Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement.

BACKGROUND AND PURPOSE: There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement. MATERIALS AND METHODS: We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of ≥70% for binary questions and agreement of ≥50% for questions with >2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback. RESULTS: A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period. CONCLUSIONS: More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.

Antiplatelet Management for Stent-Assisted Coiling and Flow Diversion of Ruptured Intracranial Aneurysms: A DELPHI Consensus Statement.

BACKGROUND AND PURPOSE: There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies. MATERIALS AND METHODS: The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society. RESULTS: Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure. CONCLUSIONS: More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.

Posterior Fossa Dural Arteriovenous Fistulas with Subarachnoid Venous Drainage: Outcomes of Endovascular Treatment.

BACKGROUND AND PURPOSE: Dural AVFs located in the posterior fossa are a rare entity. The objectives of the study were to analyze the anatomy of dural AVFs, their endovascular treatment strategies, and clinical outcomes. MATERIALS AND METHODS: Two centers retrospectively selected patients treated between January 2009 and June 2018 having posterior fossa dural AVFs. We collected patient demographics, clinical presentation, arterial and venous outflow anatomy of the dural AVFs, and treatment outcomes. RESULTS: Twenty-six patients treated endovascularly for posterior fossa dural AVFs, type III, IV, or V, were included. One hundred percent of the dural AVFs were occluded. A transarterial approach was performed in 23 dural AVFs (88.5%); a combined transarterial and transvenous approach, for 2 dural AVFs (7.7%); and a transvenous approach alone, for 1 dural AVF (3.8%). The middle meningeal artery was the most common artery chosen to inject embolic liquid (46%, 12/26). Procedure-related morbidity was 15.4% at 24 hours, 7.7% at discharge, and 0% at 6 months. Procedure-related mortality was 0%. CONCLUSIONS: Endovascular treatment offers high occlusion rates for posterior fossa dural AVFs with low morbidity and mortality rates. The arterial approach is the first-line preferred approach, even if a transvenous or combined approach would be a safe and effective option for patients with favorable anatomy.

[Evidence-based medicine: opportunities of the Propensity Score Matching (PSM) method in eliminating selection bias in retrospective neurosurgical studies]. / Dokazatel'naia meditsina: vozmozhnost' ispol'zovaniia metoda podbora bol'nykh po indeksu sootvetstviia (PSM) dlia ustraneniia sistematicheskoi oshibki otbora v retrospektivnykh neirokhirurgicheskikh issledovaniiakh.

To date, a large amount of retrospectively collected data about treatment of neurosurgical pathology have been accumulated. Modern methods of medical statistics are necessary for correct interpretation of the data. The article purpose is to demonstrate application of one of the modern methods, Propensity Score Matching (PSM), in neurosurgery. The use of PSM avoids misinterpretation of retrospectively collected data and obviates errors in planning further prospective studies. For the past 10 years, the number of published international PSM-based studies has increased more than 10-fold, with the number of articles by Russian authors accounting for less than 0.2%. In line with the tendencies of international studies, application of PSM in analysis of retrospectively collected data will enable testing of a number of hypotheses and correct planning of prospective randomized studies.

[Surgical treatment of cerebral aneurysms in the Russian Federation]. / Khirurgicheskoe lechenie tserebral'nykh anevrizm v Rossiiskoi Federatsii.

OBJECTIVE: The objective of this study was to evaluate the results of surgical treatment of cerebral aneurysms in the Russian Federation. MATERIAL AND METHODS: We analyzed performance indicators in neurosurgical departments of regional and federal health institutions of the Russian Federation for 2017. The results of surgical treatment of cerebral aneurysms (CAs) were analyzed in 19 regional vascular centers (RVCs) in several federal districts and in 3 federal centers (FCs) with the most dynamically developing vascular neurosurgery and smoothly running system of statistical data processing. RESULTS: The study included 3160 patients hospitalized to 22 medical institutions in 2017. Of these, 1808 patients were treated in RVCs, and 1352 patients were treated in FCs. We analyzed factors affecting the treatment outcome in CA patients. We identified features of CA treatment in clinics with a different amount of surgical intervention. CONCLUSION: An increase in the surgical activity in centers and simultaneous development of microsurgical and endovascular treatments for cerebral aneurysms reduce postoperative mortality. Due to the presence of a RVC network in the Russian Federation, many patients could receive necessary specialized treatment. The number of operations for cerebral aneurysms has increased 6-fold for the past 10 years.

[An experience of neurophysiological monitoring in neurosurgery]. / Opyt primeneniia neirofiziologicheskogo monitoringa pri neirokhirurgicheskikh operatsiiakh.

AIM: To evaluate the efficacy of neuromonitoring methods in prevention of postoperative neurological complications and estimation of predictive power of intraoperative changes in monitored characteristics. MATERIAL AND METHODS: Retrospective study examined 240 patients, operated in the years 2014-2015 using intraoperative neurophysiological monitoring. One hundred and seventy-three patients suffered from hemispheric lesions and 67 had lesions located in or near the brainstem. Somatosensory evoked potentials (SSEP) were monitored in 152 cases, visual in 32, brainstem acoustic in 22, transcranial motor in 36; stimulation mapping of motor cortex was performed in 69 surgeries, and cranial nerves identification in 27. EEG was recorded in 7 patients, and 3 of them were woke up during the surgery for speech mapping. RESULTS: The sensitivity of the SSEP in motor dysfunction detection was low (33%), while the specificity was relatively high (82%). These characteristics for visual and motor evoked potentials were close to 100% provided that the parameters of anesthesia met the corresponding requirements. The most effective methods in respect of prevention of postoperative dysfunctions were the stimulation mapping of functionally significant areas (motor and speech) and motor pathways mapping. CONCLUSION: Intraoperative neuromonitoring reduces a number of neurological complications after neurosurgical operations. The SSEP method is not sensitive enough in surgeries that could affect motor centers and/or pathways, and multimodal monitoring combining SSEP and motor responses recording during transcranial and/or direct electrical brain stimulation. Successful monitoring requires highly coordinated actions between neurophysiologists, neurosurgeons and anesthesiologists.

