[Carotid endarterectomy in patients with high surgical risk].

Aim of the study to examine the risk factors for carotid endarterectomy (CEA) and their effect on the results of surgical treatment in patients with chronic cerebral ischemia. The study included 340 patients who were operated in the institute from 2007 to 2011. All patients underwent CEA in various modifications. Based on the classification of surgical risk CEA proposed by Sundt, patients were divided into 4 groups. In the following analysis, we evaluated perioperative outcomes of surgical treatment in the third and fourth groups, respectively, compared the frequency of the installation of temporary intraluminal shunt (TIS) during the surgery, depending on the severity of angiographic risk factors and neurological anamnesis. Perioperative ischemic complications in the third group was 4.2%, 6.4% in the fourth respectively. In both groups, TIS required in 15% of operations. In patients undergoing surgery under regional anesthesia, shunts were used two times less frequently than in patients under general anesthesia (8.8% vs. 19.8%). Correlation between the severity of angiographic risk factors and tolerance to hypoperfusion of the brain, caused by a temporary clamping of the ICA revealed. In case occlusion of the contralateral ICA temporary shunts have been installed in 40%, with contralateral stenosis in 15% and without angiographic and risk factors in 80% of cases. The findings coincide with the results of similar studies published in the literature. Taking into account our and foreign data should be noted that CEA in patients with high surgical risk by Sundt is accompanied by an increased incidence of perioperative ischemic complications and requires more differentiated approach to the tactics of surgical treatment, and choice of the method of neurophysiological monitoring during surgery.

[Radical removal of a malignant mediastinum hemangioendothelioma with restoration of the main blood supply to the brain].

46 year old man appealed to the Cancer Research Center of RAMS in October 2012 with unverified anterior superior mediastinal tumor, which was diagnosed in 2010. Progressive compartment syndrome of the superior vena cava was observed. On examination: CT, MRI, angiography, histological and cytological examination of biopsy material did not allow to confirm the morphological structure of the tumor. Removal of the tumor with bifurcation of the brachiocephalic trunk prosthetics was performed. Immunohistochemical (IHC) study verified malignant hemangioendothelioma.

[The case of simultaneous use of direct and endovascular techniques for the reconstruction of occluded brachiocephalic trunk].

The article provides an example of successful surgical treatment of progressive chronic cerebral ischemia due to occlusion of the brachiocephalic trunk and critical stenosis of the right internal carotid artery (more than 85%). We describe a hybrid method of surgical treatment, which include direct access to the neurovascular bundle, retrograde endovascular recanalization following angioplasty and stenting of the brachiocephalic trunk during temporary occlusion of the distal internal carotid artery and carotid endarterectomy. We provide an analysis of indications for each phase of operation considering the features of compensatory collateral circulation in the basin of the occluded brachiocephalic trunk and the possible complications of surgery.

[Syndrome of cerebral hyperperfusion after carotid endarterectomy].

UNLABELLED: The aim of this study was to assess the role of different modalities in early diagnosis of cerebral hyperperfusion syndrome (CHPS) following carotid endarterectomy, as well as to develop effective treatment protocol for abovementioned complication. MATERIAL AND METHODS: Study group consisted of 61 patient who underwent uni- or bilateral carotid endarterectomy (CEA). Diagnostic modalities included transcranial Doppler study (TCD), cerebral oximetry, perfusion CT scanning and neuropsychological evaluation. STUDY RESULTS: We demonstrated that both bilateral carotid stenosis and stroke were independent predictive factors for CHPS at early postoperative period. "Classical" two-fold increase of cerebral blood flow in ipsilateral CMA was seen in 15% patients only. According to our data, predictive TCD-value was 1.48 increase of CBF. The most informative tool for early CHPS diagnosis was perfusion CT scans: preoperative mean transit time asymmetry in temporal areas (in the group of patients with unilateral carotid stenosis) correlated with CHPS development. Effective medical treatment for CHPS was achieved with Ca2+ channel antagonists use, that enabled us to prevent evolution of "mild" clinical appearance of CHPS into status epilepticus or intracerebral hemorrhage. CONCLUSION: Modern diagnostic modalities that assess brain perfusion can (with certain rate of accuracy) predict CHPS development even preoperatively. Early therapy of this complication with Ca2+ antagonists can usually control it.

[Thromboelastography as a method for preoperative screening for the hemostatic system in neurosurgical patients].

The paper analyzes the use of a method of thromboelastography (TEG) as a screening technique of diagnosing hemostatic disorders in risk-group neurosurgical patients: hemostatic disorders detectable from the data of routine laboratory tests; the administration of anticoagulants and desaggresants, the use of anticonvulsants causing impairments in the hemostatic system, hematological diseases, and hepatic cirrhosis. As compared with the routine laboratory tests, TEG is shown to diagnose hemostatic disorders accurately and promptly and to monitor the efficiency of their therapy.

[Protocol of examination and surgical management of patients with stenosing lesions of the major brain arteries].

The paper contains the protocol of examination and surgical management of patients with stenosing lesions of mail cerebral arteries. Diagnostic algorithm including evaluation of clinical and instrumental data is presented. Indications for ultrasonic (duplex scanning, transcranial Doppler study) and neuroradiological (CT, spiral CT angiography, MRI) methods of assessment of stenosing lesions are described. Indications for digital subtraction angiography as well as CT- and MR-angiographic studies in postoperative period are to be specified. Variants of reconstructive surgical procedures on carotid, vertebral and subclavial arteries, surgical revascularization of the brain and endovascular procedures on brachiocephalic arteries are discussed. Indications and contraindication to different kinds of surgical treatment and selection of anesthesia are listed. Methods of intraoperative multimodal and neurodynamic monitoring and criteria of application of temporary intraluminal shunt on the main stage of carotid reconstructions are described. Tactics of step-by-step surgical management of multiple stenosing lesions of brachiocephalic arteries is presented. The paper also contains recommendations for preoperative preparation and early and delayed postoperative management of patients.

