Transcranial ultrasonography (TUS) is a new ultrasound screening study that expands the possibilities of neurosonography. Contact numbers What is brain tus

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Irina asks:

Hello. An older child (5 years old) was diagnosed with residual encephalopathy-motor disinhibition syndrome. EEG-paroxysmal activity in all leads. (the child died tragically, but not for this reason, of course). In 2009, she gave birth to her second child. In the last stages of pregnancy, they put hypoxia, they dripped a dropper (unfortunately, I don’t remember the name of the drug). The question is. The child is VERY active. It is very reminiscent of the first child, who was also diagnosed with hyperactivity. How to determine what symptoms and signs, maybe the second one also has residual encephalopathy? It’s just that when they came to the appointment with the first one, they told me that he had a birth injury (before that, not a single pediatrician, nor in the maternity hospital, had told me this). They also said, "What have you been pulling for so long, where were you before?" The first child, I did not know that such increased excitability and activity, tearfulness and irritability is a disease, I attributed everything to a "bad" character. I'm really worried about the second one. How can you determine if he has brain disorders or not? It seems to me in behavior that there is, but suddenly I wind up, exaggerate. The child does not sleep well at night, often throws tantrums, is VERY whiny and irritable. The child is now 1 year 8 months old. Help me please. The neurologist we're talking to said it was bad parenting. Don't spoil everything. Here is the whole answer!

The fact is that the manifestations of encephalopathy can be different, and be accompanied by both excitation and inhibition of the central nervous system. In addition to visible excitation with encephalopathy, muscle tone is disturbed, tendon reflexes change. Try to contact a pediatric neurologist in the neurological department of the hospital. In addition, in a hospital or in a specialized diagnostic center, a child can have a TUS (transcranial ultrasonography) - ultrasound of the brain through the bones of the skull, which will show if there are changes in the child's brain. You can get a referral for this examination, as well as the address of the nearest center where this examination is carried out, from the local pediatrician.

Julia asks:

Good afternoon! The boy is six years old, was diagnosed with residual encephalopathy, did not speak until the age of four, began to speak indistinctly after visiting a chiropractor (during childbirth, there was a subluxation of the first cervical vertebra), currently emotional instability, mood changes rapidly, periodically rises on his toes and shakes with hands, with tension, the left eye squints, there are no judgments, logical thinking is poorly developed, performs simple tasks, distractibility from work, not perseverance, constantly moves, does not perceive questions from strangers, speaks only when necessary and then the simplest phrases.
After the acupuncture session, he began to draw and began to twitch less.
did an MRI of the brain, the conclusion of pathological changes was not revealed, the electroencephalogram showed that 1. BEA did not correspond to age, 2. mild cerebral changes, irritative, 3. no focus of pathological and paroxysmal activity was registered.
Question: do these studies confirm our diagnosis or do we need to do some additional examinations? And what can be the cause of this disease? Thanks

Unfortunately, within the framework of the Internet consultation, it is impossible to identify the causes of such pronounced neurological disorders. However, residual encephalopathy - this diagnosis is made in the presence of residual effects after an injury or some kind of disease that led to a neurological persistent pathology after some time. And not a word is said about past injuries or neurological diseases. Therefore, we cannot confirm the diagnosis.

Julia asks:

Good afternoon! The whole point is that our child did not suffer any diseases, the only thing was that there was a subluxation of the first vertebra and there was a cyst of three mm, but by the age of three months it had resolved, in a year the neurologist told us that everything was fine with us.
It all started at the age of two, when our child went to kindergarten, problems began ... The child did not talk, did not perceive the teachers, did not particularly play with the children, took what he wanted, and if they did not let him fight. After that, we turned to a neurologist, we were diagnosed with ADHD, underwent a course of treatment, nothing helped, we began to go to a specialized kindergarten, where specialists monitored him, they also could not help, the only diagnosis was residual encephalopathy.
After that, having studied all the information about our diagnoses on the Internet, we turned to a chiropractor to correct the subluxation, he first of all sent us to an REG, where it showed that we had impaired blood circulation, after a course of treatment, everything was restored to us (did REG again). After visiting the chiropractor, two years have passed, the result is there, the child began to speak better, understand the addressed speech of parents and relatives, can express his desires, but the problems remained (I wrote about them above). Our neurologists do nothing more than pills and injections, there is a diagnosis and they prescribe treatment accordingly, but it does not help us. I’m wondering on the basis of what they made the diagnosis, if we didn’t go through more than one examination then, but were only under the supervision of doctors, and the fact that we have now done an examination shows that everything is fine with his brains ... So we cannot understand the reason our child's illness. Thanks in advance.

The cause of residual encephalopathy may be a birth trauma during childbirth, fetal hypoxia, cytomegalovirus infection or toxoplasmosis, and other causes. Now it is very difficult to guess what caused this disease. At the moment, it is recommended to regularly carry out rehabilitation activities: massage, gymnastics, a course of drug therapy to improve the child's condition.

Avokado asks:

The boy is 4 years old, he does not speak well. He speaks as if with an accent, many words are incomprehensible, he distorts letters in words, he speaks complex words with difficulty. It used to start shaking at night. The neurologist prescribed soothing drops "Bunny". If the temperature rises, the child complains of headaches. Speech therapy recommended. Recently diagnosed with encephalopathy. It seems that he does not lag behind in general development (up to 1 year he learned to assemble a pyramid, a designer, now he assembles puzzles, unscrews nuts with a screwdriver, plays with other children). A little noisy, often offended and poorly spoken. Tell me how to deal with a child, what is encephalopathy and is it a very terrible diagnosis, can it be treated?

Encephalopathy is a collective concept of a group of diseases leading to functional disorders of the cerebral cortex. To predict the dynamics of the process, prescribe adequate treatment and monitor the effectiveness of treatment, it is necessary to identify the cause of the development of this disease (impaired blood circulation in the brain, toxic conditions caused by congenital fermentopathy, birth trauma or hypoxia). To diagnose the cause of encephalopathy, a personal consultation of a pediatric neurologist and a thorough neurological examination are necessary.

Avokado asks:

On ultrasound, the child was diagnosed with a curvature of the artery and narrowing of the vessels of the brain. The result is encephalopathy. Is this the cause of speech inhibition (poorly speaks at 4 years old). Is it treatable?

Perhaps as a result of poor / difficult microcirculation in the brain, there is a violation of the development of the centers responsible for speech. it is recommended to consult with a neurologist to prescribe adequate treatment, as well as with a speech therapist to correct speech.

Oksana asks:

hello. my 14 year old child suffers from headaches (BIRTH INJURY-OXYGEN STARVATION). CT - without pathology, EEG - general cerebral changes of a mild stage, paroxysmal activity along the posterior-fronto-central-parietal-temporal branches, the examination was in 2005, now they offer an EEG repeat, an oculist. Are these examinations informative, tell me, can there be any other diagnostics. BECAUSE as an EEG-paid procedure, maybe they just extort money? Thank you.

Unfortunately, in the situation you describe, the minimum scope of the examination includes: examination by an ophthalmologist, EEG recording and a personal consultation with a neurologist. If the results of the encephalogram reveal signs of organic changes in the brain, a computed tomography may be required. You can read more about the possible causes of a headache, about the diseases accompanied by this symptom, their clinical manifestations, methods of diagnosis and treatment, in our thematic section of the same name.

With the introduction ultrasound diagnostics in narrow specialties, specialized specialists more and more often supplement routine ultrasound examinations in their fields, there is an addition, and sometimes a complete change in the principles of using diagnostic ultrasound in narrow specializations. There is nothing surprising in this, because no one will argue that obstetric and gynecological ultrasound examinations without a narrow specialization of a diagnostician are now becoming less common. Absolutely the same phenomena occur in other areas of medicine. Which apparently, in the end, will lead to the complication and deepening of all ultrasound studies in narrow areas. Manufacturers of ultrasound equipment have already responded to the increasing demands of narrow specialists with the appearance of ultrasound devices that meet the needs of a particular area in diagnostics.

This study was carried out on Sonoscape ultrasound scanners.

"Experience with the use of transcranial ultrasonography (TUS) in patients of various age groups."

Gorischak. S.P., Kulik A.V., Yuschak I.A.

Enormous work is needed to develop something NEW. As it turned out, in our domestic medicine, the implementation of an already invented and tested research very often meets with resistance.
There are several reasons for this:
1. Conservative views of colleagues, management, as well as a lack of desire to even consider something NEW.
2. The inability to implement this NEW (due to material and technical shortages).

There is such an expression "Drops of water sharpen a stone with constancy."
So PIONEERS fill new directions with their enthusiasm, overcome obstacles with justification and the IDEA is embodied in LIFE.
One of these PIONEERS is a neurosurgeon, Doctor of Medical Sciences, Professor Iova A.S.
Studying his work, I liked the new concept, called "3V - technologies". Namely, "ZV-technologies" in pediatric neurosurgery.
Using the saying of J. Caesar: "Veni, Vedi, Vici" ("I came, I saw, I conquered"), the principles of a new diagnostic and treatment process in neurosurgery were formulated. "Veni" ("came") - the portability of equipment, allowing free movement to provide medical care, given the strict restriction on the movement of patients.
"Vedi" ("saw") - the ability to visualize brain tissue and brain structures with modern ultrasound scanners. The portable system Sonoscape - A6 was chosen as a method of comparison and selection.
"Vici" ("won") - the possibility of providing first and necessary assistance on the spot.

The concept of 3V-technology includes a complex of information and instrumental support for a neurosurgeon, which makes it minimally dependent on the prevailing conditions (presence of traditional equipment, a large number of related specialists, etc.). From experience, we can say that the need for them is quite wide. This applies to the provision of neurosurgical care in emergency neurosurgery, in conditions of emergency medicine, military medicine, emergency medicine, as well as planned neurological care in the regions, in conditions of limited instrumentation.

Based on the criteria of "3V technology" of our Russian colleagues, the methodology was tested and implemented in Ukraine.
In medicine, there are such concepts as screening diagnostics, express diagnostics and disease monitoring.
Screening diagnostics is the conduct of mass planned examinations in order to identify diseases before the onset of characteristic clinical symptoms. This type of diagnosis belongs to preventive medicine. Express Diagnostics it is a method of emergency, extreme, military or disaster medicine. Its task is to identify changes that threaten the patient's life in conditions of acute shortage of time and at the "sick bed". Monitoring task- to determine the type of the course of the disease (from stable to rapidly progressing), which allows choosing the optimal treatment tactics in all areas of medicine and improving the prognosis. MRI and CT, despite their very high diagnostic capabilities, cannot be used as screening for economic reasons, and the need to transport the patient to the device significantly limits their capabilities in express diagnostics and monitoring.
The technology requirements for screening, monitoring and rapid diagnostics are very similar. The main ones are to quickly obtain general information about intracranial structural changes using simple and portable equipment. Based on these data, the clinician should be able to choose the optimal tactics for additional examination.
One of the methods of neurodiagnostics is transcranial ultrasonography (TUS). Previously, it did not find wide practical application due to the insufficiently high quality of the ultrasound image, the large dimensions of ultrasonic devices and their relatively high price. The advent of a new generation of portable and affordable SONOSCAPE ultrasound machines with significantly higher image quality has renewed interest in transcranial US. Today this method is used in Ukraine for neuroscreening, neuromonitoring in children and adults. Its main advantages are the implementation of an important clinical principle - "Sonoscape device to the patient", as well as the possibility of examining patients of various age groups and in any conditions of medical care. This Sonoscape diagnostic model is rational and cost-effective, the data obtained have a high correlation with expert neuroimaging methods (CT, MRI).

