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and maturation of granulated tissue, fibroblast proliferation and epithelization.
At цитологическом research in 3 day after СО2 laser and photodynamic effect there is noted significant reduction of microflora in the smears-prints. The contents of neutrophils reduced from 91.0 % up to 75.0 % from the total number of cellular elements. The high number of degenerative forms of neutrophils is noted (57.63 ± 4.8 %), connected with their destruction under photodynamic exposure. The increase in quantity of macrophages and monocytes with phagocytosis of bacteria, tissue and cellular detritus is found. There is occurred small quantity of fibroblasts, predominantly of juvenile forms, considerably exceeding their quantity in control group (8.7 % in comparison with the basic group I - 3.1 %, basic group II - 2.2 %, respectively). The marked changes indicated about activation of regenerative processes and corresponded inflammatory-regenerative type of cytogram.
On the 5 th day after СО2 laser and photodynamic therapy microflora was not found practically. The quantity of neutrophils decreased considerably (to 63.0 ± 3.5 %). There is met a great number of macrophages and fibroblasts (15.0 ± 2.9 % and 14.2 %,
respectively), that indicated about the further activation of reparative processes.
By the 7 th day macrophages and fibroblasts appeared to be prevalent cellular elements (15.8 % and 19.3 %, respectively), the young epithelial cells are found, that allows suggestion about regenerative type of cytogram.
Thus, the presented data confirm reliably high clinical efficacy of antibacterial therapy, based on C02 laser and photodynamic effects, induced by simultaneous effect on the pathogenic microflora by physical and chemical factor.
The use of C02 laser allowed possibility for early and bloodless necroectomy, improvement of wound reparation as well as reduction of microbe contamination of the purulent wound. The method has photocoagulating properties and sterilization effect on the tissues.
The data obtained showed that the photodynamic therapy is effective enough noninvasive and safety method for the treatment of purulent wounds and serves as basis for use of the method of photodynamic therapy in the clinical practice for treatment of local acute purulent-inflammatory processe CO2 laser and traditional methods of treatment.
References:
1. Abaev Yu. K. Reference book for surgeon. Wound and wound infection. - Rostov n/D: Fenix, 2006.
2. Derbenev V. A., Azimshoev A. M., Sharifov A. D. Photoditazin in the complex treatment of the purulent wounds//Rossiskiy biotera-pevticheskiy jurnal. - 2007. - No 1. - P. 14.
3. Erokhin I. A., Gelfand B. R., Shlapnikov A. S. Surgical infection//SPs., 2003. - 106 p.
4. Koraboev U. M. Photodynamic therapy of purulent, long not-healing wounds and trophic ulcers (experimental-clinical investigation): Abstract of thesis -Doctor of Med. Sciencies. - Moscow, 2001. - 24 p.
5. Baranov E. V., Buravskiy S. K., Tretiak S. I. Antibacterial photodynamic therapy in the complex treatment of patients with purulent-septic pathology//Materials of scientific-practical conference with international participation. - Grodno, 2011. - P. 5-7.
6. Stranadko E. F., Koraboev U. M., Tolstikh M. P. Photodynamic therapy in purulent diseases of the soft tissues//Khirurgia. - 2000. -No 9. - P. 67-70.
7. Tolstikh P. I., Stranadko E. F., Koraboev U. M. et al. Photodynamic effect on the bacterial microflora of wound in experiment//Jurnal microbiologii, epidemiologii i immunobiologii. - 2001. - No 2. - P. 85-87.
8. Tolstikh P. I., Petrin S. A., Derbenev V. A., Azimshoev A. M. Use of photodynamic therapy in th complex treatment of trophic ulcers of venous etiology//The first scientific-practical conference of the North-West region of the Rossiskoy Federatcii with international participation: "High surgical, laser and informational technologii in medicine of Saint-Petersburg and North-West region of Russian Federation: prospects of the further development"; Book of Proceedings of St.-Petersburg. - 2003. - P. 17-19.