[Multimodal neuromonitoring in the early diagnosis of brain ischemia during carotid arterial reconstruction].

The paper analyzes the efficiency of multimodal neuromonitoring (transcranial ultrasound Doppler study, cerebral oximetry, and electroencephalography) for the early intraoperative diagnosis of cerebral ischemia in patients during carotid reparative interventions. On the basis of the findings, the authors have developed a diagnostic algorithm of cerebral ischemia in this group of patients at surgery. Its basis is Doppler monitoring; the data of cerebral oximetry and EEG are taken into account with the borderline values of linear blood flow velocity. The diagnosis of cerebral ischemia during operation on the carotids is a direct indication for the usage of a temporary intraluminal shunt. During carotid reconstructive interventions made under general anesthesia, the application of multimodal neuromonitoring is a valid approach and it should make the most use.

[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.

[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.

[Cerebral oximetry in neurosurgical patients with cerebrovascular diseases. I. Analysis of causes of intraoperative changes in rSO2 values and its prognostic significance]. / Tserebral'naia oksimetriia u neirokhirurgicheskikh bol'nykh s sosudistoi patologiei golovnogo mozga. Chast' I. Analiz prichin intraoperatsionnoi dinamiki pokazatelia rSO2 i ee prognosticheskoe znachenie.

A total of 144 neurosurgical interventions were performed in 138 patients with cerebrovascular diseases (arterial aneurysms in the acute and cold periods after a subarachnoidal hemorrhage, arteriovenous malformations, and carotid-cavernous anastomoses). Intraoperative monitoring of regional saturation of hemoglobin with oxygen in the blood flowing in brain vessels was carried out by a cerebral oximeter INVOS 3100 for early intraoperative diagnosis of cerebral ischemia. This paper analyzes factors affecting changes in rSO2 parameter during surgery and discusses the prognostic significance of the detected shifts. Various factors affected the time course of rSO2: decrease in AP within the framework of controlled arterial hypotone and other causes, insertion of autosupported retractor spatulae, temporary clipping and embolism of cerebral arteries, vasospasm, aneurysm rupture, dissection of arteriovenous malformation, etc. Any intraoperative shift of rSO2 surpassing 5%, no matter of what direction (decrease or increase), deserves special attention of anesthesiologist, as it indicates development of cerebral ischemia with a high degree of probability.

[Pharmacological protection of the brain during surgery in patients with giant cerebral aneurysms]. / Farmakologicheskaia zashchita mozga vo vremia operatsii u bol'nykh s gigantskimi arterial'nymi anevrizmami tserebral'nykh sosudov.

The authors discuss the results of pharmacological protection of the brain, consisting in intraarterial or intravenous infusion of drugs (sodium thiopental, nimodipine, ketamine) during intracranial interventions in 13 patients with giant arterial aneurysms of the anterior portions of Willis' circle. In some patients drug protection of the brain prevented the development of ischemic focus in the basin of temporarily occluded vessel. Intraarterial infusion of protector drugs is preferable because it allows decreasing the doses and severity of untoward hemodynamic effects.

[Use of Bullard laryngoscope in intubation of the trachea]. / Ispol'zovanie Bullard-laringoskopa dlia intubatsii trakhei.

Bullard laryngoscope was for the first time used for intubation of the trachea in 232 neurosurgical patients. The advantages of the new laryngoscope and specific problems associated with its use are discussed. The principal advantage is no need in direct laryngoscopy, which permits using this instrument in patients with short and rigid neck, in those with ankylosis of the temporomandibular joint, with injuries to, or unstable spine. The problems are mainly related to obturation of the optic system of the laryngoscope by secretion and to selection of an adequate diameter of the intubation tube.

[Use of cerebral oximetry in early diagnosis of cerebral ischemia in neurosurgical patients with cerebrovascular diseases]. / Primenenie tserebral'noi oksimetrii dlia rannei diagnostiki tserebral'noi ishemii u neirokhirurgicheskikh bol'nykh s sosudistoi patologii golovnogo mozga.

Using a new device, INVOS-3100 cerebral oximeter, the rSO2 parameter (oxygen saturation of blood hemoglobin in cerebral vessels) was monitored during neurosurgical interventions in 84 patients with cerebrovascular diseases (arterial aneurysms, arteriovenous malformations, and carotid-cavernous anastomoses). Six patients developed grave ischemic complications. In five of them the cerebral oximeter showed a more than 5% reduction of the parameter in question (by 11%, on an average). The findings permit a conclusion that cerebral oximetry is an adequate method of early diagnosis of ischemia in neurosurgical patients with cerebrovascular diseases.

[Cerebral oximeter INVOS-3100]. / Tserebral'nyi oksimetr INVOS-3100.

A new device is described: cerebral oximeter intended for monitoring cerebral oxygenation and early diagnosis of cerebral ischemia and hypoxia. The advantages and shortcomings of the proposed method are analyzed in comparison with other current methods for the early diagnosis of cerebral ischemia.