[Stepwise surgical treatment in patients with multiple stenotic and occlusive lesions of the great arteries of the brain].

The study was conducted at the Academician N. N. Burdenko Institute of Neurosurgery, Moscow, in 1999 to 2006. The paper presents the results of stepwise surgical treatment in 84 patients with chronic cerebral ischemia, caused by multiple stenotic and occlusive lesions of the brachiocephalic arteries, who underwent 183 reparative operations. Six major groups of patients with various combinations of lesions of major cerebral arteries were identified. An attempt was made to create an algorithm of the optimum stepwise surgical treatment policy in the identified groups of patients on the basis of the site, degree, and nature of stenotic lesions, by taking into account the cerebral hemodynamics and collateral circulation at all stages of surgical treatment. At the same time, changes in the degree of neurological deficit as one of the major determinants of the results of surgical treatment could be evaluated. The study has demonstrated that the chosen tactics of employing series arterial reconstructions in multiple stenotic and occlusive lesions of major cerebral arteries is an effective treatment option in patients with chronic cerebral ischemia.

[Combined surgical treatment for carotid paraganglioma]. / Kombinirovannoe khirurgicheskoe lechenie karotidnoi paragangliomy.

The paper gives a clinical example of embolization of the vascular network of carotid paraganglioma with subsequent en-block tumor removal with bifurcation of the common carotid artery and with recovery of great blood flow along the internal carotid artery through alloprosthesis of the latter. The positive effects of a combination of endovascular embolization of the vascular network of the tumor with its subsequent removal are noted. Indications for endovascular embolization and its procedure, intraoperative evaluation of cerebral collateral circulation are discussed. Those for carotid repair during en-block removal of carotid paraganglioma with bifurcation of the common carotid artery are considered.

[Surgical treatment of occlusive and stenosing lesions of brachiocephalic arteries]. / Khirurgicheskoe lechenie bol'nykh s okkliuziruiushchimi i stenoziruiushchimi porazheniiami brakhiotsefal'nykh arterii.

The results of surgical treatment of patients with occlusive and stenosing lesions of brachiocephalic arteries implemented at Burdenko's Research Institute of Neurosurgery of the Russian Academy of Medical Sciences (RAMS) during 1999-2002 are described. A total of 164 operations were made in 128 patients. Different diagnostic methods and indications for various types of reconstructive and revascularization surgeries are under discussion. A variety of the carotid endarterectomy techniques and the conditions needed for their implementation (microsurgical equipment and intraoperative multi-modality neuromonitoring) are defined. Finally, the main complications and the methods of their prevention, correction and treatment are also described.

[Somatosensory evoked potentials in the assessment of cerebral ischemia in combined operations for intracranial aneurysms]. / Somatosensornye vyzvannye potentsialy v otsenke ishemii golovnogo mozga pri kombinirovannykh operatsiiakh vnutricherepnykh anevrizm.

Combined surgery of extra-intracranial anastomosis (EICA) and occlusion of the afferent vessel by means of a balloon catheter was made in 14 patients with giant aneurysms of the internal carotid (IC) and middle meningeal artery (MMA). MMA was excluded without previously creating EICA in another patient. The purpose of the study was to define the informative value of a somatosensory evoked potential (SSEP) as an intraoperative criteria for possible permanent occlusion of the major vessel. In 9 patients, IC or MMA occlusion was shown to cause neither intraoperative SSEP changes no postoperative neurological defect. After IC occlusion one case showed 25% reductions in the SSEP amplitude, which was not followed by neurological deterioration. In another patient with IC occlusion, 40% decreases in the cortical response amplitude resulted in moderate postoperative hemiparesis. In one patient with transient IC occlusion, 50% falls in the SSEP amplitude were accompanied by poor EICA function, which made permanent IC occlusion be avoided. However, postoperative neurological defect progression was detected in 3 patients without intraoperative SSEP changes. The findings suggest that SSEP may be used to determine whether IC and MMA can be excluded at surgery for aneurysms. However, no intraoperative SSEP changes does not predict the constancy of a patient's neurological status.

[The procedure for the surgical treatment of combined arteriovenous malformations and arterial aneurysms of the brain]. / Taktika khirurgicheskogo lecheniia sochetannykh mal'formatsii i arterial'nykh anevrizm golovnogo mozga.

To choose the optimal surgical treatment, the follow-ups of 25 patients with arteriovenous malformations (AVMs) concurrent with arterial aneurysms who had been surgically treated were considered. Twenty four patients experienced spontaneous subarachnoidal hemorrhage, 16 of them were repeated and multiple. The accurate diagnosis of the source of bleeding was associated with objective difficulties. With allowance for intraoperative findings. AVMs caused hemorrhage in 14 (58%) cases, aneurysms in 6 (25%). AVMs and aneurysms in 4 (17%). Thirteen (52%) patients were operated on AVMs and aneurysms in one or two steps, 5 had operations only on aneurysms, 7, on AVMs alone. Taking into account ruptures and higher sizes of aneurysms after AVM dissection, it is concluded that it is necessary to immediately exclude saccular bifurcating aneurysms irrespective of the cause of bleeding. Possible variants of policy decisions are dealt with, by taking into account the specific features of the location of AVMs and aneurysms-the sources of hemorrhage. One-stage surgical interventions into AVMs and aneurysms are recognized to be optimal.

[Extra-intracranial microvascular anastomosis in the surgical treatment of arterial aneurysms of the brain]. / Ekstra-intrakranial'nyi mikrososudistyi anastomoz v khirurgii arterial'nykh anevrizm golovnogo mozga.

Extra-intracranial microvascular anastomosis (EICMA) was applied for surgical management of 17 patients with arterial aneurysms of the brain when the topographo-anatomical features of the aneurysm did not allow direct manipulations on it while the conditions of collateral circulation were inadequate. It is shown that EICMA is effective in surgery of almost inaccessible and giant saccular aneurysms of the brain for reducing the risk of the development of cerebral circulatory disorders of an ischemic character.