9. Richagov P., Rucinovich V. M., Ginuk V. A. To background of photodynamic therapy in purulent pathology//Actual questions of the modern surgery: Materials of Scientific Conference dedicated to 60 th anniversary of prof. Yu. S. Vinnik. - Moscow; Krasnoyarsk, 2008. - P. 387-391.
10. Jori G., Tonlorenzi D. Photodynamic therapy for the microbial infections//Photodynamic News. - 1999. - Vol. 2, No 1. - P. 2-3.
Murodova Dilorom Subhonovna, Republican Scientific Center of Neurosurgery, the Ministry of Health of Uzbekistan, Senior Researcher E-mail: [email protected]
The advantages of modern methods of diagnosis and intraoperative neuromonitoring during removal of intracerebral brain tumors
Abstract: The results of a survey of surgical treatment and observation of 66 patients with intracerebralbrain tumors of supratentorial localization. Data analysis MR-tractography allowed to choose an optimal surgical approach to tumors, to identify areas available for disposal and perform resection in an adequate amount of conservation white matter pathways of the brain, thus minimizing surgical trauma, reduced risk, and worsening of neurological deficit that determines the efficiency of operations and quality of life of patients.
Keywords: DT-tractography, white matter tracts, brain, tumor, life quality.
Introduction
Neoplastic lesions of the brain is a complex clinical problem due to the pronounced deterioration in the quality of life of patients and often poor prognosis. Primary tumors of the central nervous system make up 1.4 % of all cancers and 2.4 % of cancer mortality, while the share of malignant gliomas have to 50-60 % of all primary CNS tumors [8; 10]. The main task of a neurosurgeon at removal of intracerebral tumors is the maximum possible removal of tumors with minimal damage to the brain tissue and the establishment of a histological diagnosis. The degree of trauma critical brain structures depends on the post-operative neurological deficits and the quality of life of the patient, and the degree of resection of tumors — the duration of the period without relapsing.
The use of modern neuroimaging techniques and new technologies in surgery mass lesions becomes more widely used. This allows you to increase the degree of radical removal of the tumor with the least possible damage to functionally important brain structures [2; 5; 7].
Prospects for the development and improvement of neurosurgical diagnostic system extends the capabilities associated with neuroimaging. In this connection, noteworthy method tractography diffusion tensor (DT tractography) allows non-invasive visualization of individual white matter pathways throughout the brain. The use of DT tractography in tumor lesions of the brain provides information about the structure of abuse conductive fibers of the white matter near the borders of the tumor, which allows you to define areas of tumor invasion, and the degree of restructuring fibers under the influence of treatment [4; 5].
So far, intraoperative monitoring during removal of intrace-rebral tumors and assessment of the minimum damage to motor ways, functionally important brain structures remains relevant in neurooncology [2; 4].
Purpose of the study
Improving the results of surgical treatment and quality of life of patients with tumors of the brain using data DT tractography, neuromonitoring white matter pathways in the brain.
Materials and methods
The material of the study was the use of the data DT tractography in the planning and the choice of the angle of attack during surgery on the pathological center. Monitoring, and analysis neuromonitoring defeat pathways of white matter of the brain was performed pre-, intra- and post-operative period through the early ENMG that are practiced in the Republican Scientific Center of Neurosurgery MOH Uzbekistan.
We had analyzed the results of treatment of 54 patients which were hospitalized in the Republican Scientific Center of Neurosurgery and the Ministry of Health of the Republic of Uzbekistan and were operated under the same conditions. 32 patients of them are in the control group (I-group), and 34 are in the main (Il-group). All patients came to the clinic with conventional MRI or CT images, and DT-tractography were performed to 34 patients. The use of DT-tractography in tumor lesions of the brain provides information about the structure of abuse conductive fibers of the white matter near the borders of the tumor, that allows to determine the areas of tumor invasion, and the extent of the reorganization ofthe fibers under the influence of treatment. High probability of occurrence or worsening of neurological deficit after surgery limits the ability of tumor resection during their propagation in the functionally important areas of the brain. When planning the operation and removal of intracerebral tumors must adhere to the tactics as possible cytoreduction in functionally reasonable limits [6; 7; 8].
