[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.

[Surgical treatment of chronic cerebral circulatory insufficiency due to traumatic carotid-jugular anastomosis]. / Khirurgicheskoe lechenie khronicheskoi nedostatochnosti mozgovogo krovoobrashcheniia, obuslovlennoi travmaticheskim karotidno-iuguliarnym soust'em.

The paper describes a clinical case of traumatic right carotid-jugular anastomosis, a rare abnormality of the great arteries in the neck. It presents data on its clinical and instrumental diagnosis, a procedure for a direct surgical intervention repairing the common carotid artery and the right internal jugular vein, which has yielded a good clinical result.

[Experience with endovascular occlusion of cerebrovascular aneurysms by means of microspirals]. / Opyt éndovaskuliarnoi okkliuzii arterial'nykh anevrizm sosudov golovnogo mozga s pomoshch'iu mikrospiralei.

The paper summarizes the outcomes of endovascular treatment of 42 patients (19 males and 23 females) aged 24 to 68 years who had cerebrovascular aneurysms, 7 of them were operated on in the acute phase of subarachnoidal hemorrhage. There were small [n = 27 (61.4%)], large [n = 14 (31.8%)], and giant [n = 3 (6.8%)] aneurysms. According to their site, aneurysms were found in the internal carotid [n = 22 (50%)], the middle cerebral artery [n = 2 (4.5%)], the anterior cerebral artery-anterior communicating artery [n = 10 (22.7%)], the basilar artery [n = 9 (20.5%)], and the vertebral artery [n = 1 (2.3%)]. MDS tungsten and platinum miscospirals (Balt, France) were employed for aneurysmal occlusion. Twenty seven (61.4%) aneurysms were totally and subtotally closed by means of microspirals. Partial occlusion of the aneurysmal cavity was achieved in 12 (27.2%) cases. There were poor results associated with spiral migration into the carrying vessel in 5 patients: an increase in aneurysmal volumes occurred in 3 patients and in 2 patients with partially occluded giant aneurysms within up to a year. Three patients died. Angiographical control was exercised in 12 patients at months 6 to 18. The analysis of long-term results indicated that the aneurysms initially totally closed failed to be recanalized later on (8 patients). With subtotal or partial occlusion, there was a change in the position of spiral coils in the aneurysmal cavity, namely, their displacement to the bottom and an increase in the dimension of a functioning aneurysmal part (2 patients). The use of microspirals for occlusion of cerebrovascular aneurysms is a low-traumatic and effective treatment. The best results were obtained with the occlusion of small and large aneurysms with their well-defined neck.

[Main anastomoses of external carotid artery branches with the beds of the internal carotid and the vertebral artery and a role of pharmacological tests in the determination of their functional value at tumor embolization]. / Osnovnye anastomozy vetvei naruzhnoi sonnoi arterii s basseinami vnutrennei sonnoi i pozvonochnoi arterii i rol' testiruiushchikh farmakologicheskikh prob v opredelenii ikh funktsional'nogo znacheniia pri émbolizatsii opukholei.

In 21 patients with meningovascular tumors (meningiomas, angiofibromas, etc.), 53 vessels were tested during preoperative embolization of extracranial tumors. Two groups of drugs were superselectively intraarterially administered in turn--first barbiturates, such as thiopental sodium, 15-20 mg in 2 ml of sodium chloride solution, to detect anastomoses with cerebral vessels, then local anesthetics (lidocaine, 10-20 mg in 2 ml of sodium chloride solution, to reveal the vessels feeding cranial nerves. If drug tests were negative, the afferent was embolized with under 300 microns particles. If they were positive this was done with only large particles (above 300 microns). Injection of thiopental sodium into the occipital artery provided a positive result in 1 (1.8%) of the 53 cases. There were no complications after negative tests, followed by embolization. Drug provocative tests during embolization of the vessels feeding extra- and intracranial tumors make it possible to reduce the risk for persistent ischemic events associated with the entry of artificial emboli into the cerebral vessels and vasa nervorum and to conduct the optimum embolization of afferents.

[X-ray contrast filler for balloons at endovascular surgery (20 years of experience with original balloon filler)]. / Rentgenokontrastnyi napolnitel' dlia ballonov pri éndovaskuliarnykh operatsiiakh (20-letnii opyt primeneniia original'nogo napolnitelia ballonov).

In 1984, the authors designed a X-ray contrast balloon filler polyacryl amide gel (PAAG) that has a polymerization rate of 1-3 min. PAAG has been used to fill over 5000 balloons for nearly 20 years. With this filler, recurrent anastomoses reduced by 1.5 times as compared to previously used silicone. PAAG is a reliable and easy-to-use balloon filler. Its use as a balloon filler has been permitted by the USSR Ministry of Health.

[Anastomoses between the meningeal arteries and the cavernous sinus: the clinical picture, diagnosis and treatment]. / Soust'ia mezhdu meningeal'nymi arteriiami i kavernoznym sinusom: klinika, diagnostika, lechenie.

