[Diagnosis and treatment of non-saccular vertebrobasilar aneurysms]. / Sovremennoe sostoyanie diagnostiki i lecheniya nemeshotchatykh anevrizm vertebrobazilyarnogo basseina.

OBJECTIVE: To systematize the data on diagnosis and treatment of non-saccular vertebrobasilar aneurysms. MATERIAL AND METHODS: We have analyzed modern and fundamental studies in the PubMed database for the period 1969-2020. The following keywords were used: non-saccular aneurysm, dolichoectasia, vertebrobasilar pool. Fifty-nine studies including 1 meta-analysis, 9 case reports, 24 reviews and 25 original articles were selected. RESULTS: Analysis of literature data indicates various unresolved problems associated with difficult diagnosis and choice of treatment that results high rates of disability and mortality. CONCLUSION: Data on anatomical features of non-saccular aneurysms, such as presence or absence of perforating arteries within the affected arterial segment, analysis of electrophysiological changes following brainstem compression by aneurysm can serve as factors that will improve treatment outcomes in these patients.

[Endovascular treatment of aneurysms associated with cerebral arteriovenous malformations]. / Endovaskulyarnoe lechenie anevrizm, assotsiirovannykh s tserebral'nymi arteriovenoznymi mal'formatsiyami.

There are proximal, distal and intranidal AVM-associated aneurysms (G. Redekop, 1998). OBJECTIVE: To evaluate treatment outcomes in 120 patients with AVM-associated aneurysms. MATERIAL AND METHODS: We analyzed treatment outcomes in 639 patients with cerebral AVM who underwent 1992 endovascular procedures between 2010 and 2019. AVM-associated aneurysms were found in 120 (18.8%) cases: 81 (67.5%) patients with 69 proximal and 29 distal aneurysms, 33 (27.5%) AVMs with intranidal aneurysms and 6 (5%) aneurysms without hemodynamic connection with AVM. One hundred and one malformations (16.9%) out of 596 supratentorial AVMs and 19 (44.2%) out of 43 subtentorial AVMs were associated with aneurysms. RESULTS: Intracranial hemorrhage occurred in 349 (53.3%) out of 639 patients with AVM: 97 (80.8%) out of 120 patients with AVM-associated aneurysms and 252 (48.6%) out of 519 ones with AVM and no aneurysms. All 33 patients with intranidal aneurysms in the AVM structure and 18 (94.7%) out of 19 patients with AVM-associated aneurysms and AVM in posterior cranial fossa had intracranial hemorrhage. There were 98 aneurysms in 81 patients with AVM-associated aneurysms. Eighty-nine (90.8%) ones underwent endovascular treatment, 6 (6.1%) patients with proximal aneurysms required microsurgery. Three distal aneurysms were not repaired. Thirty-four aneurysms were embolized with spirals. Embolization with spirals and balloon assistance was performed for 41 aneurysms, spirals with stent-assistance - for 9 aneurysms (including 1 distal MCA aneurysm in hemorrhagic period). Implantation of a flow-diverting stent was performed for 5 aneurysms (1 distal and 4 proximal aneurysms). There were 8 (8.9%) complications after embolization of 89 AVM-associated aneurysms (5 thromboembolic and 3 hemorrhagic events). CONCLUSION: According to our data, intranidal aneurysms require exclusion of the parent AVM segment due to high risk of hemorrhage. Treatment of proximal AVM-associated aneurysms should be carried out prior to AVM embolization. Distal aneurysms do not regress after definitive AVM treatment and should be operated on after total AVM embolization.

[Endovascular treatment of extracranial dissecting aneurysms of cervical arteries]. / Vnutrisosudistoe lechenie ekstrakranial'nykh dissektsionnykh anevrizm brakhiotsefal'nykh arterii.