Purpose of the study– to assess the prospects of transcranial US in the diagnosis of neurosurgical diseases in children and adults by comparing ultrasound examination data with the results of MRI and CT studies.

Material and methods. The work was carried out at the Kiev Research Institute of Neurosurgery. A.P. Romadanov, Regional Children's Clinical Hospital in Odessa and SPCNR "Nodus" in Brovary (from 2012 to 2014) on Sonoscape portable ultrasound scanners. A total of 3020 patients were examined. The age of patients ranged from 1 day to 82 years. In most cases, TUS studies were performed on an outpatient basis in the FAP and the Central District Hospital (participation in the Rural Medicine program), as well as in the wards of neurological or neurosurgical departments, neonatal resuscitation at maternity hospitals, and in operating rooms.

All patients who were diagnosed with pathology during TUS underwent CT or MRI of the brain (52 cases). Transcranial US was performed according to the standard technique using a SonoScape A6 portable device with a C612 multifrequency microconvex probe and an L745 linear probe. Portability, image quality (with the ability to record on the device's hard disk), power autonomy (about 2 hours of examination on its own battery), as well as the price became the main criteria for choosing this device. The average duration of the study was 5 minutes; no special preparation of the patient was required). The results of the US screening in each case were presented as a reconstruction of the US image (the contour of the pathological object was drawn on a form with schematic drawings of the head in three projections). After that, CT or MRI was recommended, comparing the results, it was possible to evaluate the effectiveness of screening diagnostics.

Depending on this assessment, all studies were divided into 2 groups. The first group included studies in which transcranial US data made it possible to correctly suggest the localization and nature of intracranial changes. The second group included false-positive results (changes suspected in transcranial US were absent on MRI or CT).

Research results.

The results obtained are summarized in the table below.
Distribution of patients according to the nature of structural intracranial changes
and results of comparison of neuroimaging data

The "Other" group included patients with hydrocephalus (5), severe traumatic brain injury (2). All listed types of pathology had direct and/or indirect US signs of intracranial changes. Direct signs were characterized by focal changes in the US-density of the brain (objects of increased or decreased density). Indirect signs included deformation or dislocation of elements of the normal US image (eg, mass effect US syndrome). In patients with ischemic strokes, there were only minor manifestations of lateral dislocation and cerebral edema in the area of ​​stroke (contralateral displacement of the third ventricle by 1-4 mm and a decrease in the width of the lateral ventricle homolateral to the stroke).

In 90% of cases (2718), the third and lateral ventricles of the brain were visualized. Assessment of their position and size is important in the diagnosis and monitoring of intracranial changes. In 72% of patients (2174 people), it was possible to obtain a US image of the midbrain and basal cisterns. The evaluation of these data is of great clinical importance for early diagnosis and monitoring of intracranial changes in dislocation syndromes.

In 23 patients (1.1%) there were postoperative bone defects, and the study was carried out by transcranial and transcutaneous US (the sensor was located in a typical location in the area of ​​the temporal bone scale on both sides, and then on the skin over the bone defect). The presence of a bone defect of more than 20 mm in diameter made it possible to qualitatively visualize the intracranial space.
In 10% of patients, intracranial imaging was insufficient. These were mostly patients older than 60 years (302 people).
The study of false positive results of US screening (10 people) showed that sometimes ultrasound phenomena (obtained during the study) can affect the erroneous diagnosis, and their number can be reduced if the person's history is carefully studied, supplemented with an ophthalmological examination.

The discussion of the results.
In the data obtained, we can talk about the prospects of transcranial US in neuroscreening, neuromonitoring and express diagnostics in both children and adult patients. Despite the availability of MRI and CT, brain tumors reached significant sizes (up to 6 cm) by the time they were first diagnosed. This indicates the possibility of the formation of gross structural intracranial changes without typical neurological disorders not only in children but also in adults. In such cases, there are no clinical indications for the appointment of CT or MRI for a long time. Only the availability of neuroscreening technology will make it possible to detect these changes at earlier stages of the disease.

To increase diagnostic value, transcranial US should be accompanied by a concurrent, concise analysis of clinical data. It is most expedient to carry out the study in three stages. The first stage (clinical) is familiarization with the anamnesis, complaints and results of a neurological examination to determine the area of ​​the brain that should attract “increased interest” during transcranial US. The second stage (sonographic) is an assessment of intracranial echo-architectonics, especially in the area of ​​"increased interest" to identify structural intracranial changes. The third stage (clinical-sonographic comparisons) is the generalization and analysis of clinical and sonographic data to determine the adequacy of diagnosis and the choice of optimal tactics for further medical measures (for example, the use of expert neuroimaging methods, such as CT, MRI).

With the implementation of neuroscreening technology, earlier diagnosis of intracranial changes is possible. Transcranial US has special prospects in express diagnostics and neuromonitoring of traumatic and non-traumatic intracranial hematomas, since it allows conducting research in any conditions of medical care. In addition, the equipment used for transcranial US can also be used for intraoperative real-time navigation.

Conclusions:

1. Transcranial ultrasonography on Sonoscape is an affordable and quite effective method of neuroscreening, neuromonitoring and rapid diagnostics of structural intracranial changes in adult patients.
2. The effectiveness of transcranial ultrasonography is enhanced by the simultaneous analysis of clinical and ultrasonographic data.
3. The clinical and sonographic principle in neuroscreening, neuromonitoring and express diagnostics of structural intracranial changes on Sonoscape helps to choose the optimal tactics for diagnosis and minimally invasive treatment.
4. Rapid progress in the development of ultrasound technology, miniaturization of devices and reduction in their cost - the main principles of implementation in Sonoscape devices, increase the prospects for transcranial US in wide medical practice.

Source Collection of scientific papers dedicated to the 25th anniversary of Children's City Hospital No. 1 "Experience in the treatment of children in a multidisciplinary children's hospital" St. Petersburg, 2002, p123-124) A.S. Iova, Yu.A. Garmashov, E.Yu. Kryukov, A.Yu. Garmashov, N.A. Krutelev Children's City Hospital No. 1, MAPO Children's City Hospital No. 19

TUS

rear communication center

military, communications

Dictionary: Dictionary of abbreviations and abbreviations of the army and special services. Comp. A. A. Shchelokov. - M .: AST Publishing House LLC, Geleos Publishing House CJSC, 2003. - 318 p.

pipe-laying vessel

marine

Dictionary: S. Fadeev. Dictionary of abbreviations of the modern Russian language. - S.-Pb.: Polytechnic, 1997. - 527 p.

1. TU C

conditional signal table

military, marine

Dictionaries: Dictionary of abbreviations and abbreviations of the army and special services. Comp. A. A. Shchelokov. - M .: AST Publishing House LLC, Geleos Publishing House CJSC, 2003. - 318 p., S. Fadeev. Dictionary of abbreviations of the modern Russian language. - S.-Pb.: Polytechnic, 1997. - 527 p.

TUS

ship design theory

discipline of maritime educational institutions
compare: TUZHK

maritime, education and science

TUS

telematic communication services

connection

TUS

technological hydrocarbon mixture

tech.

Dictionary of abbreviations and abbreviations. Academician. 2015 .

See what "TUS" is in other dictionaries:

tus- a, m. tasser. 1. mol. Company, community. Elistratov. 2. mol. Meeting point, resting place companies. Mokienko 2000. 3. mol. Party, disco. Elistratov. 4. music Rock show. Elistratov. Lex. Mokienko 2000: party. Wed Party … Historical Dictionary of Gallicisms of the Russian Language

Tus- This page needs a major overhaul. It may need to be wikified, expanded, or rewritten. Explanation of the reasons and discussion on the Wikipedia page: For improvement / July 19, 2012. Date of setting for improvement July 19, 2012 ... Wikipedia

tus- TUSSOVKA, and, SHOULDER, and, TUS, a, m., TUSA, s, f., TUSA, s, TUSMAN, a, TUSNYAK, a, m. Gathering, party, street gatherings of youth; crowd, fight, incident; show. Tusu pull to participate in what l. collective event, celebration, ... ... Dictionary of Russian Argo

tus kіz- a, h. real decoration of the Kazakh and Kyrgyz dwellings ... Ukrainian glossy dictionary

TUS- table of conditional signals rear communication node ... Dictionary of abbreviations of the Russian language

tus (tu-єs)- you are here? … Lemkivsky Slovnichok

Tus (disambiguation)- Tus: Tus is a city in Iran. Tus lake in Khakassia. Tus, Anton Croatian military leader ... Wikipedia

Tus Keyes- a patterned felt carpet, decorated with red and black cloth appliqué, often combined with embroidery; wall decoration of the dwelling of the Kazakhs. Tus kees. From the Kokchetav region of the Kazakh SSR. 19th century Central Museum of the Kazakh SSR. Alma ... Art Encyclopedia

tus kees- a patterned felt carpet, decorated with red and black cloth appliqué, often combined with embroidery. Wall decoration of the Kazakh and Kyrgyz dwellings. * * * TUS KIIZ TUS KIIZ, patterned felt carpet, decorated with appliqué made of… … encyclopedic Dictionary

tus-kiiz- Tus keez. From the Kokchetav region of the Kazakh SSR. 19th century Central Museum of the Kazakh SSR. Alma Ata. Fragment. tus kiiz, a patterned felt carpet decorated with red and black cloth appliqué, often combined with embroidery; wall… … Art Encyclopedia

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In our Center, you can undergo the following types of ultrasound examinations:

- Neurosonography

- Transcranial ultrasonography

- Duplex scanning of head and neck vessels with rotating samples

- Ultrasound of the hip joints (children under 1 year old)

Ultrasound of the vessels of the upper and lower extremities (arteries and veins) for children

Ultrasound of the brain, or neurosonography (NSG) is a method of studying the brain and other structures located in the cranial cavity using ultrasound. Usually, brain ultrasound is performed in children with an open fontanelle or sutures through which ultrasound can penetrate into the cranial cavity. Neurosonography is performed to determine the state of the brain, the size of its individual parts, the presence of some defects in the development of the brain or pathological formations (hematomas, cysts, etc.). Ultrasound is an absolutely safe research method that has no contraindications and side effects.

Neurosonography is a method that does not require special training, anesthesia and can be performed even on a sleeping baby.

Transcranial ultrasonography (TUS) - a method for express diagnostics (screening) and monitoring of intracranial structural changes, based on ultrasound examination of the brain directly through the bones of the skull.

To date Ultrasound of the hip joints in children is the most reliable and accurate diagnostic method for detecting dysplasia. And in comparison with X-rays, it is also safe, especially since X-rays cannot be done to children under 6 months old. In addition, ultrasound allows you to diagnose not only bone, but also cartilage tissue. Ultrasound makes it possible to obtain a detailed image of the joint, which makes it possible to establish with high certainty the existing pathology: subluxation, hip dysplasia or dislocation, and therefore prescribe adequate treatment.

Ultrasound has many advantages over X-ray. But, unfortunately, this method can only be used for children under one year old: after 12 months, a bone head is formed, which does not transmit ultrasound and makes it impossible to see the acetabulum. After a year, radiography remains the only way to diagnose.

duplex scanning is an ultrasound examination in the mode of simultaneous transmission of a black-and-white image and an image of blood flow.

Duplex scanning is based on the Doppler effect and is designed to view vessels where they are not visible with conventional ultrasound. As a rule, this type of study is effective for detecting pathologies in the arteries and veins of the limbs, neck, and brain.

