 years. PTS were classified as early (occurred from 1 to 7 days after TBI) and late (occurred later than 7 days).Forty-three people (18.1%) experienced early seizures, 15 patients (6.3%) had late seizures. The early seizures were the significant predictor of the late seizures. In the group of patients with early seizures, the proportion of severe TBI was significantly higher. Subdural hematoma, depressed skull fracture, alcohol abuse were reliable predictors of early and late PTS. Thus, these factors increased the risk of posttraumatic epilepsy (PTE).Цель исследования. Оценка заболеваемости и факторов риска возникновения посттравматических приступов. Материал и методы. Обследовали 237 пациентов с черепно-мозговой травмой (ЧМТ) разной степени тяжести, госпитализированных в отделения нейрохирургии Москвы и находившихся под наблюдением в течение 2 лет. Посттравматические приступы были классифицированы как ранние (возникшие с 1-х по 7-е сутки после ЧМТ) и поздние (отмечавшиеся позднее 7 сут). Результаты и заключение. Ранние приступы наблюдали у 43 (18,1%) больных, поздние - у 15 (6,3%). Было установлено, что ранние приступы являются фактором риска поздних. В группе пациентов с ранними приступами доля тяжелой ЧМТ была достоверно выше. Субдуральная гематома, вдавленный перелом черепа, злоупотребление алкоголем явились достоверными предикторами ранних и поздних посттравматических приступов. Таким образом, наличие вышеуказанных факторов повышает риск развития посттравматической эпилепсии.

Haemorrhage within the posterior fossa (PF) after supratentorial surgery is a very rare and exceedingly dangerous complication. Only 28 cases were found in the literature. Up to now, no pathogenetic factor has decisively proven to be the cause of this phenomenon. We present clinical details of a patient operated on for aneurysm of the anterior communicating artery. Lumbar drainage was used during surgery, with the loss of a large amount of cerebrospinal fluid (200 ml). Other causes in our case which may have led to cerebellar shift or a critical increase in transmural venous pressure with subsequent vascular disruption and haemorrhage were extreme head rotation during lengthy surgery and blood pressure peaks in the early postoperative period. Repeated computed tomography (CT) allowed immediate diagnosis of this complication and control of its conservative management. After postponed ventriculoperitoneal shunt, the patient recovered completely.

More than 70% of hypertensive hemorrhages are located in deep brain structures. The removal of such hematomas using encephalotomy is accompanied by additional cerebral trauma and often results in unsatisfactory outcomes. The puncture aspiration with local fibrinolysis is one of the minimal invasive methods for treatment of intracerebral hematomas (ICH). The puncture and aspiration of liquid part of ICH (not more than 20% of ICH volume) is performed via small burr hole. Afterward the catheter is placed into ICH cavity and fibrinolytic is injected via this catheter in postoperative period for lysis of ICH solid part. The lysed blood is aspirated within 1-4 days. The last generations of fibrinolytics are very effective concerning intensity of blood clot lysis and practically have no systematic effect on blood coagulation system during their local usage. Morphological examinations showed that usage of fibrinolysis leads to formation of smaller cysts in the region of former hematoma as well as reparative processes in perihemorrhagical zone are expressed better comparing with treatment methods without usage of fibrinolytics. The morphological pattern is also confirmed by clinical signs of neurological deficit regress corresponding to damage focus. We operated 124 patients with parenchymal hemorrhages and 28 patients with intraventricular hemorrhages using described minimally invasive method at the base of Scientific Research Institute of Emergency Care n.a. N.V. Sklifosovsky. The applied method allowed decreasing lethality from 35% to 21% among patients with parenchymal ICH and from 98% to 48% - among patients with ventricular hemotamponade underwent usage of ventricular drainage combined with local fibrinolysis.

The new possibilities in therapy of cerebral aneurysms, arteriovenous malformations and hypertensive intracranial hematomas recently have come into the neurosurgical sphere due to development of neurovisualization and neurophysiology methods and widely usage of microsurgical principles as well as neuroendoscopy, neuronavigation systems and methods of intraoperative control for operative radicality in surgery of non-traumatic intracranial hemorrhages. Besides this progress was not possible without extensive development of several aspects of anesthesiology and reanimatology focused on anesthetic management and intensive care of neurosurgical patients in particular. Timely diagnostics and optimal choice of treatment methods in patients with non-traumatic intracranial hemorrhages allow to achieve good functional outcomes with trend to mortality minimization.

