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Introduction: The problem of choosing surgical approach in the treatment of CSF leak is the subject of discussion depending of the location and the size of the bone defect of the skull base. Materials and methods: 37 patients with nasal CSF leak were treated. In 17 cases, nasal CSF leak was caused by meningo(encephalo)cele. Spontaneous nasal cerebrospinal fluid occurred in 14 cases. In 3 cases, nasal CSF leak was the result of traumatic brain injury (in one case, the cause of nasal CSF leak was post-traumatic meningoencephalocele of the frontal sinus); in the other 3 cases there was postoperative wound nasal cerebrospinal fluid. Results and discussion: Groups of patients were formed depending on the use of vascularized or moved (free) flaps: 1). Multilayer plastics of bone defects of the anterior and middle cranial fossae using displaced (free) flaps. 2). Multilayer plastic of bone defects of the anterior and middle cranial fossa using a nasoseptal flap or middle nasal concha on the leg. In all cases (100%) nasal CSF leak was eliminated. External lumbar drainage was performed in 6 patients and only in cases where the plastic of the bone defect was performed by displaced free flaps. Conclusions: 1). The use of endoscopic endonasal techniques is a minimally invasive method to close skull base bone defects (including large – more than 20 mm) in the area of the anterior and middle cranial fossae. 2). Subcranial approaches are expedient, effective and technically more convenient for nasal CSF leak defects of the frontal sinus and defects in the anterior cells of the etmoid bone.3). Vascularized flaps is expedient for plastic at middle (11-20 mm) and big (more than 20 mm) bone defects of skull base.

Objective: to analyze the results of using various methods of plastic closure of bone defects of the anterior cranial fossa (ACF) floor when removing craniofacial tumors of the ACF floor depending on the size of the defect. Materials and methods. A retrospective analysis of treatment outcomes of 122 patients with craniofacial tumors of the ACF floor was carried out. According to the nature of the lesions malignant craniofacial tumors were detected in 98 (80.3%) patients, and benign ones in 24 (19.7%) patients. The following neurosurgical approaches to craniofacial tumors of the ACF floor were used: bifrontal - in 58 (47.5%) patients, subcranial - in 49 (40.2%), transbasal Derome - in 8 (6.5%), frontotemporal - in 4 (3.25%), expanded endoscopic - in 3 (2.45%). In 52 (42.6%) cases, endoscopic endonasal assistance was used, most often in the case of plasty of large ACF floor defects to revise the surgical defect, assess the sufficiency of plasty and tamponade of the nasal cavity with balloon catheters. Results. Patients were divided into groups depending on the bone defect of the ACF floor: median - in 27 (22.1%), middle-expanded - in 71 (58.2%), middle-lateral - in 24 (19.7%). The following types of plasty of the bone defect of the ACF floor were used: pedicle flap - 83 (68.0%) cases, free flap - 22 (18.1%), pedicled periosteal flap with reinforcement - 17 (13.9%). Postoperative complications occurred in 17 (13.9%) patients: nasal liquorrhea in 10 (8.2%) patients (of which 6 underwent reoperation to eliminate it), in 7 patients it was complicated by meningoencephalitis, in other 7 (5.7 %) - meningoencephalitis without signs of nasal cerebrospinal fluid. Postoperative mortality was 0.71% (1 patient). The frequency of nasal cerebrospinal fluid in the group of plasty using a free flap was 13.6% (3 cases), meningoencephalitis - 4.5% (1 observation), in the group of plasty using pedicle flap - 4.8% (4 cases) and 6.0% (5 observations), in the group of plasty using a pedicle flap with reinforcement - 17.6% (3 cases) and 11.7% (2 observations). In 33 (27.1%) cases the use of the author's method of bone defect plasty of the ACF floor with duplication of complications were not registered. Conclusions. Significant size and spread of bone defects of the ACF floor increase the risk of postoperative complications. The use of free flaps for plasty of the bone defect of the ACF floor is ineffective and is associated with a high risk of complications. The proposed method of plasty of the posterior parts of the ACF floor by duplication of the periosteal flap promotes the sealing of the posterior parts, where suturing causes certain difficulties. Reinforcement of plasty from the side of the nasal cavity due to endoscopic technique using tamponade or balloon catheters reduces the incidence of postoperative complications.