As a result of the study, the speed of blood flow, the localization of narrowings are determined, the presence of aneurysms and obstructions to blood flow is detected. Thus, after a full diagnosis, the doctor can accurately determine the cause of headaches, warn of possible hemorrhages and thrombosis.

The study does not require special preparation.

Vascular ultrasound limbs is a method using ultrasonic waves that allows you to show the vessels (arteries and veins) graphically and evaluate the parameters of their condition. In order to analyze the characteristics of blood flow, the property of an ultrasonic wave is used to visualize a picture when reflected from moving blood cells.

The study does not require special preparation.

Dissertation abstractin medicine on the topic Minimally invasive methods of diagnosis and surgical treatment of brain diseases in children (opportunities and prospects)

2 L "" to" RIGHTS OF THE MANUSCRIPTION

NOVA Alexander Sergeevich

MINIMALLY INVASIVE DIAGNOSTICS AND SURGICAL TREATMENT OF BRAIN DISEASES IN CHILDREN (opportunities and prospects)

St. Petersburg - 1996

The work was performed at the St. Petersburg Medical Academy of Postgraduate Education

Official opponents:

Doctor of Medical Sciences, Professor Yu.N. Zubnov;

Doctor of Medical Sciences, Professor A.A.Artaryan;

Doctor of Medical Sciences, Professor L. Blichterman

Lead organization - Military Medical Academy

The defense will take place * y ((p "0 (_ 1996 at "M" hours

at a meeting of the dissertation council D 084.23.01 at the Russian Research Neurosurgical Institute. prof. A.L. G1olenova (192104, St. Petersburg, Mayakovskogo str., 12)

The dissertation can be found in the library of the Russian Research Neurosurgical Institute. prof. AL.Polenova

Scientific Secretary of the Dissertation Council Doctor of Medical Sciences SL.Yatsuk

GENERAL PERFORMANCE

Relevance of the topic. Anatomical and physiological features of the child's body significantly complicate the diagnosis and surgical treatment of brain diseases (Babchin I.S. et al., 1967; Lrendt A.A., Nersesyants S.I., 1968; Zemskaya A.G., 1971; Babichenko E. I., 1985; Konovalov A. N. et al., 1987; Artaryan A. A. et al., 1990; Khokhlova V. V., 1990; Raimondi A. J., 1987; Cheek W. R. et al., 1994). Despite the widespread use of modern methods of neuroimaging (computed tomography - CT, magnetic resonance imaging - MRI, etc.), often, by the time the diagnosis is clarified, already pronounced structural intracranial changes are formed. This is due to the possibility of a long asymptomatic course and the atypical initial clinical manifestations of the disease, the complexity of identifying and interpreting neurological disorders in children, especially in younger age groups (Ratner A.Yu., 1975; Brodsky Yu.S., Verboval.N., 1990; Levene M. J. et al., 1988; McLaurin R. L. et al.. 1989).

Large reserve capacity of the child's body can lead to stable compensation of the disease. On the other hand, when the pathological process is pressed and as these possibilities gradually disappear, a rapid decompensation of the child's condition occurs.

All this limits the choice of optimal treatment tactics, leads to a relatively large number of palliative operations, surgical interventions performed according to vital indications, etc. (Romodanov A.P., 1965, 1981; Khachatryan V.A., 1991; McLaurin R.L. et al., 1989; Cheek W.R. et al., 1994).

That is why in childhood neurosurgery the issues of early diagnosis and evaluation of the dynamics of the intracranial state are of paramount importance (Likhterman L.B., 1983; Konovalov A.N., Kornienko V.N., 1985; Vereshchagin N.V. et al., 1986 ; Kuznetsov C. B., 1986; Kornienko V. N. et al., 1987, 1993; Gaevy O. V. et al., 1991; Scliellinger D., 1986; Zimmerman R. A., Bilaniuk L. T., 1986; Levene M. J., 1988; Kirkwood J.R., 1990; Barkovich A.J., 1990; Auer L.M., Velthoven V.V., 1993).

In view of the increased sensitivity of children to additional "stressful" loads, "minimal trauma" is recognized as the most important requirement for diagnostic and therapeutic methods.

todam (ParaitsE., Senashi I., 1980; Sirovsky E.B., 1984; Kharkevich N.G., 1986; Balagin D.M. et al., 1987; Mikhelson B.A. et al., 1988; Smith R.M., 1980 ; Barkovich A.J., 1990; Creighton R. et al., 1994).

In recent years, a new branch of neurosurgery has been formed, which includes a number of surgical treatment methods: stereotactically oriented neurosurgery, neuroendoscopy, perforated surgery, endovascular neurosurgery, and radiosurgery. All of them are united by the concept of "minimally invasive methods". The first three of them are most often used in neuropediatrics (Grentz N.I. et al., 1979; Gorelyshev S.K., 1994; McLaurin R.L. et al., 1989; Auer L.M., Vekhoven V.V., 1993; Cheek W.R. et al. , 1994).

The main goal of these methods is to achieve high efficiency with minimal traumatization of body tissues undamaged by the pathological process.

Special works devoted to the study of the features of instrumentation and the use of these methods in pediatric neurosurgery are not enough, although the relevance of this topic is undeniable (Konovalov A.N. et al., 1985, 1987; Karakhan B.V., 1990; Vinogradov I.N. ., Snigirev B.C., 1991; Shevelev I.N., 1994; Shcherbuk Yu.A., 1995; Raimondi A.J., 1987; McLaurm R.L. et al., 1989; Auer L.M., Veithoven V.V., 1993; Cheek W.R et al., 1994).

The need for further developments in the field of early diagnosis and sparing methods of surgical treatment in children is noted in the Russian "Program of Scientific Research in Neurosciences (1993-2000)".

Purpose and objectives of the study. The purpose of this study is to increase the efficiency and reduce the traumatic nature of diagnostic and surgical techniques in the treatment of brain diseases in children.

To achieve this goal, it was necessary to solve the following tasks:

1. To develop a system for preclinical and early diagnosis of intracranial structural changes in children, including mostly painless, sufficiently informative and accessible modern research methods.

2. To propose a method for non-invasive observation of the dynamics of intracranial structural changes, which makes it possible to conduct studies in real time and at the patient's bedside.

3. To study the informativeness of the dynamic clinical and morphological assessment of the patient's condition and determine its significance for the choice of individual tactics of neurosurgical treatment.

4. To study the features of the tactics and possibilities of low-traumatic endoscopic "!!" stereotaxic operations in children.

5. To clarify the possibilities of non-invasive intraoperative diagnostics and intraoperative monitoring of the structural intracranial state.

6. To develop a toolkit that ensures the use of minimally invasive methods of surgical treatment of brain diseases in children in a wide clinical practice.

7. Suggest a method for preclinical and early diagnosis of postoperative complications and relapses of the disease.

New, introduced into the study of the problem. Developed: a) new effective diagnostic techniques - standard head ultrasonography in infants and standard transcranial ultrasonography (TUS);

b) tactics of clinical and sonographic assessment of the intracranial state;

c) methods of early diagnosis and monitoring in case of cerebral compression syndromes, hydrocephalus, intracranial cysts and other diseases; d) a multi-purpose operating neurosurgical system that allows the use of the main methods of minimally invasive operations in children; e) an available method of stereotaxic guidance to ensure minimally invasive neurosurgical operations.

The following are described: a) echo-architectonics of the brain image during ultrasonography (US) is normal; b) diagnostic and differential diagnostic US-signs of pathological conditions most frequently encountered in pediatric neurosurgery; c) the main artefacts arising from TUS.

The following are proposed: a) classification and tactics of using the US-studies of children; b) tactics of stepwise application of neuroimaging methods (US screening, US data verification and US monitoring); c) tactics of pansonography, providing non-invasive express diagnostics of pathology in concomitant TBI (cranial and extracranial injuries); d) classification of endoscopic operations in children.

The possibility of clinical and sonographic monitoring of the intracranial state in the choice of individual tactics for the treatment of neurosurgical diseases of the brain in children was assessed.

Clarified: a) the origin of some US-phenomenon (for example, high echo density of liquor in cisterns of the base of the brain, etc.); b) methodology and tactics of operations with intraoperative US monitoring; c) tactics of application and possibilities of endoscopic and stereo-taxic operations in children.

"Practical; the value of scientific results. The developed tactics of step-by-step neuroimaging can be considered optimal in pediatric neurosurgery. It is characterized by efficiency, minimal invasiveness, accessibility, and also provides the possibility of early, including preclinical diagnosis and assessment of the intracranial state in real time. All this Taken together, it allows significantly narrowing down the indications for CT and MRI, minimizing the use of cerebral angiography, ventriculography, and practically eliminating the use of diagnostic subdural punctures, diagnostic burr holes, and brain punctures in children.

The proposed tactics of clinical and sonographic monitoring allows in some cases to avoid surgery (for example, in the conservative treatment of epidural hematomas in children).

Thus, the prerequisites for the use of individual neurosurgical tactics and interventions at the early stages of the development of the disease have been created.

The use of intraoperative and postoperative US monitoring provides preclinical diagnosis of structural intracranial postoperative complications and relapses of the disease.

The proposed method of pansonography in severe combined traumatic brain injury (TBI) makes it possible to reduce the indications for additional traumatic diagnostic procedures (puncture of the pleural cavity, laparocentesis, etc.), as well as to choose the optimal tactics of diagnosis and treatment in conditions of time pressure.

Currently, minimally invasive methods of neurosurgery are used only in highly specialized centers, while the mobile targeted neurosurgical operating system developed by me makes it possible to use them in a wide clinical practice.

Implementation into practice. In the process of performing this work, the following scientific developments were introduced: a) standard TUS and US of an infant gallop; b) tactics of staged neuroimaging; c) clinical-sonographic monitoring of the intracranial state (in the pre- and postoperative periods); d) ultrasonic stereotaxic guidance; e) stereoneuroendoscopic operations; f) endoscopic operations and conservative treatment for epi- and subdural hematomas in children; g) pansonography method for severe concomitant TBI.

Doctors of medical institutions of St. Petersburg, Monchegorsk, Magnitogorsk, Kursk, Petrozavodsk, Ulyanovsk and a number of other cities in Russia, Belarus, Moldova and Pil-shi have been trained in the above methods.

A diagnostic complex for the early detection of organic brain diseases in children has been organized in St. Petersburg, which implements the proposed tactics of staged neuroimaging (on the basis of children's city hospitals No. 19 and No. 1).

I I

Petersburg Medical Academy of Postgraduate Education, a cycle of thematic improvement of doctors "Ultrasonography in the diagnosis of organic diseases of the central nervous system in children" has been developed and is being carried out, and certain provisions of the work are included in the materials of most other cycles conducted at this department.

Basic provisions for defense.

1. Ultrasonography performed through the bones of the skull using a set of strictly oriented scanning planes ("standard 1-transcranial ultrasonography") is a non-invasive, effective and affordable screening method for assessing the structural intracranial state in children.

2. The developed diagnostic complex provides early diagnosis and monitoring of structural intracranial changes in pediatric patients with neurosurgical diseases of the brain, combining high efficiency, minimal invasiveness and accessibility.

3. The proposed multifunctional neurosurgical operating system provides the ability to perform the main types of

minimally invasive operations in children and allows them to be widely used in everyday practice.