To compare the severity of brain dislocation, the rate of its progression according to CT results and clinical signs of dislocation syndrome (DS) in patients with unfavorable form of massive ischemic stroke (MII).We analyzed the results of examination and treatment of 114 patients with unfavorable course of MII. Patients were stratified by the type of DS course into two groups: group 1 with unfavorable course (91 patients) and group 2 with favorable course (23 patients). Patients were compared by disease course and outcome as well as by progression rate and severity of brain dislocation. Twenty-seven patients of group 1 underwent decompressive craniectomy (DC).All patients of group 1 had DS decompensation and, therefore DS course was assessed as unfavorable. All patients of group 1, who received only conservative treatment, died from brain dislocation. In patients treated with DC in addition to conservative treatment, the fatality rate was 48%. In this group, we singled out 3 variants of DS course: fulminant, progressive and delayed. In patients of group 2, the fatality rate was 52%. The patients died from non-cranial complications and DS course in this group was regarded as favorable.In patients with unfavorable course of MII, the risk of fatal outcome from temporal-tentorial impaction is determined both by the severity and progression rate of transverse dislocation of the middle brain structures. DS in patients with unfavorable course of MII can have favorable or unfavorable course. The unfavorable course is characterized by fulminant, progressive or delayed DS progression rate. The unfavorable course of DS is an absolute indication of administration of DC.Цель исследования. Проведение сравнительного анализа между выраженностью дислокации головного мозга, темпом ее развития по данным КТ и клиническими проявлениями дислокационного синдрома (ДС) у пациентов со злокачественной формой массивного ишемического инсульта (МИИ). Материал и методы. Проведен анализ результатов обследования и лечения 114 больных со злокачественным течением МИИ. По типу течения ДС больные были разделены на 2 группы: 1-я группа - с неблагоприятным типом течения ДС (91 человек), 2-я группа - больные с благоприятным типом течения ДС (23 человека). Больных обеих групп сравнивали по течению и исходам заболевания, а также темпу развития и выраженности дислокации головного мозга по данным КТ. В 1-й группе 27 пациентам выполнили декомпрессивную краниотомию (ДКТ). Результаты. У всех больных 1-й группы имелась декомпенсация ДС, в связи с чем его течение было расценено как неблагоприятное. Все больные 1-й группы, которым проводили только консервативное лечение, умерли. У больных 1-й группы, которым консервативное лечение было дополнено ДКТ, летальность составила 48%. В этой группе выделили 3 варианта течения ДС: фульминантное, прогредиентное, отсроченное. У пациентов 2-й группы летальность составила 52%. Пациенты умерли от внечерепных осложнений, поэтому тип течения ДС в этой группе был расценен как благоприятный. Заключение. У больных со злокачественным течением МИИ риск летального исхода от височно-тенториального вклинения определяется не только выраженностью, но и темпом развития поперечной дислокации срединных структур головного мозга. ДС у больных со злокачественным течением МИИ может протекать по благоприятному и неблагоприятному типам. При неблагоприятном типе темп развития ДС может быть фульминантным, прогредиентным и отсроченным. Неблагоприятное течение ДС является абсолютным показанием к ДКТ.

Эффективность хирургической профилактики ишемического инсульта доказана в ряде международных рандомизированных исслед ований. Нерешенными остаются вопросы о сроках проведения вмешательств, критериях отбора больных, технике таких операций. В обзоре проведен анализ 46 источников литературы, посвященных данной тематике. Существующий значительный арсенал хирургических методик позволяет с успехом проводить реваскуляризирующие операции у пациентов с острыми ишемическими инсультами и поражением экстра- и интракраниальных артерий. Преимущество выполнения ранних каротидных эндартерэктомий у пациентов с малым инсультом и транзиторными ишемическими атаками (ТИА) является неоспоримым. Предметом продолжающейся дискуссии является проведение экстренных эндартерэктомий и тромбинтимэктомий у пациентов с инсультом в ходу, crescendo ТИА, острой окклюзией внутренней сонной артерии. Накоплен немалый опыт выполнения таких вмешательств, однако для уточнения их эффективности необходимо проведение рандомизированных исследований. Использование микрохирургической техники позволило выполнять шунтирующие операции и открытые эмболэктомии в ситуациях, ранее считавшихся некурабельными. Ключевые слова: острый ишемический инсульт, реваскуляризирующие операции при остром инсульте. The effectiveness of surgical prevention of ischemic stroke has been demonstrated in several international randomized studies. Issues about the surgery time, patient selection criteria, surgery techniques remained unresolved. We have reviewed 46 publications in this field. The current vast arsenal of surgical techniques allows to conduct revascularization surgery procedures in patients with acute ischemic stroke and lesions of extra- and intracranial arteries. The benefits of early carotid endarterectomy in patients with mild stroke and transitory ischemic attacks (TIA) are undeniable fact. Necessity of urgent endarterectomy and thrombintimectomy in patients with stroke, TIA, acute inner carotid artery occlusion is a subject of current discussions. The experience in performance of these interventions has been accumulated but randomized studies are needed to verify their effectiveness. Microsurgical techniques have made it possible to perform bypass surgery and open embolectomy in situations earlier considered as incurable.