The operation is performed under the control of intraoperative monitoring of mechanogram using needle electrodes in m.bicepsbrachi, m.quadricepsbrachi and m. quadricepsfemoris, established with geterolateralnoy side. Computer system SYNAPSIS with software "Neyrotex», Russia was used.
Results and discussion
In describing the degree of radical surgery we stuck to the classification, which uses the terms total, subtotal removal and open biopsy.
Investigation of diagnostic tumor supratentorial localization showed that at the time of detection, tumor, more than half (53.9 % of cases) of patients had a tumor size of 35 to 60 mm., which is visually proved DT tractography and defeat pathways of the cerebral white matter brain.
Table 1. - Distribution of patients according to the degree of radicalism removing the tumor of Education
Volume remove a brain tumor Q-ty operations, abs. %
I-group II-group
The total 17 (53.1 %) 13 (38.2 %)
Subtotal 12 (37.5 %) 19 (55.9 %)
Biopsy open 3 (9.4 %) 2 (5.9 %)
After making analysis of the data DT tractography, the results showed that more than half (55.9 %) primary surgical interventions ended with subtotal removal of the tumor, total removal of the tumor was possible in 38.2 % of cases, open biopsy in 5.9 % of cases that shown above in Table 2 number.
In all cases, the resection of the tumor was performed its histological verification. According to histological features in the supratentorial brain tumors in patients oligodendrogliomav identified 18 (27.3 %) cases, anaplastic astrocytomas — 15 (22.7 %), fibrillar astrocytoma — in 11 (16.7 %) cases, fibrillar-protoplasmic astrocytoma -to 9 (13.6 %), glioblastoma — 9 (13.6 %) cases and meta-stataz brain tumor — 4 (6.1 %), which is written below (Table 2.)
Table 2. - The distribution of patients depending on the histological structure
Pathological diagnosis Number of observations
abs. %
Oligodendroglioma 18 27.3
Anaplastic astrocytoma 15 22.7
Fibrillar astrocytoma 11 16.7
Fibrillaryastrocytoma, protoplasmic 9 13.6
Glioblastoma 9 13.6
Metastasis 4 6.1
Total: 66 100
The results of our study showed that the improvement in outcomes of surgical treatment of patients with intracerebral tumors supratentorial localization depended on the evaluation of the changes of the white matter of the brain in terms of visualizing pathways D-tractography.
From Table 3 it is clear that in the study group (II) after surgery in the early period of profound hemiparesis has resolved to moderate hemiparesis in 2 cases, and moderate hemiparesis to slight hemiparesis in 3 cases, the most high information DT-tractography has been featured in determining the surgical approach and scope of the operational resection of tumors located in the temporal lobe of the brain in the area of the intersection of pathways coming from Broca's area to Wernicke's area, where the visual beams of radiation is placed. In tumors convexital localization, in which there is
no particular difficulty in terms ofthe surgical approach, the main is- the projection pathways can lead to the appearance or expressed sue is the amount of the radical removal of the tumor, especially if deepening paresis when seemingly total removal of the tumor and the patient has no gross neurological disorders. Surgical damage of the great surgical treatment [9; 10; 11].
