Difficult Cases in Surgery of Gunshot Wounds to the Skull and Brain - A Single Center Experience

Aim: To analyze the results of treatment of patients with difficultcombat traumatic brain injuries caused by a gunshot (gTBI), todevelop practical recommendations for their treatment on the basisof personal experience and analysis of literature sources.Method: The results of treatment of 2,120 wounded May 2014 toJanuary 2017 have been analyzed. Combat gTBIs were diagnosedin 160 patients. The following groups have been referred to severegTBIs: А. By the kind of the wounding shell: bullet, multiplefragmentation mine and explosive brain injuries, B. By the natureof the wound canal: diametrical, diagonal. С. By the location of thewound canal: bilateral, transventricular, transbasal, penetratingwounds with the injury of paranasal sinuses. D. By the presenceof severe structural injuries of the brain substance: injuries ofsubcortical ganglia, brain stem, and cerebellum, extended loci ofbrain contusion and crushing, multiple loci of brain contusion andcrushing. E. By the presence of injuries of functionally importantbrain vessels: main arteries (trunks and their major branches).venous sinuses.Results: Difficult severe injuries were diagnosed in 74 (46.25%)patients out of 160 cases of combat gTBIs. 18 patients out of160 patients with gTBIs died. Mortality comprised 11.25%. Themortality rate for severe combat gTBIs is 24.3%.Conclusion: Detection at the stage of diagnosing of severe combatgTBIs takes surgical tactics and intensive therapy into the rightdirection in accordance with developed practical recommendations

Modern Concepts of Microsurgical Treatment of Large and Giant Vestibular Schwannomas

Aim: To improve the results of treating large and giant vestibularschwannomas. Method: A prospective study of surgical treatment of 67 consecutivepatients with vestibular schwannomas (VS) during the period from 2011 to 2016. All patients were operated on by the author of thestudy. The results of treatment were compared with the previousperiod (2006 - 2010). VSs were removed using the retrosigmoidapproach. The function of the facial nerve was analyzed. In addition, English sources on the Internet were analyzed. Results: Two (3%) patients with medium VS, 12 (17.9%) withmoderately large VS, 31 (46.3%) with large VS and 22 (32.8%) withgiant VS were operated on. Thus, large and giant schvannomasoccurred in 79.1% of cases. Total removal of VS was performed in59 (88.1%) cases, subtotal in 7 (10.4%), and partial in 1 (1.5%) case. In the study group 2 patients died. Postoperative mortality rate - 3%. Conclusion: In the surgical series of studies patients with large andgiant VSs, which were discovered in 79.1% of cases, predominate. The main objective of VS surgery is a maximum complete removalof the tumor while preserving function of the brain stem, bloodvessels and cranial nerves. Application of modern technologies (ultrasound aspiration, trepanation of the internal auditory canal, neuromonitoring of the facial nerve function, preoperative surgeryplanning based on multimodal operation support) allows toincrease radicality of surgeries and to improve functional outputseven for large and giant VSs

Retrosigmoid Approach to the Cerebellopontine Angle Tumors - A Single Center Experience with a Systematic Review of Literature

Aim: To study special features of applying the retrosigmoidsuboccipital approach (RSSA) in surgery for cerebellopontineangle (CPA) tumors, the possibilities for expanding the approach,complications and ways of their prevention.Method: The prospective analysis of the RSSA application in 112patients with CPA tumors, who were examined and treated in Mechnikov Hospital from 2010 to 2016 inclusive, has been made. All patients were operated on by the author of the study. TPC tumorswere removed using the retrosigmoid approach with the followingequipment: microscopes, electrotrepans, ultrasonic dissectoraspirator, high-frequency coagulation with bipolar coagulationtweezers, and intraoperative neuromonitoring system.Results: By applying the RSSA, we removed 67 vestibularschwannomas (VS), 4 non-vestibular schwannomas (3 schwannomasof caudal group of CNs and 1 schwannoma of trigeminal nerve), 30 CPA meningiomas, 7 epidermoid tumors, 1 hemangioblastoma, 1 chondroblastoma, 1 choroid papilloma, 1 cancer mts. Ownexperience and literature analysis allow to make the conclusionsabout advantages and disadvantages of RSSA application. Conclusion: RSSA is a safe and relatively simple technique with avery low percentage of complications. RSSA provides an excellentpanoramic examination of the entire CPA and a wide opening ofthe tumor regardless of its type and size. At all stages dissection isperformed under a direct visual control, in such a case the locationof the cranial nerves can be determined at an early stage, thusincreasing the chances of preserving the nerves and allowing radicalremoval of the tumor

Surgical treatment of combat craniocerebral gunshot wounds combined with paranasal sinuses injury