Approbation of work. The main provisions of the dissertation were reported at the 1X European Congress of Neurosurgeons (Moscow, 1991); at meetings of the republican problem commission "Children's Neurosurgery" (1992); at the section of pediatric neuropathologists in St. Petersburg (1993); on the Academic Council of the St. Petersburg Medical Academy of Postgraduate Education (1994); at the jubilee scientific and practical conference dedicated to the 125th anniversary of the Children's Hospital. KAraukhfus (St. Petersburg, 1994); at meetings of the association of neurosurgeons (1994, 1995) and neuropathologists (1994, 1995) of St. Petersburg; at congresses of neurosurgeons in Poland (Lodz, 1994; Wroclaw, 1995); at the 1st Congress of Neurosurgeons of Russia (Yekaterinburg, 1995).

The dissertation materials were presented at the Conference of Neurosurgeons of the Baltic Republics (1983); at the 3rd and 2nd All-Union Congresses of Neurosurgeons (1983, 1989); at the scientific conference of neurosurgeons of Ukraine (1984); at the International Symposium on Functional Neurosurgery (Tbilisi, 1985); at the XXXI-th World Congress of Surgeons (Stockholm, 1991); at the 13th Congress of the European Society of Pediatric Neurosurgeons (Berlin, 1992); at the 20th Medical Congress of the Balkan countries (Constanta, 1992); at the XNUMXth Congress of the Association of Surgeons of Romania (Iasi, 1993).

The structure and scope of the dissertation. The dissertation consists of an introduction, 7 chapters, a conclusion, conclusions, practical recommendations, an index of references and an appendix. It is set out on pages (Usl. p.l), illustrated with 112 figures and 29 tables. The bibliographic index includes 296 sources, including 134 domestic and 162 foreign authors.

Characteristics of the material and research methods.

The object of the study were children aged from the first 7 hours of life to 15 years, divided into two groups. The first included 5806 children.

The main goal of examining patients in this group is to develop a technique and tactics for step-by-step neuroimaging, as well as to study the features of US imaging in normal conditions and in various types of neurosurgical pathology.

The second group consisted of 116 children who were treated with operations using minimally invasive technique (19 microneurosurgical operations, 21 stereotaxic and 75 neuroendoscolic operations) or conservative treatment of intracranial hematomas (6 patients). This group of children was analyzed in order to clarify the features of the implementation and effectiveness of these methods of treatment, as well as to evaluate the functionality of the developed multi-purpose operating neurosurgical system.

All patients who were hospitalized underwent a comprehensive examination.

Leading importance was attached to the combination of clinical data and the results of the use of neuroimaging methods (US, CT and MRI). For US, we used SSD-260 and SSD-500 devices (Aloka, Japan) complete with sector (3.5 MHz) and linear (5 MHz and 7.5 MHz) sensors. When describing normal and pathological echo-architectonics, the generally accepted terms were used: nrnep-, iso-, hypo-, and anisoechogenicity (objects of increased, unchanged, reduced and uneven acoustic density, respectively). Formations with an ultrasonic density corresponding to the density of the liquid were designated as anechoic.

CSF scintigraphy (radionuclide cisternography, ventriculography and stethography) was used to clarify CSF dynamics. We used an LVOF gamma camera with a PDP 11/34 computer (USA) and a DTPA radiopharmaceutical (pentatekh) Tc 99t (at a dose of 1.8-2.0 mbk/kg).

Other diagnostic methods were also used: echo-encephalography, electroencephalography (routine and special techniques), as well as neuro-ophthalmological, neuroradiological and cerebrospinal fluid examination. In epilepsy, special importance was attached to special electrophysiological methods associated with artificial activation of the epileptic focus and / or surgical manipulations (simultaneous or chronic stereotaxic EEG) (Chkhenkeli S.A., Shryam-ka M., 1990; Stepanova T.S., Vinogradova D. .A., 1990).

Cerebral angiography was performed only if a pathology of cerebral vessels was suspected. Ventriculography was used mainly at the initial stages of work or during stereotaxic operations.

For intracranial endoscopy, a BF P10 bronchofibroscope (Olympus, Japan) with a controlled bend of the distal end was used. The main characteristics of the endoscope are as follows: the outer diameter is 4.8 mm, the diameter of the instrumental channel is 2.0 mm, the view with a field of view angle is 90%, the bending angle of the distal end is up to 180*.

Initially, endoscopic operations were performed using a Karl Store rigid hysteroscope (diameter 5 mm, instrumental channel 2 mm).

Manipulations were controlled using a color television system, which included: I) a color portable TV "Color TT CT-1407" (Japan); 2) EVK-103 endoscopic video camera (NIPK Elektron, Russia).

To document the material, an OM-In camera (Olympus) and a video recorder (Panasonic NV-SD25AM, Japan) were used.

Statistical processing of the material was carried out on an IBM AT personal computer with the Statgraphics software package (version 3.0).

Ultrasonography (research methods and normal image)

Two standard methods of US-study of the brain in children have been developed: US of the head of an infant (for examining children under the age of 1.5 years et "and transcranial US (for patients from 1.5 to 15 years old). These standard techniques consist in the use of certain points and a set of strictly oriented complementary scanning planes.

The proposed technique of transcranial US (TUS) is a continuation of the studies carried out by L. BLichterman (1977-1983), as well as V. A. Karlov and V. B. Karakhan (1980). The standard US of the infant's head was developed on the basis of the method of transfontanellar US proposed by E.G. Grant (1986). Changes and additions made in the process of work made it possible to adapt it to the tasks of neonatal neurosurgery.

The concepts of "point", "plane" and "mode" of scanning were distinguished. The letters of the Latin alphabet were used to designate them.

Under the scanning point, the area where the sensor is located was taken. The points were chosen taking into account the maximum "ultrasonic transmission". The following scanning points were used: a) frontal point ("F" - frontalis) - 1 cm above the border between the middle and outer third of the superciliary douche; b) temporal ("G" - temporalis) - 2 cm above and 1 cm anterior to the external auditory canal; c) parietal ("P" - parietal) - 4 cm above the external occipital protuberance and 4 cm lateral to the midline; d) occipital ("O" - occipitalis) - directly below the occiput and 2-3 cm lateral to the midline; e) suboccipital ("So" - suboccipital) - in the midline 2-3 cm below the occiput.

When examining infants, the "Fa" point (fonticulus anterior, anterior fontanelle) was used, and after the fusion of the fontanel, "B" (bregma, vertex) was used. The scanning plane was determined by the spatial orientation of the sensor and was designated by a specific letter and number. When scanning, the following planes were distinguished: a) horizontal ("H" - horisontalis), when the longitudinal axis of the sensor was located along the line connecting the outer corner of the eye with the external auditory canal (Berlin horizontal); b) sagittal ("S" - sagittalis), when the longitudinal axis of the sensor was placed along the sagittal sinus (longitudinal brain scan); c) frontal ("F" - frontalis) - planes of transverse scanning of the brain.

We used sector and linear sensors with a frequency of 3.5 MHz and 5 MHz, respectively, which was abbreviated as "3.5S" "5L".

Individual elements of brain echo-architectonics were identified by comparing US images with data obtained from CT and/or MRI; as well as from stereotactic atlases (Talairach J. et a!., 1957; Schaltenbrand G., Bailey P., 1977). The brain study planes, similar in spatial orientation, were compared.

In table. 1 and table. Figure 2 shows the characteristics of scanning modes for standard brain US techniques.

To clarify some US phenomena (hyperechogenicity of the basal cisterns, US-syndrome of "brain death"), a US study of the brain was performed in 12 deceased (aged from the first hours of life to 7 years).

Table 1

General characteristics of scanning modes with standard TUS

US points US planes US transducer Basic US image elements normal

T H1 3.55 Midbrain (*), cisternae of the base of the brain (*), posterior cerebral artery, mediobasal parts of the frontal and temporal lobes, lateral fissure of the brain.

H1 51 Homolateral temporal horn (*), convexital surface of the temporal cortex, middle cerebral artery, cisterns of the base of the brain, midbrain.

H2 3.53 Visual tubercles (*), third ventricle (*), anterior horns of the lateral ventricles, interhemispheric fissure, island, lateral fissure of the brain, middle cerebral artery, retrothalamic cistern, pineal body.

NZ 3.5E Body of the lateral ventricles (*), choroid plexuses, septum pellucidum, head of the caudate nucleus.

V 51 Section of the anterior cerebral artery and the anterior horn of the lateral ventricle on the scanning side (*), the surface of the brain in the area subject to the probe.

P N s Vascular plexus in the area of ​​the glomus, the surface of the brain subject to the sensor.

O H 51 Soft tissues of the occipital region and scales of the occipital bone, typical US image of the cerebellar tissue.

5o n 3.5E Tops of the pyramids of the temporal bones (*), cerebellar hemispheres, medulla oblongata, clivus, frontal bone, dorsum of the Turkish saddle, bridge.

V 3.55 Bridge (*), medulla oblongata, fourth ventricle, anterior cistern of the bridge.

n 51 Occipital bone, occipital cistern, cerebellar hemispheres, medulla oblongata.

*_- marker of this standard plane.

table 2

General characteristics of scanning modes in the standard US of the brain of infants_"

Accurate VOS Flat Sensor Main image elements OK

Pa(B) JO 3.53 Orbital part of the frontal bone, perforated plate, cockscomb, wall of the eyeball (*), longitudinal fissure of the cerebrum, frontal lobe.

P "(B) 3.55 Olfactory sulcus (*), longitudinal fissure of the cerebrum, eminence of the sphenoid bone, lesser wing of the sphenoid bone, greater wing of the sphenoid bone, furrows of the convexital surface of the brain, lateral fissure of the brain, frontal and temporal lobes of the brain.

Pa(B) P2 3.5E Lateral fissure of the brain; cistern of optic chiasm (*), lateral ventricle, corpus callosum, insula, choroid fissure, frontal and temporal lobes of the brain, scales of the temporal bone, base of the middle cranial fossa.

РЗ 3.5B Lateral ventricles, third ventricle (*), optic tubercle, caudate nucleus, choroid plexus, corpus callosum, transparent septum, choroid fissure, temporal lobe, brainstem, petrous temporal bone, Bish's fissure.

MV) YAZ 51- Falke, interhemispheric fissure, sagittal sinus, medial-conventional parts of the sensory-motor region, lateral ventricles, third ventricle (*), thalamus, caudate nuclei, choroid plexuses, corpus callosum, transparent septum.

Pa(B) P4 3.5E Fourth ventricle (*), cerebellar vermis, cerebellar hemisphere, tentorial foramen margin, brainstem, Bish's fissure, mediobasal temporal lobe, insula, optic tubercle, choroid plexus, lateral ventricles, choroid fissure, tentorium cerebellum.

Pa(B) Z.bB US-phenomenon of "arrival" (*), choroid plexus, plate of quadrigemina, cerebellar tenteum, occipital bone, pyramid of temporal bone, cerebellum, parietal and occipital regions of the cerebral cortex.

Continuation of table 2

SA point Plane Sensor Main image elements normal

Pa(B) P6 3.55 Choroid plexus, cerebellar tenteum, cerebellum, corpus callosum, falx cerebrum, US-phenomenon "doll" (*).

f7 3.5E Falx cerebrum, occipital lobe pole, posterior parietal lobes.

YV) th 3.5E Third ventricle (*), aqueduct of the brain (*), fourth ventricle (*), cingulate sulcus, corpus callosum, transparent septum, bones of the base of the anterior l * cranial fossa, interpeduncular cistern, bridge, anterior cistern of the bridge, medulla oblongata, large occipital cistern, cerebellar vermis, fourth ventricle, aqueduct of the brain, lamina quadrigemina, cistern of the lamina quadrigemina (cistern of the vein of Gapen), interthalamic fusion, occipital bone

3.53 Talamo-caudal notch (*), optic tubercle, choroid plexus, head of the caudate nucleus, anterior horn of the lateral ventricle, bones of the base of the anterior cranial fossa, cerebellum.