Table 3. - Comparative distribution of patients for neurological deficit
Neurologic manifestations Before surgery After surgery
I-Group II-Group I-Group II-Group
Abs n = 32 % Abs n = 34 % Abs n = 32 % Abs n = 34 %
Without movement disorders 3 9.4 5 14.7 2 6.3 5 14.7
Easy hemiparesis 11 34.4 10 29.4 9 28.1 13 38.2
Moderate 10 31.3 11 32.4 14 43.8 10 29.4
Deep hemiparesis/hemiplegia 6/2 25.0 7/1 23.5 4/3 21.8 5/1 17.7
Currently, surgical treatment of gliomas cannot be radical, due to the biological characteristics of the tumor, but survival is directly linked to radical surgery. Optimal tumor resection can be performed only when it is clearly located, and its boundaries are clear. Every neurosurgeon faces the problems of the relation of the tumor and the important anatomical structures during surgery. Therefore, the interest recently increased in research on the use of DT tractog-raphy [3; 4; 7; 11].
At the planning stage surgical intervention determine intact furrow surrounding the tumor, and then, in accordance with the contours of the projection boundaries tumor resection is possible in the cortex approaching the perifocal area. Determining the spatial relationship of the tumor with the adjacent portions of the cortex and subcortical pathways depending on the tumor location and extent ofits spread allows to choose the tactics of surgical approach [8; 9].
We observed regression of neurological deficit among the operated patients of the group, which contributed to the flow of postoperative period without complications and improved the quality of life and its duration.
Data of mechanogram used for noninvasive and more complete removal of the tumor with the greatest possible preservation of pathways and visualized the potential increase in the amplitude of the muscle and the appearance of sharp peaks in the motor tract irritation and allowed the surgeon to more accurately determine the angle of attack, the amount of tumor resection. We have used computer system «Sinapsys» (Neyrotex, Russia), 4-channel electric stimulator, bipolar with rhythmic stimuli at 1 Hz. Bipolar electrodes used in a rounded shape for registration of surface. We investigated the median and tibial nerve by the standard method with the definition of conduction velocity (CV) for the efferent fibers, the amplitude of muscle response and excitation thresholds. Application ENMG step intra- pre- and post-study allows to evaluate and objectify pyramidal tract functional insufficiency prior to surgery, to control, store and minimize surgical trauma fibers pathways and finally determine a strategy of drug therapy after surgery.
Changes fibers white matter of the brain caused by neoplastic processes may be characterized as a dislocation, edema, infiltration, degradation. Development of adequate surgical approaches and development of microsurgical techniques are important factors in maintaining the functional integrity of the pyramidal tract in surgical interventions on the brain. Involvement of the efferent fibers of the pyramidal way into the capsule of the tumor stroma causes neurological deficit in the form of restriction of active movements of the limbs, identifying topography anatomic interest of the motor area.
According to our analysis at ENMG distinguish 2 types of conduction disturbances on motor ways:
1. The compression-compression irritative;
2. ischemic.
Computer program averaging curves and operating automatic miscalculation.
Table 4. - Compression-irritative disorders
Conduction velocity (CV) efferent 30.5 m/s control
N b/k — 50 m/s (n. medianus)
29.8 m/s N n/K — 49.5 m/s (n. femoralis)
A max 2.5 mk V 2.8 - 3.0 mk V 5.0 - 5.5 mk B 7.5 - 8.7 mk B
Excitation threshold (ET) Sharply reduced 4 - 3 mA 7 - 8 mA
Table 5. - Ischemic disorders
Conduction velocity (CV) efferent 19.8 - 21.5 m/c control
55 m/s
19.5 - 22.5 m/c 49.5 m/s
A max 1.25 mk V 1.9 - 2.5 mk V 5.5 mkV 7.5 - 8.7 mkV
Excitation threshold (ET) 10 - 15 mA N7-8mA
It was found that pyramids disorders in patients with supra-tentorial tumor localization, accompanied by a greater or lesser degree of impaired muscle potentials, depending on the nature and extent of lesions tumaroznogo lobe. Pronounced ENMG parameter changes were observed in 12 patients with a sharp decline in the M-response amplitude and conduction velocity of efferent fibers. Moderate settings ENMG violations were found in 22 patients.