Abstract. Results of surgical treatment of 30 patients with combat-related gunshot traumatic brain injuries (GTBI) combined with paranasal sinuses injury (PNS) were analyzed. The injuries resulted from local armed conflict in the Eastern Ukraine. Object and methods. The patients were consistently enrolled in the prospective study in the period from May 25, 2014 to December 31, 2017. This group of patients made up 16.3% of all GTBI patients treated during that period. All patients underwent high-resolution cranial CT at admission. Frontal sinus injuries were observed in 25 (83%) cases; ethmoid bone injuries, in 13 (43) cases; sphenoidal sinus injuries, in 1 (3%) case. 26 (87%) patients had penetrating wounds; 4 (13%) patients, non-penetrating cerebral wounds. Fragment mine blast wounds were observed in 26 (87%) cases; 4 (13.3%) wounds were caused by bullets. Blunt wounds were diagnosed in 17 (57%) patients; bound shot wounds, in 7 (23%) patients; penetrating wounds, in 6 (20%) patients. GCS score after initial resuscitation ranged from 5 to 15 (average 10.6±3.5). Four non-penetrating brain wound patients were treated conservatively. Initially, 26 (87%) patients underwent surgery. Emergency intervention was performed to remove intracranial hematoma, close dura mater defects and restore skull base while simultaneously sealing ethmoid and frontal air sinuses. Well-vascularized frontal and lateral pericranial flaps on pedicle in various modifications were used to close frontal sinus and anterior cranial fossa defects. Outcomes. Nasal liquorrhea was observed in 12 (40%) patients at admission and in 2 (7%) patients after treatment. Purulent and septic complications were only detected in 1 (3%) patient. The complications had the form of combined meningoencephalitis, ventriculitis, and subdural empyema. Favourable treatment outcomes (good recovery or moderate disability) in 6 months after treatment were detected in 24 (80%) patients; unfavourable outcomes (severe disability or death), in 6 (20%) patients. Vegetative state was not observed in treated patients. Two lethal cases were not associated with paranasal sinus injury. In one case, there was a severe primary brain injury; in the other case, severe combined internal organ injuries with multiple organ failure

Late Results of Surgical Treatment of Peripheral Nerves Gunshot Injuries

Aim: To analyze late results of surgical treatment of the sequela ofperipheral nerve gunshot injuries (PNGI). Method: The analysis of treatment results of 19 injured personswith PNGI. Injuries were received during a local armed conflict inthe east of Ukraine. Results: 20 surgeries were performed. 8 (42.1%) persons underwentupper extremity nerve surgeries, and 11 (57.9%) persons underwentlower extremity nerve surgeries. 4 persons with ulnar nerve lesionsand 3 injured persons with median nerve lesions were operatedon. Another injured person had both median nerve and radialnerves lesions. 4 persons with sciatic nerve lesions and 7 injuredpersons with peroneal nerve lesions underwent surgeries. Shell, that wounded: 5.45 caliber bullet - 6 (31.6%); fragments from thegrenade shells explosion (AGS) - 3 (15.8%); fragments of the minesreleased from a mortar launcher - 10 (52.6%). During surgery, theanatomical nerve rhexis with the end neuromes formation wasdetected in 10 (52.6%) injured persons, 5 (26.3%) injured personshad inner neuromes. Nerve neurolysis was performed in 3 cases;neurolysis with the installation of a temporary stimulator wasperformed in 6 cases. Microneurorrhaphy was performed for 7 persons, and autotransplantation was made for 4 persons. Motorfunction recovery was evaluated using the scale of R.B. Zachary, W.Holmes (1946) (modified at St. Petersburg Research Institute namedafter Polenov). 8 (42.1%) injured persons had 0-2 points, 5 (26.3%) injured persons had 3 points, other 5 (26.3%) injured persons had 4points, 1 injured person (5.3 %) had 5 points

Critical thresholds of intracranial pressure after severe traumatic brain injury

The article considers the monitoring of intracranial pressure as an important prognostic factor of predicting the treatment outcomes in the cases of severe craniocerebral trauma. Realizing the problem of defining the degree of intracranial hypertension as an urgent issue of neurophysiology and taking into consideration the ambiguity of the methods traditionally used to define this indicator the authors focus on the substantiation of the new threshold values of intracranial pressure maximizing the statistic difference between mortality/survival and favorable/adverse outcomes of treatment and established in the course of analyzing the results of the prospective study conducted on 100 consecutively included patients in the dynamics of the severe brain injury in the intensive care departments of Mechnikov Dnipropetrovsk Regional Clinical Hospital in the period from 2006 to 2012. Obtained with use of the parenchymal sensors for measuring intracranial pressure on the Brain Pressure Monitor REF HDM 26.1/FV500 manufactured by Spiegelberg (Hamburg, Germany) during 11657 recorded hours of observation, the data were processed due to the algorithm of the ROC curve analysis used to establish the most informative parameter of intracranial hypertension. The research revealed the dependance of treatment results in two groups of patients (survived/died and favorable/adverse outcomes) on the five basic indicators of intracranial pressure (dose, duration, intensivity of intracranial hypertension/ average and maximum levels of intracranial pressure). Groups of patients with two different treatment results most likely differ in terms of the intensity of intracranial hypertension, namely, due to the average value of exceeding the threshold of intracranial pressure of 15 mm Hg. The received thresholds of average intracranial pressure for the distribution of treatment outcomes are lower than the indicators accepted in many recent recommendations. The average value of exceeding the threshold of intracranial pressure of 15 mm Hg which is about 7 mm Hg (7.38 for the results survived/died; 7.06 for favorable/adverse outcomes) should be recognized as the most significant prognostic criterion for the differentiation of patients with different results of treatment