Pa(B) 32 3.5c Body, anterior, posterior, and inferior horns of the lateral ventricle, choroid plexus with VGO tangle (*), cerebellum tent, occipital bone.

W BZ 3.55 Island (*). Circular sulcus of the islet, short gyrus of the islet, central sulcus of the islet, long sulcus of the islet.

D V 51. Correspond to those in transcranial ultrasonography (see Table 1.)

T H1 3.5B;5 Correspond to those in transcranial ultrasonography (see Table 1.)

t H2 3.53 Correspond to those in transcranial ultrasonography (see Table 1.)

t NZ 3.53 Correspond to those in transcranial ultrasonography (see Table 1.)

* - a structure is marked, which is a marker of this standard plane.

Diagnostic capabilities of ultrasonography

In the process of work, the results of 7295 US studies of the brain, conducted in 5806 children aged from 3 days to 15 years, were analyzed.

In terms of age, all patients were divided into the following groups: up to the first year - 20%; 1-3 years - 12%; 3-14 years old - 65% and over 14 years old - 3%. Those. in 80% of children, the examination was carried out after the closure of the fontanelles.

The features of the US-image in the most common types of neurosurgical pathology were studied.

General characteristics of US studies are presented in Table. 3.

Table 3

General characteristics of the conducted US studies

Features of US studies Quantity

abs % abs %

Conditional norm 30 0.5 30 0.4

Birth brain damage in newborns 43 0.7 151 2.1

Malformations of the brain 96 1.6 290 4.0

Hydrocephalus 374 ate 1121 15.4

Traumatic brain injury 866 14.9 1038 14.2

Brain tumors 41 0.7 145 2.0

Atrophic changes 628 10.8 764 10.5

Slight organic changes 1139 19.6 1143 15.7

Prochiv 369 6.5 393 5.3

There were no organic changes 2208 38.1 2208 30.2

Examination in cadavers 12 0.2 12 0.16

TOTAL: 5806 100.0 7295 100.0

The possibility of monitoring structural changes at the level of the midbrain is shown. Depending on the characteristics of its deformity, US signs of lateral and axial dislocation of the brain, as well as their individual variants (102 children), were identified.

With diffuse cerebral edema, as it increased, the ventricles of the brain gradually narrowed, and then completely disappeared, the basal

cisterns, the amplitude of pulsation of cerebral vessels decreased and the overall echogenicity of the brain image increased (36 children).

Birth brain damage was identified in 43 infants (151 US studies). Hemorrhagic lesions (24) were as follows: intraventricular hemorrhages (8), cephalohematomas (4), combination of cephalohematoma with epidural hematoma (2), unilateral subdural accumulations (4) and bilateral subdural accumulations (6). There was a lack of effectiveness of the traditional tactics of transfontanellar research (according to E.G. Grant et ah, 1986), the use of which did not allow the detection of meningeal hematomas in 4 children. The developed technique for US examination of the baby's head made it possible to eliminate the shortcomings of transfontanellar scanning.

In 19 patients, hypoxic-ischemic lesions (leukomalacia) were revealed. Features of US imaging in hemorrhagic and ischemic perinatal brain injuries are described in detail in the literature (Burkova A.C., Sichinava L.G., 1989; Strizhakov A.N. et al., 1990; Grant E.G. et al., 1986; Guzzetta F., 1991). „

In the group of newborns, only in one case there was a need for CT.

The features of US imaging in malformations of the central nervous system were studied: congenital intracranial cysts (44), cerebral erythema (16), microcranium (11), craniostenosis (2), microcephaly (9), congenital stenosis of the aqueduct of the brain (7), Dandy syndromes -Walker (2) and Arnold Chiari II (6), are-nesias of the corpus callosum (3) and interventricular septum (3), as well as schizencephaly (4).

US-signs are described in phakomatoses (tuberous sclerosis with intraventricular tumor - 1, Sturge-Weber disease - 2, Recklinghausen disease - 1). one

In case of arteriovenous malformations (2), a zone of uneven hyperechogenicity was revealed in the area of ​​their location.

Hydrocephalus was diagnosed in 374 children (1121 US studies). In cerebral US in infants, the presence of hydrocephalus and the degree of its severity were determined, the form and nature of concomitant anomalies of brain development were specified, and, in addition, the presence of other pathological processes. The severity of hydrocephalus was assessed by the width of the lateral ventricles and by the index of the lateral ventricles (Alzen G. et al., 1983). Communicating hydro-

cephaly (SG) was detected in 310 children (819 studies). It was characterized by the expansion of the ventricles of the brain, the large occipital cistern, the interhemispheric fissure, bone-marrow diastasis, and visualization of the CSF flow paths. When scanning in the 80 (3.58) mode, the pulsation of the bottom of the third ventricle was determined with an amplitude of 2-3 mm.

In occlusive hydrocephalus (OH), the US image depended on the level of occlusion. For example, in stenosis of the cerebral aqueduct (175 studies in 35 children), a combination of the following US symptoms was characteristic: symmetrical expansion of the lateral and third ventricles of the brain, lack of cerebrospinal fluid in the interhemispheric-parasapptal region of the brain, sharp deformation and displacement of the bottom of the third ventricle downward, significant narrowing of the interpeduncular cisterns, expansion of the aqueduct of the brain above the occlusion and the lack of visualization below this level. The remaining 29 patients had other levels of CSF flow obstruction (interventricular orifices, fourth ventricle, etc.)

Transcranial US (TUS), which also easily reveals the lateral and third ventricles, made it possible to assess not only the severity of hydrocephalus in all patients of this group, but also to suggest its form.

Repeated US studies made it possible to objectify the dynamics of ventriculomegaly. At the same time, it was considered adequate to determine the width of the third ventricle, the depth of the homolateral temporal horn, and the width of the contralateral lateral ventricle in the region of its body. The use of the described technique of ventriculometry made it possible to detect even minimal expansion of the ventricles in children under 15 years of age and to trace the dynamics of hydrocephalus.

Ventriculomegaly, detected in hydrocephalus and other diseases according to TUS, was confirmed in 832 children using transfontanellar US, in US through bone defects, CT or autopsy. In doubtful cases, l and scurvy graphic studies or ventriculography with water-soluble contrast agents were performed.

In TBI in children, US is of particular importance, since the method allows assessing the intracranial structural state already in the first 10-15 minutes after the child is admitted to the hospital.

Epidural hematomas (EDH) were revealed in 22 children, and subdural hematomas (SDH) in 22 children. In 12 children, SDH was acute. A total of 136 US studies were performed in this group of patients. A typical US-recognition

A lump of shell hematomas was the presence of a zone of altered eschgenity in the area adjacent to the bones of the cranial vault (with EDH - in the form of a biconvex or plano-convex lens, and with subdural - crescent-shaped). Along the inner border of the hematoma, the acoustic phenomenon of "marginal amplification" was revealed in the form of a hyperechoic strip, the brightness of which increased as the hematoma gradually became liquid.

US monitoring of the intracranial state made it possible to distinguish the stages of the natural evolution of intracranial hematomas. Nal

For example, with epidural hematomas, the following stages were observed: iso-hypoechoic (up to 10 days after TBI); anechoic with a constant volume of hematoma (from 10 days to 1 m?s after TBI); anechoic with a decrease in volume (up to 2 months) and the stage of outcome. EDH can almost completely disappear after 2-3 months. after TBI (6 children). " four

US signs and features of US evolution of intracerebral (12) and intraventricular (15) hematomas were studied. " "

There were no characteristic US signs of concussion, mild to moderate brain contusion, or subarachnoid hemorrhage. With severe bruises (33 children), several variants of the US image were identified: a) isoechoic foci, determined only by -

iass effect; b) foci of slight hyperechogenicity with an indistinct border and an insignificant mass effect; c) lesions with small areas of high echogenicity and mass effect; d) hyperechoic foci (similar in density to the choroid plexuses) with a mass effect.

In case of depressed skull fractures, US allows specifying the localization, area and depth of depression, as well as the type of fracture.

Pansonography (PS) in full or reduced scope was used in the examination of 12 children with concomitant TBI. In PS, the following extracerebral injuries were identified: hemothorax (2), rupture of the spleen (2), avulsion of the kidney (1), and fracture of the femur (3). In all cases, the diagnosis was confirmed by traditional methods and/or during surgery.

In the group of children examined by US, brain tumors were found in 41 patients. A total of 145 US studies were performed in this group.

Depending on the characteristics of the focus of pathological density, three types of US imaging of brain tumors in children have been distinguished:

a) homogeneous "zones of increased density with clearly defined edges (characteristic of solid, usually periventricular tumors); b) indistinctly demarcated, inhomogeneous hyperechoic zones (characteristic of infiltrating tumors or in the presence of necrosis and hemorrhages in them); c) a combination of one of the described variants with anzhogenic zones, often significant in size (typical for cystic tumors).

All types of brain tumors are characterized by US-signs of mass effect

(dislocations, asymmetry of the ventricles, deformation of the normal elements of the echo-architectonics of the brain according to the volumetric type).

Features of US manifestations in supratentorial hemispheric tumors (10), tumors of the chiasmal-sellar region (7), tumors of the floor of the third ventricle (1), tumors of the posterior parts of the third ventricle and pineal body (4), tumors of the lateral ventricles ( 4), tumors of the cerebellum (15) and brainstem (3).

I Studied US-signs of inflammatory (16) and atrophic changes (628) of the brain in children. For example, in brain abscesses (3), a hyperechoic zone with fairly clear boundaries was noted, in the center of which a zone of reduced echo density was detected. In these patients, the mass effect was quite pronounced.

The ability of US to assess the intracranial state in real time appears to be very promising. These possibilities implement US-contrasting, which makes it possible to note the amplitude of the pulsation of the vessels of the brain and parenchyma. The last two methods can be attributed to studies of the functional state of the brain. In total, US-contrast was performed in the examination of 14 children in the form of US-ventriculography (8), US-cystography (3), US-abcessography (2) and US-subdurography (1). US-contrasting was carried out by introducing 4-5 ml of saline or CSF into the studied cavity. At the moment of insertion, turbulent movements occurred, spreading throughout the studied cavity, which made it temporarily hyperechoic (usually within 5-10 seconds).

The main artefacts that appear in the US and methods of their identification are studied. The most common artifacts are: reverberation, main noise, comet tail phenomenon, dorsal amplification phenomenon and ultrasonic shadow.

Efficacy of trascranial US was evaluated in children aged 1 to 15 years. For this, two indexes were used. The sensitivity index (SI) was determined by the relationship between the number of children in whom SS-signs of structural intracranial changes were detected, their area was determined (A), and those children (B), in whom SS-dain were later confirmed by traditional methods (HI = B / A x 100%). The ability of the method to reveal not only the presence and localization of the pathological process, but also its nature was determined by the specificity index (SI). It was calculated by analogy with the ICH.

It was possible to verify the data obtained by TUS in 253 patients. Verification methods were as follows: CT (122), MRI (7), cerebral angiography (3), craniography (24), puncture method (24), venous triculotraphy (3), subdurography (1), operations (57) and autopsy (12)

In I] children (6.7%), the results of TUS turned out to be erroneous, and false-positive were in three patients (1.2%), and false-negative - in 14 (5.5%). Thus, the HI is 93.3%. At the same time, IP reaches only 68%.