The findings of 106 patients with arteriosinus anastomoses formed by the meningeal arteries and cavernous sinus were analyzed. The clinical symptoms, the specific features of the course of this abnormality and the principle of its diagnosis are summarized. Based on angiographic data, 4 types of anastomoses were identified by X-ray and anatomic signs: 1) the anastomoses formed by the meningeal branches of the internal carotid and cavernous sinus (45.4%); 2) those formed by the branches of the external carotid and cavernous sinus (9.3%); 3) the branches of both the internal and external carotids are involved in anastomotic blood supply (38.1%); 4) a combination of carotid-cavernous and arteriosinus anastomoses (7.2%). According to the sources of blood supply, the patients received endovascular treatment (external carotid branch embolization, fistula balloon occlusion), radiation surgery or combined treatment. The differential approach to treating patients with arteriosinus anastomoses at the site of the cavernous sinus yielded good results in 78.9% of cases.

Management of giant intracranial ICA aneurysms with combined extracranial-intracranial anastomosis and endovascular occlusion.

Nine patients with giant internal carotid artery (ICA) aneurysms (greater than 2.5 cm in diameter) were subjected to a combined extracranial-intracranial (EC-IC) bypass procedure and endovascular ICA occlusion during 1987 and 1988. The procedures were performed under one anesthetic. In all cases the collateral circulation had been judged insufficient on the basis of a strict preoperative testing protocol including: cerebral panangiography, electroencephalography, somatosensory potential recording, and cerebral blood flow monitoring during manual compression of the ICA in the neck. There were four intracavernous ICA aneurysms, four carotid-ophthalmic artery aneurysms, and one supraclinoid ICA aneurysm. All patients showed symptoms and signs of compression of the surrounding nervous structures. In the five cases of intradural lesions, the artery was occluded at the level of the aneurysm neck, so the ophthalmic artery had to be occluded. There was, nevertheless, no case of worsening of vision following surgery, and all nine patients showed significant improvement following the combined procedure. A combined EC-IC bypass procedure and endovascular ICA occlusion allows for immediate verification of the surgical results and appears to be a worthwhile method for treating giant intracranial aneurysms.

[Electroencephalography in aneurysms of the internal carotid artery during endovascular operations]. / Elektroéntsefalografiia pri anevrizmakh vnutrennei sonnoi arterii vo vremia éndovaskuliarnykh operatsii.

The authors studied the functional condition of the brain in patients with arterial aneurysms of the internal carotid artery in different stages of treatment by the endovascular method with the use of a balloon catheter. From experience in 122 cases it is shown that complex neurological and electrophysiological examination must be conducted before, during, and after the operation. It is established that EEG allows changes of brain activity to be revealed earlier than the neurological signs of circulatory deficit occur. They are detected for a longer period also during the restoration of cerebral functions. In view of this, EEG helps in appraising the state of cerebral collateral circulation (Matas' test, functional occlusion of the vessel during the operation), choice of the policy of the endovascular intervention, and prognosis of possible complications.

[Proton therapy in clinical neurosurgery]. / Protonnaia terapiia v neirokhirurgicheskoi klinike.

The use of proton beam irradiation in neurosurgical clinical practice helps to find a solution to the problem of the treatment of inoperable malformations employing this method in some cases as an alternative to surgical intervention. Hypophyseal tumors, tumors of the cavernous sinus, arteriosinusal anastomoses in the cavernous sinus area, and arteriovenous malformations are irradiated at the N. N. Burdenko Institute of Neurosurgery, USSR, AMS using the medical proton beam of the Institute of Theoretical and Experimental Physics. Methods of "piercing" irradiation and methods with the use of Bragg's peak are being developed. At present over 200 patients with hormonally active hypophyseal tumors, 30 patients with tumors of the cavernous sinus, 23 patients with deep seated arteriovenous malformations, and 10 patients with spontaneous arteriosinusal anastomoses in the cavernous sinus area have been irradiated. This method seems to hold promise in neurosurgical practice. Extension of the range of clinical applications of proton beam therapy in neurosurgery requires the development of various techniques of irradiation, all possible approaches to various targets on the basis of contemporary methods of computerized diagnosis, topometry and irradiation design.

[Proton irradiation of spontaneous arterio-sinus anastomoses in the cavernous sinus region]. / Protonnoe obluchenie spontannykh arteriosinusnykh soustii oblasti kavernoznogo sinusa.

Altogether 10 patients with spontaneous arteriosinusal anastomoses in the cavernous sinus area have been irradiated at the N. N. Burdenko Institute of Neurosurgery, USSR AMS. since 1983 using the synchrotron of the Institute of Theoretical and Experimental Physics. A "piercing" method with a proton beam of 12 mm in diameter (in one case 10 mm) was employed. Nine patients had unilateral anastomoses with the blood supply from branches of the internal and/or external carotid arteries, and one patient had a bilateral anastomosis. Irradiation was given in 2 fractions, in 2-3 days, the maximum total dose was 50-60 Gy. Regression of ophthalmological symptoms was noted 2-3 months after irradiation. Convalescence was noted in 8 patients, a follow-up period in 2 patients was insufficient. Of 7 patients examined by angiography complete thrombosis of the anastomosis was noted in 4, considerable reduction of the blood flow was noted in 3.

