[Surgical prevention of ischaemic strokes by means of an extraintracranial microanastomosis (EICMA) in the carotid basin]. / Khirurgicheskaya profilaktika ishemicheskikh insul'tov s ispol'zovaniem ekstra-intrakranial'nogo mikroanastomoza (EIKMA) v karotidnom basseine.

BACKGROUND: Not less than 50% of all ischaemic strokes appear to occur resulting from pathology of extracranial arteries. Occlusions and stenoses are more commonly encountered in carotid arteries, with the incidence of occlusion of the internal carotid artery (ICA) ranging from 5 to 10% within the structure of all lesions of brachiocephalic arteries (BCA). AIM: The study was aimed at assessing the results of a surgical procedure of extra-intracranial microanastomosis (EICMA) performed in patients presenting with occlusive and stenotic lesions of BCA at the Neurosurgical Department. PATIENTS AND METHODS: During the period between January 1st 2009 to September 30th 2015, specialists of the Neurosurgery Department of the Research Institute of Emergency Medical Care named after N.V. Sklifosovsky treated a total of 1,101 patients presenting with atherosclerotic lesions of BCA, with a total of 1,038 surgical interventions performed. Of these, there were 837 operations of carotid endarterectomy and 180 operations of EICMA in the carotid basin. The indications for performing EICMA in patients from the group with occlusive-stenosing lesions of the major arteries of the head and neck were as follows: the presence of occlusion of the internal carotid artery or M1 segment of the middle cerebral artery, verified by the findings of angiographic examinations; previously endured ischaemic-type cerebral circulation impairment in the basin on the side of occlusion; a decrease in the perfusion reserve of the brain on the side of occlusion by the findings of positron emission tomography (PET), single-photon emission computed tomography (SPECT) or CT-perfusion with loading tests. RESULTS: After performing EICMA, the neurological status in patients averagely improved by 1.2 points according to the NIH Stroke Scale; by 0.5 point according to the Rankin scale, and by 3.5 points according to the Rivermead Mobility Index (Table 1). The dynamics of functional outcomes of EICMA turned out to depend on the terms of the operation (R=2143, p<0.05) and the degree of neurological deficit prior to surgery (R=3422, p<0.05): the deeper the neurological deficiency was and the sooner after acute cerebral ischaemia (ACI) the operation was performed, the more significant restoration of the functions was at the moment of discharge from hospital. Major complications of EICMA in patients operated on at various terms of ischaemic stroke were as follows: recurrent cerebral circulatory impairments - in 6 (3.3%) patients, subdural and intracranial haemorrhage - in 2 (1.1%), temporal deepening of the neurological deficit on the background of reperfusion, confirmed by the findings of SPECT - in 2 (1.1%), pneumonia with a lethal outcome - in 1 (0.6%), fatal ischaemic stroke of the opposite hemisphere - in 1 (0.6%) subject. The lethality rate amounted to 1.1% (2 cases). The risk for the development of complications was higher in elderly and aged patients (75 years and over), in patients with pronounced neurological deficit and significant somatic disorders. CONCLUSION: The indications for surgical prevention of recurrent ischaemic stroke by means of EICMA should be based on the following factors: the presence of confirmed occlusion of the ICA, a history of endured acute cerebral ischaemia, and decreased cerebrovascular reserve. Performing a surgical intervention is not appropriate for patients presenting with pronounced neurological deficit and significant somatic pathology. Careful selection of patients, the use of modern methods of neuroimaging, and intraoperative control make it possible to achieve favourable functional outcomes and to decrease the postoperative complications rate.