The disadvantages of TUS include: a) a decrease in its effectiveness when examining children over the age of 12 years; b) the presence of artifacts;

c) limited possibilities of documentation of diagnostic results;

d) the great importance of the doctor's experience in the interpretation of the US image.

The presence of defects in the bones of the skull in a child significantly improves the quality of the US image. The most effective are "ultrasonic windows" over 2 cm in diameter.

For the purpose of a more detailed study of objects directly adjacent to the sensor (for example, in the US diagnosis of skull fractures), the study was performed through a water bolus (a thin rubber balloon filled with water).

To detect extracranial injuries in combined TBI, a pansonotraphy technique was proposed - one-stage, neurosonotraphy and examination of the chest (thoracic US), abdomen and pelvic organs (abdominal US), long tubular bones (skeletal US). The main goal of extracranial US is the rapid diagnosis of traumatic injuries in the indicated areas. Pansonography is of particular importance in the examination of patients in a coma. Paisonography was performed without any special

preparation of the patient, in parallel with resuscitation and other manipulations.

Tactics of a phased neuroimaging

Despite the rather high diagnostic capabilities of CT and MRI, they remain far from the "ideal" diagnostic method in neurosurgery (Likhterman LB, 1983).

The features of neuroimaging methods were assessed from the point of view of their compliance with the main criteria of an "ideal" diagnostic method (Table 4).

Table 4

Comparative assessment of the diagnostic capabilities of the main methods of morphological neuroimaging

Criteria for the "ideal* method of neuroimaging in children METHOD

CT NMR US

High” efficiency: -”-+ ++ )■+++ ++

Painless +++ ++++

Harmlessness +-M- ++++ ++++

Transition without patient preparation ++ ++ ++++

Possibility of monitoring with any rhythm of repeated studies + + ++++

Bedside examination - - ++++

Speed ​​of carrying out - - ++++

Ease of maintenance of the device - - ++++

Possibility of application in any conditions - - +++Ch-

Real-time exploration - - ++++■

Low research cost - - +++-+

Ease of interpretation +++ +

In the table, the sign "+" marks the correspondence (the most complete - H+++") and the sign that the method does not correspond to a specific criterion.

It can be seen from this table that US, on the one hand, and CT (MRI), on the other, surprisingly complement each other. Taken together, they meet all the basic requirements for an "ideal" diagnostic method.

Taking into account these data, a step-by-step neuroimaging tactic was proposed, which included three stages: 1) US screening; 2) specification of the diagnosis (differentiated use of CT or MRI); 3) US monitoring.

US screening was performed in 5764 children. The screening diagnosis was based on previously described US syndromes.

Taking into account the data obtained and the peculiarities of the pathogenesis of various neurosurgical diseases in children, indications for US screening and differentiated screening programs were developed.

■Updating US data was required in the examination of 184 patients. The examination methods of the second stage were chosen differently, depending on the data obtained at the first stage (CT in 122 and MRI in 7 children).

"US-monitoring" is repeated US performed at different (individual) time intervals to monitor the dynamics of the intracranial state in a verified pathological process. US monitoring was used in 485 children.

It was extremely important to carry out postoperative US monitoring, which makes it possible to objectify the dynamics of structural intracranial changes, timely detect the formation of postoperative complications, relapses of the disease or cerebral atrophy.

Repeated clinical and sonographic studies were used for the structural and functional assessment of the intracranial state.

The concepts of "clinical-sonographic state" and "clinical-sonographic variant of the course of the disease" differed. The clinical and sonographic state of the brain is a cumulative assessment of intracranial structural changes and associated functional disorders. It characterizes the state of the brain at the time of examination and refers to a static parameter. The clinical and sonographic variant of the course of the disease is a dynamic criterion, which was determined on the basis of an assessment of the data of clinical and sonographic monitoring.

To objectify individual treatment tactics for intracranial hematomas, a scoring clinical sonographic dynamic scale (KSDS) for assessing the intracranial state was proposed (Tables 5-6).

Table 5

Criteria for scoring the clinical condition of the patient_

Ots-ka in a point. Nriteria

State of consciousness (*) Focal neurological disorders Vital functions disorders **

hemispheric craniobasal stem

0 Clear (15*) - - -

1 Clear (15) Do not reach the degree of paresis

2 Clear (15) - stunning 1 (14-13) Moho-, hemiparesis Mild dysfunction of individual cranial nerves Single (spontaneous nystagmus) Mild impairment in 1 parameter

3 Stunning 11 (12-10) Mono- and hemiplegia, epileptic seizures, aphasia Severe dysfunction of individual cranial nerves Anisocoria, decreased pupillary response to light, limited upward gaze, homolateral pyramidal insufficiency, dissociation of meningeal symptoms along the body axis Moderate impairment

4 Sopor-coma 1 (5-9) Bi-, tri- or heteroplegia Pronounced disorders of the function of the cranial nerves Paresis of the upward gaze, gross anisocoria, divergence along the horizontal or vertical axis, tonic spontaneous nystagmus, a sharp weakening of the photoreactivity of the pupils, bilateral pathological foot signs, decortication rigidity Expressed by 1 or more parameters

5 Coma 11-III (3-4) Sharply pronounced and gradually disappearing Total ophthalmoplegia, bilateral fixed mydriasis Decortication rigidity, diffuse hypo- and atony, arephlensia Sharply pronounced, critical

* - the state is indicated in points according to the Glasgow Coma Scale (bSv); ** - used indicative indicators of characteristics of vital functions generally accepted in pediatrics.

Table 6

The main US criteria for assessing the structural intracranial state_

Score B point. Basic US - criteria for neurosurgical diseases in children

Volume of the lesion, in % (*) * Compression of the brain Cerebral edema Ventriculomegaly (according to ITBI)

1 <2 <3 <0,3 <0,7 Асимметрия отдельных фрагментов боковых желудочков и/или смещение срединных структур мозга до 5 мм Незначительное сужение желудочков мозга (на 2-3 мм) - 0,3

d 2-4 3-7 0.4-1 0.7 -1.4 Insignificant unilateral compression of the midbrain with asymmetry of the legs up to 3 mm Significant narrowing of the lateral ventricles (>3 mm), but with preservation of their anenogenicity, narrowing and shortening of eversion pattern of basal cisterns 0.3 - 0.4

3 5-7 8-11 1.0 -1.5 1.5-2.2 Unilateral compression of the cerebral peduncles with their asymmetry of more than 3 mm, dislocation hydrocephalus and rotation of the trunk Lateral ventricles are detected only by the pattern of the vascular plexuses, disappearance of eversion and deformation pattern of basal cisterns 0.4 - 0.6

4 8-10 12-15 1.6-2 2.3 - 3.0 Bilateral compression of the midbrain peduncles, decrease in the amplitude of the posterior cerebral artery pulsation Sharp decrease in the pulsation of the pattern of the basal cisterns 0.6 - 0.8

5 >10 >15 >2 >3 Disappearance of pulsation of the posterior cerebral artery Absence of pulsation in the pattern of basal cisterns >0.8

* - the volume of the pathological formation as a percentage of the volume of the intracranial space - (the volume index of the pathological focus).

The value of intracranial pathological objects was determined using a volume index (VOI), which was calculated by the formula: VOI - OPO/TMC x 100%, where OPO is the volume of the pathological object, VMI is the volume of the brain skull. GRO was calculated by the formula: GRO = n/6 x A x B x C or GRO = 0.52 x A x B x C, where A, B, C are the diameters of the intracranial object, i = 3.14 (Kornienko V.N. et al., 1987). TMC was calculated similarly. The diameters of the skull and intracranial pathological object were determined from soiograms.

The intracranial state was recorded as a fraction, where the numerator corresponded to the score of the functional (clinical) state, and the denominator corresponded to the severity of US changes. At the same time, the highest score was chosen as the overall score in each of the two groups of criteria.

Various clinical and sonographic variants of the course of intracranial hematomas were distinguished: A - regressive; B - stable; B - undulant; G - slowly progressing; D - rapidly progressive.

The possibilities of using HFCS when choosing individual treatment tactics were studied in a group of children with epidural hematomas (EDH). Under supervision there were 33 children with EDH aged from 2 to 14 years. Almost all children were hospitalized shortly after the injury. Three types of treatment tactics were used: a) hematoma removal during craniotomy; b) delayed endoscopic hematoma removal; c) conservative treatment.

In the diagnosis of EDH, early clinical and sonographic assessment of the intracranial state with subsequent clinical and sonographic monitoring was considered the most effective. Features of individual treatment tactics for EDH in children, depending on the clinical and sonographic variant of the course of the disease, are presented in Table. 7.

Table 7

Features of individual treatment tactics

with pidural hematomas in children_

Features of treatment Number Main clinical and sonographic options

Conservative treatment 6 0/1A; 1A/1A; 0/2A; 1A/2A

Delayed endoscopic operations 6 0/1B; 1B/1B; 0/2B; 1B/2B

Early craniotomy 21 Other options

There were no complications or deaths with conservative* treatment and the use of tactics of delayed endoscopic operations. Ka-amnesis from 4 ms. up to 7 years old.

Multipurpose operating neurosurgical system

To ensure the possibility of widespread use of minimally invasive treatment methods in pediatric neurosurgery, the task was set to develop a multi-purpose operating neurosurgical system (MONS) that meets the following basic requirements: versatility, accuracy, simplicity and reliability in operation, as well as mobility and economic availability. Taking into account current trends in neurosurgery and the characteristics of childhood, a universal operating system should provide the possibility of isolated or combined use of classical neurosurgery, microneurosurgery, stereotaxic and endoscopic neurosurgery, as well as stereotaxic navigation and intraoperative monitoring of the structural intracranial state. No descriptions of systems with such functionality have been found in the specialized literature.

MONS consists of main, working and phantom devices. The combination of these assemblies and special attachments makes up target kits with different possibilities. Most of the components of various kits are unified and the expansion of these functional capabilities of the system is associated with the complication of its completeness. If necessary, the system configuration can be changed or supplemented even during the operation, depending on the specific intraoperative situation.

The MONS set for microneurosurgical operations includes the main device of the system, units for its installation on the operating table, and clamps with self-locking retractors. In this set, MONS was used during 19 operations with various positions of the patient on the operating table (including sitting and lying face down).

The set for stereotaxic US guidance without a phantom device consists of the main and working devices, supplemented with a US sensor holder, adapters for stereotaxic instruments and a special guide. When changing tools in the tool holder, their length

These axes coincide and correspond to the "central beam" of the US sensor. If, during intraoperative US, the sensor is installed in such a way that the “central beam” passes through the target object, then changing the instruments in the holder will ensure that various instruments are pointed at this target but in the chosen trajectory, and knowing the depth of the target location will ensure an accurate hit on it.

MONS suggests three options for US-stereotactic guidance without the use of a phantom device: a) coaxial guidance; b) misaligned guidance; c) remote coaxial guidance. The use of each of these options is determined by specific surgical tasks.

Coaxial and non-coaxial guidance was used in operations performed through burr holes (for example, neuroendoscopic operations).

Remote US-stereotactic guidance was used for accurate access to small and deep-seated objects during microneurosurgical operations.

The set for implementation of stereotaxic US guidance with a phantom device is designed to provide stereotaxic guidance along a trajectory independent of the position of the US sensor. This kit was used for US-stereotactic guidance during operations when bone access was performed by flap craniotomy. The system in this kit has been tested in 20 experimental operations and 2 operations in the clinic. Hit accuracy ± 2 mm.