Mannose-containing glycotopes of leucocytes in neuro-oncologial disease

There is a tendency to an increase in the incidence of tumors of the central nervous system in Ukraine. Among the primary brain tumors in adults, glioblastomas predominate. With the growth, differentiation and malignization of cells, the structure of membrane glycoproteins changes. In the oncologic process, there is a change in the expression of the number of glycoconjugates on the membranes of malignant cells. Therefore, the change in glycobiological indicators in cancers can be a priority direction of the research, namely, the development and improvement of existing methods of treatment. The aim of the work was to establish quantitative changes in the glycosylation of leukocytes and separately in their lymphocyte fraction upon neuro-oncological diseases. The subject of the study were blood leukocytes of patients with brain tumors

Prognostic factors of intracranial purulent-septic complications of combat-related gunshot penetrating skull and brain wounds

Purpose – to analyze the structure of intracranial purulent-septic complications (IPSC), determine the factors influencing development of purulent-septic complications in patients with combat-related gunshot penetrating skull and brain wounds (CRPSBW), determine the effect of intracranial PSC on patients’ outcomes. A prospective analysis of results of examination and treatment of 121 patients was performed. All patients had gunshot penetrating skull and brain wounds sustained in combat conditions during a local armed conflict in the Eastern Ukraine. Evaluation of treatment outcome included analysis of mortality in 1 month (survived/died) and dichotomous Glasgow Outcome Scale (GOS) score in 12 months (favorable/unfavorable outcome). 121 wounded men aged 18 to 56 (average, 34.1±9.1) were included in the study. Intracranial purulent-septic complications (IPSC) were diagnosed in 14 (11.6%) gunshot CRPSBW patients. The following prognostic factors had statistically significantly correlation with the risk of intracranial purulent-septic complications development: wound liquorrhea on admission (p = 0.043), intraventricular hemorrhage (p = 0.007), bone fragments left in the wound (p = 0.0152), and duration of inflow-outflow wound drainage for more than 3 days (p= 0.0123). Intracranial PSC patients had mortality rate of 50%, and only 14.3% of those patients had a favorable outcome according to GOS score in one year. Presence of intracranial PSC had statistically significant association with mortality rate (p=0.0091) and GOS score in one year (p=0.0001). Мета – провести аналіз структури внутрішньочерепних гнійно-септичних ускладнень (ВГСУ); визначити фактори, що впливають на розвиток гнійно-септичних ускладнень у пацієнтів з бойовими вогнепальними проникаючими пораненнями черепа і головного мозку; визначити вплив внутрішньочерепних ГСУ на результати лікування пацієнтів. Проведено проспективний аналіз результатів обстеження та лікування 121 пораненого. Всі постраждалі мали вогнепальні проникаючі поранення черепа і головного мозку, отримані в бойових умовах у ході локального збройного конфлікту на сході України. Оцінка результату лікування включала аналіз летальності через 1 міс. (вижив / помер) і дихотомічну оцінку за шкалою виходів Глазго (ШВГ) через 12 міс. (сприятливий / несприятливий результат). У дослідження включено 121 поранений чоловік у віці від 18 до 56 років (у середньому – 34,1±9,1 року). Внутрішньочерепні гнійно- септичні ускладнення (ВГСУ) діагностовано в 14 (11,6%) поранених з вогнепальними проникаючими черепно-мозковими пораненнями. Статистично значуще корелювали з ризиком розвитку внутрішньочерепних гнійно-септичних ускладнень такі прогностичні фактори: наявність рани та ліквореї при надходженні (р = 0,043), наявність внутрішньошлуночкового крововиливу (р = 0,007), залишені кісткові фрагменти в рані (р=0,0152) і тривалість припливно-відливного дренування рани більше 3-х діб (р=0,0123). Летальність серед пацієнтів з внутрішньочерепними ГСУ становила 50%, а сприятливий результат за ШВГ через рік мали тільки 14,3% поранених з внутрішньочерепними ГСУ. Наявність внутрішньочерепних ГСУ статистично значущо була пов'язана з летальністю пацієнтів (р=0,0091) і оцінкою за ШВГ через рік (р=0,0001)

Mannose-containing glycotopes of leukocytes in neuro-oncological disease

There is a tendency to an increase in the incidence of tumors of the central nervous system in Ukraine. Among the primary brain tumors in adults, glioblastomas predominate. With the growth, differentiation and malignization of cells, the structure of membrane glycoproteins changes. In the oncologic process, there is a change in the expression of the number of glycoconjugates on the membranes of malignant cells. Therefore, the change in glycobiological indicators in cancers can be a priority direction of the research, namely, the development and improvement of existing methods of treatment. The aim of the work was to establish quantitative changes in the glycosylation of leukocytes and separately in their lymphocyte fraction upon neuro-oncological disease