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To analyze the results of surgical treatment patients with the third ventricular pathology. Objective. To improve methods of transchoroidal dissection. To make enough space for surgery of the third ventricle by expanding the foramen of Monro. To reduce the risk of surgical treatment in the pathology at the posterior compartment of the third ventricle. Materials and methods. The results of treatment of 27 patients with tumors and colloid cysts to the third ventricle were analyzed. In all 27 patients endoscopic frontal transcortical approach was perfomed. In 24 cases of them extended anterior choroidal dessection was perfomed (transchoroidal and transforaminal approach); in 3 cases-transcortical transforaminal approach (without choroidal dissection). In all case there was fully endoscopic removal (100 %). Results. Gross total resection was achieved in 14 cases, subtotal resection-in 13 cases. Karnofsky Performance Scale in the postoperative period demonstrated ≥ 70 points in all patients. Complications occurred in 4 patients (14.8 %). No postoperative mortality was observed. Conclusions. 1. Transcortical transforaminal approach can be used for the pathology in the anterior compartment of the third ventricle. 2. Transcortical transchoroidal approach can be perfomed for the pathology, which localized or spread into the posterior part of the third ventricle. 3. Anterior transchoroidal dissection can be combined with transforaminal approaches if the ventricular hydrocephalus is not much expressed, foramen of Monro is not much enlarged to complete transforaminal proccedure as well as when the tumor spreads to the posterior compartment of the third ventricle. 4. The number of complications related to the frontal transcortical transventricular approach in our series is 14.8 %, and they had transient nature and relapsed within a month postop; no postoperative mortality.

Objective: To determine the effectiveness of intraoperative Doppler ultrasound in the surgical treatment of pituitary adenomas with invasive parasellar growth into the cavernous sinus Knosp 3 and Knosp 4. Material and Methods. During 2009–2017, 71 patients with pituitary adenomas (PA) with extension into the cavernous sinus Knosp 3 and Knosp 4 were retrospectively reviewed. According to the size PA were divided into pituitary macroadenomas, (from 10 to 40 mm) in 45 (63.4%) patients, and giant PA (over 40 mm) – in 26 (36.6%) patients. Cavernous sinus invasion Knosp 3 and 4 was identified in 47 (66.2%) and 24 (33.8%) patients respectively. Non-secreting PA - 43 (60.5%) patients and hormone-secreting PA - 28 patients (39.4%). Endoscopic endonasal trassphenoidal (EET) approach was used in all cases. Laterally expanded EET (LEEET) approach was used in 29 cases. Intraoperative Doppler ultrasound (IDUS) was used in 36 (51%) cases. Results. Intraoperative Doppler ultrasound was used in cases of Knosp 3 extension in 23 (32.4%) cases and in Knosp 4 - in 13 (18.3%) cases. Gross total resection, including extension into the cavernous sinus using IDUS was achieved in 22 (62.7%) patients. In cases where IDUS was not used, gross total resection was achieved in 19 (52.7%) cases. In cases where the IDUS was not used, recurrence rate was 7.3%, with IDUS - 5%. Biochemical remission was achieved in 22 (78.6%) cases. Liquorrhea nasalis after surgery was observed in 6 (8.4%) cases, meningoencephalitis - in 1 (1.4%) case, oculomotor palsy -3 (4.2%) cases. Conclusions. Intraoperative Doppler ultrasound is an informative method that provides safe resection of pituitary adenomas with cavernous sinus extension with a low level of possible postoperative complications. Parasellar extension of Pituitary adenomas into the cavernous sinus Knosp 4 significantly reduces the possibility of gross total resection. However, the use of intraoperative ultrasound makes it possible to determine safe boundaries for manipulation both medially and laterally from the internal carotid artery, increasing the level of radicality and the duration of clinical remission. Intraoperative Doppler ultrasound during endoscopic endonasal transsphenoidal surgery of pituitary adenomas with parasellar extension allows to identify the internal carotid artery in the tumor stroma with the existing changed skull base anatomy. Dura incision under intraoperative Doppler ultrasound reduces the risk of internal carotid artery injury.