The set for X-ray stereotaxic guidance includes the main, phantom and working devices, a special stand with horizontal and vertical cassette holders, as well as additional parts and tools (bridge of the nose, ear guides, deep multi-contact electrodes, destructors, etc.).

When performing intracranial endoscopic operations, the most effective equipment was considered to be a set of equipment that included the following main functional units: 1) targeting kit; 2) endoscopic kit; 3) irrigation and aspiration system; 4) a set of intraoperative US monitoring; 5) set of endoscopic televideo monitoring; 6) a set of vmeo-documentation.

The developed MONS was used in various neurosurgical operations in children.

Minimally invasive treatment methods in pediatric neurosurgery

The need for accurate spatial intraoperative orientation is a necessary condition for ensuring minimally invasive interventions. Possibilities of surgical US were studied in 35 cases. Depending on the tasks to be solved, the following variants of intraoperative US are distinguished: a) US-ornation; b) stereotaxic US guidance; c) US-mospornng.

US orientation is one of the sequential stages of neurosurgical intervention, the tasks of which are: a) clarifying the features of surgical topography (the depth of the pathological object, its spatial relationship with the brain ventricles, large vessels, etc.); b) selection of the optimal zone of cerebral incision and the direction of the surgical approach; c) control of ongoing manipulations (for example, the radical removal of the tumor or the quality of the stoma); d) intraoperative diagnosis of intracranial complications.

Stereotactic US-Nedsnie is the use of US to spatially reproduce the position of a target object in the cranial cavity and ensure accurate alignment of surgical instruments (eg, an endoscope) to it. In this case, stereotaxic technique is used.

Intraoperative US monitoring is a study conducted in parallel with any manipulation to evaluate its effectiveness in real time. The described variants of intraoperative US were used during 21, 10 and 4 operations, respectively.

Stereotactic surgery with x-ray guidance.

X-ray stereotaxic guidance was used in 21 children in the surgical treatment of drug-resistant epilepsy. The age of these patients ranged from 5 to 15 years. The following were considered indications for surgical treatment: a) localization of the epileptic focus in the temporal lobe; b) the presence of seizures for as long as 3 years; c) the period of unsuccessful conservative treatment - at least 2 years; d) progression of the course of epilepsy; e) the severity of clinical manifestations (epileptic seizures at least 4 times a month, the tendency of the disease to series or the presence of status epilepticus). In this group of patients, stereo-

axial and combined operations using techniques described in detail in the literature (Zemskaya A.G. et al., 1975; Kanael E.I., 1981; Garmashov Yu.A., 1990; Chkhenkeli S.A., 1990, etc. ).

In 14 cases, simultaneous stereotaxic surgery was performed, and 3 - implantation of long-term deep electrodes, and in 4 more patients, combined surgery with destruction of deep and resection of cortical structures involved in epileptogenesis was performed. The main stereo-gaxic targets are amygdala complex on one side (3), amygdala complex on both sides (8), hippocampus on one side (2), amygdala complex and hippocampus on one side (3), amygdala complex on both sides and hippocampus on one side (3), amygdala complex on both sides, hippocampus and area of ​​Forel H1 on one side (1) and area of ​​Forel H1 on both sides (1). .

In combined operations, stereotaxic amygdalotomy was performed simultaneously with temporal lobectomy (1 child) and subpial resection of the lesion in the frontal lobe (1 child), and amygdalohippocampotomy was performed with subpial resection of the lesion in the temporal lobe and in the frontotemporal region (but in 1st child).

The main importance in determining the effectiveness of the operation was attached to the dynamics of epileptic seizures. Patients were divided into 4 (Zemskaya A.G., 1970) groups: I - disappearance or decrease in the frequency of epileptic seizures up to 1-2 times a year (19%); 2 - a decrease in the frequency of epileptic seizures by tens and hundreds of times or a significant relief of their structure (29%); 3 - a slight decrease in the frequency of epileptic seizures and / or relief of their structure, the disappearance of status epilepticus and series of seizures (38%); 4 - no change (14%).

In the early postoperative period, hyperthermia (38-39°C) was observed in 3 patients, xanthochromia of the cerebrospinal fluid - in 4 children, confusion, disorientation - also in 4 children.

The duration of postoperative follow-up ranged from 2 to 6 years (average 5 years).

The obtained results indicate that the functional features of the MONS provide the possibility of performing stereocapped and combined operations in children.

Endoscopic surgeries for occlusive hydrocephalus 65 endoscopic surgeries (EO) were performed in 60 children with occlusive hydrocephalus (OH). There were general and differentiated indications for surgical treatment. Common indications included: a) progression of hypertensive-hydrocephalic manifestations; b) the presence of occlusion of the cerebrospinal fluid outflow tract; c) the impossibility or increased risk of lnkvoroshunting operations; d) the immediate proximity of the ocunated intracranial cavity to the functioning elements of the pulmonary system. Contraindications to EO are as follows: a) the thickness of the cerebral plaque is less than 10 mm; b) severe somatic pathology; c) inflammatory changes in the skin in the area of ​​the proposed surgical intervention; d) anatomical features that do not allow performing endoscopic manipulations. High protein content, moderate pleocynthosis and the presence of erythrocytes in the CSF were not considered contraindications.

The leading role in clarifying the intracranial state was given by US, CT, MRI, liquorography and liquorological studies. Depending on the nature of the disease and the level of occlusion, various EOs were performed.

The stages of EO with stereotaxic US guidance were as follows: I) head fixation in the main MONS device; 2) imposition of a burr hole with a crown cutter (or transfontanellar access); 3) stereo-taxic US-pointing of the endoscope to the target object; 4) introduction of the endoscope into the lumen of the endoscopic cavity (the cavity in which the target is located); 5) endoscopic orientation and approach to the target; 6) US verification of the endoscopic target; 7) endoscopic manipulations in the area of ​​the target structure; 8) endoscopic control of the effectiveness of manipulations; 9) US-control of the adequacy of manipulations; 10) control review RS; 11) the final stage.

At the final stage of EO, the main importance was attached to the prevention of liquorrhea. The bone disc was placed in place and the wound was sutured tightly. Contraindications to EVTS are narrow interventricular holes and occlusion of the interpeduncular cistern. "

In case of violation of the CSF flow through the cerebral aqueduct (34 patients), endoscopic ventriculocisternostomy (EVCS) was performed with the formation of standing in the area of ​​the bottom of the third ventricle (ventriculus teitius - Vt) and restoration of CSF outflow from it into the interpeduncular cistern

(cisterna interpeduncularis - Ci.ipd). This type of oneation was designated as EVCS (Vt-Ci.ipd), or more briefly - EVCS. A stoma 5–6 mm in diameter was formed in the region of the premamillary pocket using a special perforator.

Endoscopic cystoventriculostomy (ECVS) was used for intracranial intra- or paraventricular "aggressive" cysts (12 children). The essence of the operation was endoscopic perforation of the cyst wall with the formation of a communication between the lateral ventricle and the cyst cavity with a diameter of 5-10 mm. A burr craniotomy was performed taking into account the localization of the cyst." In case of arachnoid cysts of the chlasmal-sellar region (3 children), an anterior transventricular approach was used on the side of the subdominant hemisphere with the imposition of a stoma in the region of the cyst wall, protruding into the lateral ventricle through the "expanded interventricular foramen, /

Endoscopic membranotomy (2 children) is indicated in the presence of intraventricular adhesions in the form of membranes that separate the lateral ventricle, which leads to local ventriculomegaly of its area, isolated from the CSF drainage pathways. The purpose of the operation is to form a hole in the insulating membrane. ^

Endoscopic interventriculostomy (EIVS) consists in restoring the communication between the individual ventricles of the brain when they are separated. EIVS with various endoscopic targets was used in ochobhomj during combined operations. Isolated EIVS with restoration of communication between the lateral ventricles of the brain with occlusion of the interventricular foramen by imposing a stoma in a transparent septum - EIVS (1-11) - was made to one child.

Neuroendoscopic operations with multiple endoscopic targets (combined EO) were performed in 10 patients. 9 of them have. was? multilevel hydrocephalus, and one patient had a tumor of the quadrigeminal plate with occlusion of the cerebral aqueduct. In this patient, the targets were the fundus of the third ventricle (EFCV) and the tumor (endoscopic biopsy). ^

With multilevel OH, the main task of EO is to convert hydrocephalus into a single-level one, which makes it possible to use one standard bypass operation in the future. In this group de-

tey, along with the described operation EIVS (1-H), other variants of intervengriculostomy were also used: a) EIVS (1-III) - restoration of communication between the lateral and third ventricles of the brain in case of occlusion of both interventricular openings by imposing a stoma in the region of the posterior-upper sections the third ventricle (the area of ​​the commissure of the arches), subject to the common lateral ventricle; b) EIVS (SH-GU) - restoration of communication between the third and fourth ventricles of the brain in conditions when they are separated by a thin section of brain tissue by applying a stoma in the area of ​​​​the most thinned (translucent) wall; c) EIVS (1-GU) - restoration of communication between the lateral and fourth ventricles of the brain in conditions when they are separated by a thin area of ​​brain tissue by imposing a stoma in the area of ​​​​the thinnest section of the diverticular protrusion of the wall. In these children, operations were performed in one or more stages. One-stage EO with multiple targets was performed in 7 children. In 5 of them, EVCS was performed together with EIVS (2), ECVS (1), endoscopic membranotomy (1) and tumor biopsy (1). In another 1 patient, the targets were the cyst wall and the transparent septum.

In three cases, a staged combination of endoscopic targets was carried out. The combinations were as follows: a) EVCS+EKVS (lpa stage); b) EIVS (1-I) + EKVS + EIVS (1-1U), the operation was performed in 4 stages; c) EIVS (N1) + EIVS (1-Sh) + EIVS (Sh-1U) + EVCS (the operation was performed in 2 stages). The intervals between stages ranged from 2 to 5 weeks.

With single-level OH, stabilization of the disease after EO was obtained in 21 children (43%). In 27 children of this group (55%), the disease continues to progress, however, in 79%, it was possible to convert OH into communicating pseudofalsh (SH).

With multilevel hydrocephalus, stabilization was achieved in 2 children (20%), and in 7 patients the disease progressed, although in 6 (60%)

and? they succeeded in translating multilevel hydrocephalus into a single-level one, and in I (\C1%) - into a communicating form.

Postoperative complications were observed mainly at the initial stage of work in 9 children (15%): subdural accumulation of CSF (4),

nontriculitis (3) and intraventricular hemorrhages (2). In the early postoperative period, two children died as a result of asphyxia. Mortality was 3.3%.

In cases of stabilization of hydrocephalus, the clinical effect was persistent (the duration of follow-up was up to 8 years). With progressive hydrocephalus, shunting operations were subsequently performed (in 17 - ventri-|.7 loperitoneal shunting and in 12 - lumboperitoneal shunting). In this ipynne children, EO allowed to reduce the number of shunts in 7 children, use a luiboperitoneal shunt instead of a ventriculoperitoneal shunt (12), and expand the indications for surgical treatment (2).

The interval between EO and shunting ranged from 1 to 14 months (average 2.4 months). ■

One child with shunt infection underwent endoscopic removal of the ventricular catheter from the lumen of the lateral ventricle (the catheter remained after an attempt to remove the ventriculoperitoneal shunt)

Endoscopic surgery for intracranial hematomas

A total of 12 intracranial hematomas were removed using endoscopic techniques in 10 children. The age of the Patients ranged from 2 to 15 years. The causes of intracranial hematomas were as follows: a) traumatic brain injury in 8 children; b) complication of ventriculoperitoneal shunt - 1 child (chronic bilateral epidural hematoma and subdural hematoma on the left); b) AVM bleeding - 1 patient.