The paper deals with the assessment of cerebral perfusion in patients in the acute period of acute cerebrovascular accident before and after revascularization surgery. It gives a clinical example of using contrast-free perfusion magnetic resonance imaging (MRI) in a patient with hemodynamic ischemic stroke. The use of this technique made it possible to determine indications for early carotid endarterectomy for the contralateral internal carotid artery and to evaluate positive postoperative changes in cerebral perfusion and the patient’s neurological status. The authors analyzed the current literature on this problem with a particular emphasis on the possibilities of using dynamic susceptibility contrast-enhanced and arterial spin-labeling contrast-free perfusion MRI in this category of patients. Carotid endarterectomy in the acute period of acute cerebrovascular accident can improve cerebral hemodynamics and the patient’s neurological status and prevent recurrent cerebral circulatory disorders. Indications for this surgery should be determined by taking into consideration the results of perfusion MRI techniques (single-photon computed tomography contrastenhanced and contrast-free perfusion MRI).

The objective of the present work was to study syntopy of the artery of labyrinth using block-preparations of the posterior cranial fossa, variants of its branching-off from the vertebro-basiliar basin (VBB), and peculiar features of its anatomical structure. A total of 12 block-preparations of the posterior cranial fossa were available for the investigation. They were preliminarily stained with red latex and fixed in a three-point system. These procedures were followed by retrosigmoid craniotomy, opening of dura mater in the supero-lateral part of the cerebellomedulllary cistern, traction of the cerebellum, and blunt separation of the basiliar artery (BA). Variants of branching of the antero-inferior cerebellar artery (AICA) and branching of the artery of labyrinth from AICA were studied. It was shown that the artery of labyrinth branches off from the antero-inferior cerebellar artery in 100% of the cases. The latter artery formed a loop in 14% of the cases (3 ears). The average diameter of the labyrinth artery was 0.32 mm and its mean area 0.06 sq.cm. The artery of labyrinth branched off from the posterior para-stem segment of the antero-inferior cerebellar artery in 42.6% of the cases (9 ears), and from the anterior para-stem segment of AICA in 14.2% of the cases (3 ears). Within the conventional «rhombus», the artery of labyrinth was straight in 76.2% of the cases (16 ears) and arc-shaped in 23.8% (4 ears).Цель исследования - изучить на блок-препаратах задней черепной ямки синтопию лабиринтной артерии (ЛА), варианты ее отхождения от сосудов вертебрально-базилярного бассейна (ВВБ), а также особенности ее анатомического строения. Исследованы 12 блок-препаратов задней черепной ямки, предварительно прокрашенных красным латексом. Препараты были фиксированы в трехточечной системе, после чего выполняли ретросигмовидную краниотомию, вскрывали твердую мозговую оболочку в верхнелатеральной части большой цистерны, проводили тракцию мозжечка, производили тупую отсепаровку базилярной артерии (БА). При этом анализировали варианты отхождения передней нижней мозжечковой артерии (ПНМА), а от нее ЛА. По нашим данным, ЛА отходила от ПНМА в 100% случаев. ПНМА делала петлю в 14% случаев (3 уха). Средний диаметр ЛА составил 0,32 мм, средняя площадь - 0,06 мм2, средний диаметр - 0,32 мм. От заднего парастволового сегмента ЛА отходила в 42,6% случаев (9 ушей), от латерального парастволового сегмента ПНМА - в 42,6% (9 ушей), от переднего парастволового сегмента ПНМА - в 14,2% (3 уха). Ход ЛА в условном 'ромбе' был прямым в 76,2% (16 ушей), дугообразным - в 23,8% (4 уха).