[Transarterial and transvenous embolization of deep binodal arteriovenous malformation of the brain].

INTRODUCTION: The multimodal approach to treatment of arteriovenous malformations yields good results. However, small and deep malformations still pose a big problem for surgeons. Transvenous embolization was designed as an alternative for the cases when endovascular treatment is required and conventional transarterial embolization is not available. CASE STUDY: A 41-year-old patient with binodal malformation in the subcortical nuclei of the left hemisphere of the brain, which had previously become a source of massive parenchymal ventricular hemorrhage, was operated on using the transarterial and, for the first time in our clinic, transvenous approaches. Transarterial embolization of the thalamic node of malformation was performed as the first step. After 6 months, transvenous embolization of the hypothalamic node of malformations was performed as the second step. Successful operation was ensured by using a stable coaxial guiding catheter system with the maximum distal approach and intranidal positioning of a microcatheter with detachable distal portion upon temporary occlusion of afferent vessels of the malformations using a balloon catheter. The operation resulted in total thrombosis of the malformation. No perioperative complications were observed. Control examination in 6 months did not reveal recanalization of the malformation. CONCLUSION: The transvenous approach can be successfully used in endovascular treatment of small and deep arteriovenous malformations with a single drainage vein, which are inaccessible to direct surgery. It can also be used when radiosurgery is associated with a high risk in cases where transarterial embolization is infeasible.

rf Electrode sheath formation near a concave electrode.

In this work we present experimental results concerning electrode sheath and ion flux formation near a concave electrode with the dimension of a cavity comparable to the electrode sheath length. It is shown that the secondary electron emission can play a crucial role in plasma molding over the electrode surface. It is also observed that plasma has a tendency to "self-leakage" in electrode cavities.

[Intracranial cavernous angiomas: ultrastructural and immunochemical study]. / Vnutricherepnye kavernoznye angiomy: ul'trastrukturnoe i immunogistokhimicheskoe issledovanie.

43 brain cavernous angiomas (CA) were clinically and morphologically studied. The presence of smooth muscles and endotheliocytes in the trabeculae was confirmed. The sources of blood supply and the nature of medullary changes at the CA periphery were clarified. The hypothesis of CA hormonal dependence has been rejected.

[The age-related characteristics of the dopaminergic regulation of prolactin secretion in men]. / Vozrastnye osobennosti dofaminergicheskoi reguliatsii sekretsii prolaktina u muzhchin.

Age-specific time course of prolactin secretion and features of dopaminergic regulation of this hormone secretion were studied in boys aged 3 to 15 and in adult men aged 20 to 25. Blood plasma prolactin concentration was found reduced in boys, and this hormone level, characteristic for adults, sets up at the age of 9-11. Dopaminergic regulation of prolactin secretion undergoes three stages in boys: Stage 1--hyperreaction to introduction of a receptor antagonist at the age of 3 to 8, Stage 2--at the age of 9 to 11--reduced reaction to D2 receptor blocking, though this reaction being much higher than in adults, and Stage 3 (at the age of 12-15)--development of a normal reaction characteristic of adults.

[Uterine pregnancy and endometrial cancer]. / Matochnaia beremennost' i rak éndometriia.

An observation of the uterine pregnancy combined with endometrial adenocarcinoma and uterine body endometriosis in a woman of 4.2 with the obesity of III degree, and hypertension is described. Chorion willi, decidual tissue, large pieces of the endometrium with decidual conversion of stroma and numerous monstrous closely packed glands with arrangement of nuclei in several rows and moderate mitosis are found histologically in the uterine curettage. Tumour cells formed at places solid bands with pseudocribrous structures. Uterus with its appendages was removed. Histologically reversible endometrial changes after the interrupted pregnancy are found with foci of an atypical glandular hyperplasia but without tumour elements. Endometriosis foci in the myometrium and a diffuse theca-cell hyperplasia in the ovaries are observed.

[Malignant fibrous histiocytoma of the neck with metastases to the brain]. / Zlokachestvennia fibroznaia gistiotsitoma shei s metastazami v golovnoi mozg.

A case of malignant fibrous histiocytoma with multiple brain metastases in a 48-year-old man is described. The tumour (5 X 6 cm in size) located under m. sternocleidomastoideus, surrounded inner carotid artery and grew into its wall. Pseudoaneurysm (4 X 5 cm in size) with thrombosis was found 2 cm over the tumour. There were multiple metastases (from 1 to 3 cm in diameter) in the right brain hemisphere. The tumour consisted of fibroblast-like cells, polymorphic histiocyte-like cells, with one or several nuclei, Touton cells, and osteoclast-like cells and groups of xanthoma cells.