BACKGROUND: Dissecting aneurysms of extracranial cervical arteries are a rare vascular pathology. To date, there is no consensus on the choice of optimal surgical approach for these aneurysms. OBJECTIVE: To evaluate the effectiveness of endovascular treatment of various extracranial dissecting aneurysms. MATERIAL AND METHODS: There were 19 patients with 21 extracranial dissecting aneurysms for the period from January 1, 2013 to October 19, 2020. Clinical examination, ultrasound and neuroimaging data were considered to determine surgical intervention. RESULTS: Nineteen patients underwent 20 intravascular interventions: aneurysm embolization with detachable coils with stent-assistance (n=9), flow-diverting stent implantation (n=5), arterial reconstruction with a stent for carotid stenting (n=3), aneurysm embolization with balloon assistance (n=1), aneurysm embolization with detachable coils without assistance (n=2). There were no complications. All patients were discharged without neurological impairment after 1-5 days. Long-term results of control angiography were analyzed within 1-19 months in 12 patients. All aneurysms were completely occluded. Asymptomatic occlusion of flow-diverting stent together with aneurysm occurred in 1 patient with low compliance to antiplatelet therapy. Other 6 patients are scheduled for elective angiography. CONCLUSION: Extracranial dissecting aneurysms of cervical arteries require vigilance due to their rare occurrence and risk of severe complications. In our opinion, intravascular interventions are advisable for these patients as effective and safe procedures.

[Unfavorable outcome of giant vertebral artery aneurysm. Clinical case and literature review]. / Neblagopriyatnyi iskhod techeniya gigantskoi anevrizmy pozvonochnoi arterii. Klinicheskoe nablyudenie i obzor literatury.

OBJECTIVE: To demonstrate the unfavorable natural course and prognosis of giant vertebral artery aneurysm, to analyze the literature, and to conduct a postmortem histopathological study of the features of this disease.

[Endovascular embolization of high-flow arteriovenous fistulae with non-adhesive agents in the structure of cerebral arteriovenous malformations on the background of adenosine-induced cardioplegia]. / Opyt endovaskulyarnoi embolizatsii vysokopotokovykh arteriovenoznykh fistul v strukture tserebral'nykh arteriovenoznykh mal'formatsii neadgezivnymi embolizatami na fone adenozin-indutsirovannoi kardioplegii.

OBJECTIVE: To analyze the initial results of endovascular embolization of cerebral arteriovenous malformations involving high-flow arteriovenous fistulae with non-adhesive agents on the background of cardioplegia. MATERIAL AND METHODS: There were 13 patients who underwent surgery in 2018. Embolization of AVM with non-adhesive agents (ONYX, SQUID) was performed on the background of temporary cardiac arrest achieved by bolus intravenous administration of adenosine triphosphate. CONCLUSION: Adenosine administration in endovascular treatment of AVM with non-adhesive agents is able to improve the safety of surgical intervention and ensure more qualitative embolization.

[Molecular mechanisms of growth and recurrence of cerebral arteriovenous malformations: part 2 (our own research)]. / Molekulyarnye mekhanizmy rosta i retsidivirovaniya tserebral'nykh arteriovenoznykh mal'formatsii. Chast' 2 (sobstvennye issledovaniya).

BACKGROUND: Cerebral arteriovenous malformations (AVM) are not static congenital formations. These structures can grow, recur, and even appear de novo after a "complete" cure. OBJECTIVE: To analyze the dynamics of angiogenic factors before and after embolization of cerebral AVMs. MATERIAL AND METHODS: The study enrolled 314 patients with AVM who underwent endovascular treatment at the Department of Brain Vessels Surgery of the Polenov Russian Research Neurosurgical Institute for the period from 2011 to 2017. The control group included 33 healthy volunteers. Their age was comparable to that in the main group. The levels of serum vascular endothelial growth factor (VEGF), angiopoietin-2 (ANG-2) and matrix metalloproteinase-9 (MMP-9) were measured before and in 24 hours after endovascular embolization using enzyme-linked immunosorbent assay (Personal Lab, «Adaltis¼, Italy). RESULTS: Increased levels of VEGF, MMP-9 and ANG-2 were observed in 48.4% of primary patients with AVM. No correlation of increased level of these factors with gender, age, co-morbidities, localization and structure of AVM was found. High level of VEGF and MMP-9 was typical for AVM Spetzler-Martin grade III, AVM with hemorrhagic course, drainage into the deep cerebral veins and with afferents from the external carotid artery. Total embolization of AVM led to normalization of all elevated angiogenesis factors. In contrast, partial embolization resulted augmentation of VEGF and MMP-9 levels. CONCLUSION: Normalization of all elevated growth factors after total embolization confirms the absence of potency for AVM recurrence. Identification of the factors predisposing to possible growth of AVM should be a justification for total resection of AVM. Persistent elevation of serum growth factors after total embolization in accordance with the angiographic criteria may be a sign of subtotal occlusion of AVM.