[Superselective catheterization of cerebral vessels]. / Superselektivnaia kateterizatsiia mozgovykh sosudov.

Superselective catheterization of 213 cerebral vessels in 84 patients with arteriovenous malformations (AVM) of the brain was conducted by means of different designs of balloon catheters and catheters without balloons. The authors performed superselective contrast study of 48 vessels of the 2nd order, 120 vessels of the 3rd order, and 45 vessels of the 4th order. Catheters were introduced into 35 branches of the anterior cerebral artery, 124 branches of the middle cerebral artery, anterior villous artery, catheters, twin-lumen balloon catheters and balloons with two catheters, balloon catheters with an opening in the head end of the balloon or those in which the balloon was made airtight temporarily, and catheters without balloons were tested. The authors prefer catheters with an open balloon and those without balloons for superselective catheterization of afferent vessels of AVM and for subsequent intravascular thrombosis.

[Embolization of branches of the external carotid artery in nosebleeds complicating Rendu-Osler-Weber disease]. / Embolizatsiia vetvei naruzhnoi sonnoi arterii pri nosovykh krovotecheniiakh, obuslovlennykh bolezn'iu Randiu--Oslera--Vebera.

Eleven cases with severe nasal hemorrhage caused by diseases of the vascular system (Rendu-Osler-Weber disease) are analysed. The results of angiography in patients with this pathological condition and the angiographic picture of changes in the branches of the maxillary artery which caused bleeding are described. The emergency therapeutic measures in severe epistaxis and the methods of surgical treatment are discussed. Twenty-five endovascular operations were performed. The authors demonstrated the possibility of superselective catheterization of the external carotid artery branches with subsequent embolization in arresting severe bleeding from the nose in hemorrhagic angiomatosis.

[Reorganization of cerebral hemodynamics after occlusion of the afferent vessels of arteriovenous aneurysms]. / Perestroika mozgovoi gemodinamiki posle okkliuzii afferentnykh sosudov arteriovenoznykh anevrizm.

The character of blood supply to the affected cerebral hemisphere was studied on the basis of angiography performed before and after occlusion of the afferent vessels of large arteriovenous aneurysms in 90 patients and study of cerebral circulation on a gamma chamber in 30 patients. It was established that the affected cerebral hemisphere is supplied with blood from the vascular basin of the same side. The importance of the regional blood flow is determined by the localization and the sources of blood supply to the aneurysm. Before the operation, the maximum decrease of regional blood flow was found in zones with contiguous blood supply, namely in the parietal and parieto-temporal areas. The occlusion of afferent vessels of the aneurysm leads to an increase in the flow of blood aneurysm is supplied with blood from the cortical arterio-arterial anastomoses in the zones of contiguous blood supply.

[Use of balloon catheters in cases of traumatic pseudoaneurysm of the carotid artery complicated by profuse nosebleed]. / Primenenie ballona-katekera v sluchaiakh travmaticheskikh lozhnykh anevrizm sonnoi arterii, soprovozhdaiushchikhsia profuznymi nosovymi krovotecheniiami.

The endovascular method of occlusion of the cerebral vessels with a balloon catheter was applied in 16 patients with false traumatic aneurysms of the carotid cavernous segment attended by profuse nasal bleedings. All the patients were admitted in a grave condition with marked posthemorrhagic anemia. Angiography and endovascular operations were conducted as emergency measures. Separable and inseparable balloon catheters were used. It was proved that in small false aneurysms it is possible to occlude the cavity of the aneurysm with the balloon preserving the blood flow in the carotid artery (2 patients). In giant aneurysms complete arrest of the blood flow was only possible in occlusion of the ruptured area together with the carotid artery (14 patients). In all patients the aneurysms were completely occluded and the hazard of hemorrhages was eliminated. In 13 patients postoperative complications in the form of embolisms of the cerebral vessels caused permanent disorders of cerebral circulation and disability of the patients. The authors believe endovascular occlusion of rupture of the internal carotid artery with a balloon to be the most adequate operation in this emergency disease.

[Neuropsychological approach to detecting the anterior, middle and posterior cerebral artery "steal" syndromes]. / Neiropsikhologicheskii podkhod k vyiavleniiu sindromov "abkradyvaniia" perednei, srednei i zadnei mozgovykh arterii.

Neuropsychological symptoms of "robbing" the anterior, median, and posterior cerebral arteries due to the ischemia caused within their basins by arteriovenous aneurisms were studied. The disappearance of the "robbing" symptoms after occluding the influx vessels of the aneurism by a separable balloon-catheter (62 observations), or after radical excision of the arteriovenous aneurism (81 observations) was taken for the control. The dynamics of the "robbing" symptoms in the process of the endovascular operations was followed. The importance of the "robbing" and the local symptoms associated with the localization of the vascular conglomerate for the clinic of arteriovenous aneurisms is demonstrated. A high sensitivity of the neuropsychological tests to changes of the cerebral hemodynamics is noted.