Intracranial hematomas were removed during elective (8) and urgent (2) interventions. The time from the onset of hematoma to surgery ranged from 4 to 30 days (on average, 18 days).

In children with planned EO, hematomas were detected during US screening and confirmed by CT. Subsequently, repeated US studies were carried out, and when the hematoma was liquefied, as well as there were no signs of a decrease in its size, EO was performed. In all patients, except for one, the volume of intracranial hematomas was in the range of 40-80 ml (in one patient, bilateral chronic hematoma against the background of hyperfunction of the nontriculoperitoneal shunt reached 500 ml).

The main stages of endoscopic removal of meningeal hematomas: 1) TUS with reconstruction of the hematoma projection on the scalp; 2) planning a skin incision" and a burr hole; 3) access to the hematoma (burr craniotomy using a crown burr); 4) removal of the hematoma; 5) US control of the completeness of removal; 6) installation of subgaleal drainage; 7) final stage In the presence of dense clots, a wide-channel aspiration system was used.

In case of intracerebral hematoma, the stages of EO differed in that after burr craniotomy, US-stereotactic guidance was performed, an endoscope guide was inserted into the hematoma cavity and an endoscope was inserted through it.

Urgent EO (2) was performed in cases where the use of traditional methods of treatment was impossible (1 patient had recurrent AVM hemorrhage with cerebral ventricular tamponade and another child had recurrent epidural hematoma against the background of severe vital disorders). In the latter case, EO was performed in the intensive care unit in parallel with resuscitation (after removing one suture from the sutured postoperative wound). Despite the removal of the hematoma, the outcome was fatal.

General characteristics of intracranial hematomas and the results of their endoscopic removal are presented in Table. eight.

Table 8

General characteristics of intracranial hematomas and the results of their endoscopic removal_■

Character of hematoma Total Hematoma location Results

1 2 3 4 5 6 A B C

Epidural 7 2 - 2 2 - 1 6 1*

Multiple cloud ** 1 - - - - 1 - 1 - -

Intracerebral 1 - - - 1 - - 1 - -

Intraventricular 1 - 1 - - - - - 1* -

Total: 10 2 1 2 3 1 1 8 1* 1*

1 - fronto-posterior-basal; 2-fronto-parietal; 3 - fronto-temporal; 4 - temporo-parietal; 5-frontal-parietal-temporal-occipital; 6-occipital with extension into the subtentorial space; A - good result (restoration of the initial intracranial structural and functional state); B - unsatisfactory result (the presence of pronounced residual intracranial structural and neurological disorders); B - lethality.

* - urgent operations; "* - bilateral epidural hematoma with unilateral subdural hematoma.

There were no complications in the elective EO group. To tamnez is from 4 months. up to 2 years (on average - 1 year and 2 months). To date, all children in this group showed almost complete recovery of the original (previously hematoma) intracranial structural and clinical state.

Thus, the developed diagnostic and surgical techniques can reduce trauma and increase the effectiveness of diagnostics and treatment for brain diseases in children.

1. Head ultrasonography using standard research methods (a set of strictly oriented, complementary scanning planes) is a non-invasive, effective and affordable method for assessing the structural intracranial state in children. In case of non-closed large fontanel, ultrasonography is performed through the temporal and frontal bones, the fontanel and can be considered the method of choice in the diagnosis of organic changes in the brain. After the fusion of the large fontanel, the study is carried out through the bones of the skull ("trans" cranial ultrasonography), being a screening method for diagnosing these changes in children under the age of 15. Approbation of head ultrasonography on a large clinical material (more than 7 thousand examinations) makes it possible to reasonably include it to a modern diagnostic neurosurgical complex.

2. Step-by-step application of neuroimaging methods in children (ultrasonographic screening - verification of the detected pathology by CT and/or MRI - ultrasonographic monitoring) provides early and preclinical diagnosis of structural intracranial changes, assessment, their dynamics and includes three sequentially performed stages. The first stage of examination (ultrasonographic screening) is the widespread use of ultrasonography in children in cases of neurological symptoms or previous brain diseases that contribute to the emergence of neurosurgical pathology. At the second stage, using high-resolution diagnostic methods (CT and/or MRI), the nature and localization of the pathological process is specified. The final, third stage of the survey

is repeated, if necessary, multiple use of ultrasonography (ultrasound monitoring), in order to determine the dynamics of the identified changes (including in the postoperative period).

3. The choice of optimal surgical tactics for brain diseases in children should be based on a comprehensive dynamic assessment of structural and functional changes in the brain. The simplest and most accessible method for this is clinical and sonographic monitoring, which consists in the simultaneous assessment of the dynamics of the neurological status and ultrasonography data.

4. Simultaneous use of ultrasonography of the head, chest, abdomen, small pelvis and long tubular bones ("pansonography") is a highly informative and non-invasive method for rapid diagnosis of cranial and extracranial injuries in children, which determines the prospects of this method not only for examination patients in the hospital, but, most importantly, in the conditions of disaster medicine. ~

5. The proposed multi-purpose operating neurosurgical system, which includes kits for microneurosurgical, endoscopic and stereotaxic operations and provides the possibility of their isolated and combined use, allows for the majority of minimally invasive surgical interventions for various types of neurosurgical pathology of the brain in children. The simplicity of the design and functionality of the operating system provide a basis for its wider practical use in neurosurgery.

6. Ultrasonographic stereotaxic guidance can be considered as an alternative to traditional computed tomographic stereotaxic guidance for "acoustically visible" target objects, characterized by sufficient accuracy, ease of technical support and practical implementation. These features determine the prospect of using this method in the surgical treatment of brain diseases in children. In the conditions of emergency neurosurgery, it has undeniable advantages over computed tomographic stereotactic guidance.

7. The use of stereotaxic and endoscopic thepics in the treatment of certain forms of hydrocephalus, intracranial hematomas, and "aggressive" cysts can be considered as the method of choice in cases where traditional neurosurgical operations are impossible or at a high risk of their complications.

8. In neuroendoscopic operations, the most effective is the use of flexible endoscopic systems with a controlled distal end, ultrasonographic stereotaxic targeting and "double" control of manipulations (visual observation through the optical system of the endoscope in combination with intraoperative ultrasonographic monitoring), which allows:

a) identify the selected intracranial target and accurately bring the endoscope to it, especially in conditions of difficult visual review and / or the absence of traditional endoscopic landmarks;

b) monitor ongoing endoscopic manipulations and evaluate their effectiveness using ultrasonographic contrast, which allows for multiple visualization of controlled intracranial fluid-containing cavities;

c) d to determine the occurrence of intraoperative complications and clarify further surgical tactics.

9. The proposed set of diagnostic and therapeutic measures, as well as surgical instruments, determine the prospects for the development of pediatric neurosurgery, taking into account modern general trends in surgery - early (preclinical) diagnosis and minimally invasive surgical interventions.

1. The appearance of minimal neurological symptoms in a child or a traumatic brain injury (regardless of its severity, including birth injury) can be considered as indications for the use of brain ultrasonography. The detected ultrasonographic signs of structural changes in the brain, which require or may require surgical treatment, necessitate the use of CT or MRI, depending on the nature and localization of the pathological process. Further clarification is possible

dynamics of intracranial structural changes during repeated (sometimes - multiple) ultrasonographic studies (ultrasonic-graph monitoring).

2. Taking into account the frequent discrepancy between the severity of intracranial structural changes and clinical manifestations in children, a simultaneous assessment of neurological and ultrasonographic data in dynamics (flash-sonographic monitoring) can be recommended to determine individual treatment tactics. Such a tactic makes it possible to identify structural intracranial changes, postoperative complications or relapses of the disease at an early stage or in the preclinical stage.

3. Of particular importance of ultrasonographic monitoring lies in the possibility of objectifying the dynamics of the intracranial state in edema and dislocations of the brain. Repeated measurements of the width of the ventricles of the brain, the size and shape of the midbrain make it possible to clarify the diagnosis, evaluate the effectiveness of conservative treatment, and choose the optimal surgical tactics. The use of simultaneous ultrasonographic examination of the brain and other organs (for example, chest and abdominal cavities, etc.) provides early diagnosis of not only cranial, but also extracranial pathological changes. Intraoperative ultrasonographic monitoring makes it possible to obtain additional anatomical and topographic data, clarify the surgical approach, control the adequacy of the manipulations performed, and in cases of intracranial complications, identify them during the operation and choose the optimal treatment tactics.

A. For the wide use of minimally invasive technologies in pediatric neurosurgery, the developed multi-purpose operating neurosurgical system can be applied due to its versatility, simplicity, accessibility and mobility. This system provides the possibility of microneurosurgical, endoscopic and stereotaxic operations with ultrasonographic stereotaxic guidance. A necessary condition for the use of ultrasonography for stereotaxic guidance is the "acoustic visibility" of the target object. Ulyrasonographic guidance can be carried out even if the need for it arose during the operation.

5. During endoscopic operations, the most effective is the use of flexible endoscopes with a controlled distal end, ultrasonographic stereotaxic targeting and "double" control of manipulations (observations through the optical system of the endoscope in combination with intraoperative ultrasonographic monitoring). Ultrasonographic contrasting allows multiple visualization of fluid-containing intracranial cavities and assessment of their communication.

6. Endoscopic surgery can be used for some forms of occlusive hydrocephalus, "aggressive" intracranial cysts, "asymptomatic" hematomas, or hematomas with minimal neurological manifestations. With progressive occlusive hydrocephalus, due to stenosis of the cerebral aqueduct and contraindications to CSF ​​shunting operations, endoscopic ventriculocisternostomy with the formation of a stoma between the third ventricle and the interpeduncular cistern is effective. The presence of "aggressive" intra- or paraventricular cysts can be considered as an indication for endoscopic cystoventriculostomy. With intracranial hematomas, it is possible to use their endoscopic removal or conservative treatment, but this requires careful monitoring of the dynamics of clinical manifestations and structural intracranial changes.

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56. Iova A.S., Garmashov Yu.A., Petraki V.L. Intracranial endoscopic operations in pediatric neurosurgery (opportunities and prospects). The article was prepared by order of the editors of the journal "Neurosurgery Issues", 1996, No. 2.

List of inventions.

2. Device for fixing bone fragments. Copyright certificate No. 1752356, 1990.

3. Method of surgical treatment of occlusive hydrocephalus. Application for invention No. 94025625 dated 07.07.94 (together with VL Petraki, Yu.A. Garmashov).

4. Method for assessing the state of the brain. Application for invention No. 94-022310 dated 06/23/94, positive decision on formal examination dated 08/25/94 (together with Yu.A. Garmashov).

5. The method of stereotaxic guidance. Application for invention No. 95105181/14 dated April 10, 1995 (together with Yu.A. Garmashov).

I express my deep gratitude to the head of the Department of Pediatric Neuropathology and Neurosurgery of the St. Petersburg Medical Academy of Postgraduate Education, Professor Yu.A. Garmashov, who is the scientific consultant of this work.

I would like to express my special respect and gratitude to Prof. L.G.Zsmskaya, my teacher and inspirer of the presented study.

I consider it my pleasant duty to express my heartfelt gratitude to the staff of the Research Institute for Maternal and Child Health (Chisinau) and the Children's City Hospital No. K.A. Raukhfus (St. Petersburg), as well as to all those who provided all possible assistance and

support.

Type SP "LAPO Ъk. Tchr. ; )-