[Surgical treatment of large and giant vertebrobasilar aneurysms manifested by brainstem compression symptoms]. / Khirurgicheskoe lechenie krupnykh i gigantskikh anevrizm vertebrobaziliarnogo basseina, proiavliaiushchikhsia simptomatikoi kompressii stvola golovnogo mozga.

The study aim was to analyze the results of surgical treatment of vertebrobasilar (VB) aneurysms manifested by brainstem compression symptoms. MATERIAL AND METHODS: The study included 8 patients operated on in the period between 2014 and 2017. All patients underwent intravascular intervention; two patients had open surgery at the second stage. RESULTS AND CONCLUSION: Intravascular intervention, both alone and in combination with open surgery, is effective treatment of VB aneurysms whose clinical picture is manifested by brainstem compression symptoms. The use of flow-diverting stents in most cases has provided good radicalness in the long-term period, without worsening the functional outcome. Treatment of fusiform aneurysms of the basilar artery trunk requires separate consideration and an individual approach due to a high risk of thrombosis of short branches feeding the brainstem.

[Methods to assess competence of indirect cerebral revascularization in children]. / Metody otsenki sostoiatel'nosti nepriamoi revaskuliarizatsii golovnogo mozga u detei.

The use of catheterization cerebral angiography (CCA) to assess collateral blood flow through an indirect anastomosis is traumatic for children, uses a high radiation dose, and requires anesthetic care in most cases. AIM: we aimed to compare the capabilities of triplex ultrasound (TU) of vessels, magnetic resonance angiography (MRA), computed tomography angiography (CTA), and CCA in assessing the competence of indirect cerebral revascularization (ICR) in children. MATERIAL AND METHODS: ICR was performed in 18 children in 24 hemispheres (24 operations). The results were evaluated by Matsushima classification-based comparison of the data of preoperative and postoperative clinical examinations, TU of the superficial temporal artery, magnetic resonance imaging (MRI) and computed tomography (CT) of vessels, and selective cerebral angiography. RESULTS: After surgery, improvements in the neurological and neuropsychological status were assessed. Matsushima grade A collaterals were found in 12 (50%) cases, grade B collaterals were present in 3 (13%) cases, grade C collaterals were present in 7 (29%) cases, and grade D collaterals were detected in 1 (4%) case; in 1 (4%) case, the superficial temporal artery was not enhanced. MR angiography visualized 18 (75%) indirect anastomoses, CT angiography revealed 4 indirect anastomoses, and TU visualized 4 indirect anastomoses. Comparison of preoperative and postoperative TU data for the superficial temporal artery revealed significant changes in blood flow in the form of increased rate indices and a decreased resistance index; mean values of indices for each angiographic class of revascularization and significant differences in pre- and postoperative observations were calculated. CONCLUSION: Examination of ICR competence using CCA is necessary in the presence of persistent clinical signs of chronic cerebral circulatory insufficiency, absence of increased blood flow and decreased peripheral resistance in the superficial temporal artery, and lack of anastomosis according to MRA. The most optimal techniques for postoperative examination are MRA with perfusion and diffusion maps and TU.

[Extrapontine myelinolysis developed after aneurysmal subarachnoid hemorrhage (a case report and literature review)]. / Ekstrapontinnyi mielinoliz, razvivshiisya posle anevrizmaticheskogo subarakhnoidal'nogo krovoizliyaniya (sluchai iz praktiki i obzor literatury).

TOPICALITY: Central pontine and extrapontine myelinolysis is a rare and dangerous form of the demyelinating process of undefined origin, the development of which is associated with a very low sodium level in the blood (hypernatremia). OBJECTIVE: To describe a rare case of extrapontine myelinolysis as a complication occurring in the hemorrhagic period of anterior communicating artery aneurysm rupture as well as to demonstrate that this condition can be diagnosed intravitally. CONCLUSION: Clinical vigilance of extrapontine myelinolysis may promote the timely diagnosis and treatment of this disease, which is a potential cause of death. Pulse-therapy with glucocorticoids provides the opportunity to achieve regression of neurological symptoms and to stabilize the patient's condition.