The most serious violations of the parameters ENMG registered among patients with frontal and frontoparietal localization of cases in supratentorial localization of brain tumors. At the same time, it is often marked a sharp decline in SPI efferent fibers and reducing the amplitude of M-response to current high threshold of irritation. Such violations we see as ischemic changes related to the disease process involving direct anatomical structures pyramidal pathway. These hypoxic ischemic brain dysfunction requires special measures, improves blood flow to the brain, both during surgery and in the postoperative period (the introduction of vasoactive drugs, volume expansion of BCC, locally applique with papaverine.
In 19 cases, most often in tumors of the parietal and temporal localization-parietal and 1 cases with occipital localization parameter changes ENMG affects of moderate decline of CV efferent fibers, reducing the amplitude of M-response due to lower threshold of irritation.
These changes were seen as a reaction to the activation coinciding with stimulation of the pyramidal tract due to dislocation disorders, swelling, etc. Typically, these violations were reversible in the postoperative period and defined us as a compression — irritative
showing the processes of excitation of neurons. Research ENMG performance in the preoperative period in patients with tumors supratentorial localization, had predictive value for postoperative course and degree of recovery of pyramidal disorders.
In most cases, patients with compression — the nature of the pyramidal irritative disorders in the postoperative period had positive dynamics in the conductivity improvement ENMG parameters. In 10-15 % of cases, the dynamics of indicators ENMG were noted.
In patients with ischemic pyramidal disturbances positive trend was recorded in 62.1 % of cases. In 37.9 % of patients speakers are not
Table 6. - The quality of life of patients with supratentorial
detected. And in 21 % of patients ENMG reduction options were recorded after surgery.
Dynamics of ENMG postoperative defined tactics of drug therapy. Metabolic drugs, nootropics, antioxidants and stimulants are prescribed after the positive dynamics of the IPN and the excitation threshold. Vasoactive drugs with the reduction of BCC added to the treatment in reduction indicators ENMG.
The study offunctional status, family and social adaptation (quality of life) of patients also showed a significant dependence of the results of treatment of morphological characteristics of the tumor and minimal trauma pathways of the brain during surgery [2; 7; 8].
localization tumors after treatment with radical surgery ( %)
The volume of tumor resection Group Quantity The quality of life after treatment, % Points By Karnofsky
good Satisfactory Unsatisfactory
Total I-gr n = 17 n = 5 (29.4 %) n = 7 (41.2 %) n = 5 (29.4) 64.3
Il-gr n = 13 n = 4(30.8 %) n = 6 (46.1 %) n = 3 (23.1 %) 68.6
Subtotal I-gr n = 12 n = 5 (41.7 %) n = 5 (41.7 %) n = 2 (16.6 %) 69.9
Il-gr n = 19 n = 10 (52.6 %) n = 8 (42.1 %) n = 1 (5.3 %) 78.1
Biopsia I-gr n = 3 - n = 1 (33.3 %) n = 2 (66.7 %) 55.3
II-gr n = 2 - n = 2 (100 %) - 60.3
The table 6, the performance of surgery in patients of the main group in the subtotal removal of tumors, accompanied by a good performance in the future quality of life — 78.1 points on the Kar-nofsky scale. At the same time performing surgery in the control group, both in total and subtotal tumor removal in patients QOL Karnofsky lower than that in the basic group.
Thus, the optimization of the volume of the removal of the tumor tissue is directly connected with the possibilities of preoperative surgical planning, specifying the topography of the tumor, to obtain the most complete information about the relationship of the tumor to important functional areas of the cerebral cortex and white matter of the conductive fibers.
Conclusions:
1. Data Analysis MR tractography allows you to choose the best surgical approach to the tumor, define available to remove sections and complete removal of an adequate volume of preserving FIA and white matter pathways in the brain.
2. Removal of intracerebral tumors under the control of intraoperative monitoring using data DT-tractography provides intraoperative precision and safety of surgery, to minimize surgical trauma, thereby reducing the risk of neurological deficit, which determines the efficiency of the operation and a good quality of life.
9.
10.
11.
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