Caracterización de la morbilidad de la endarterectomía carotídea / Characterization of the morbidity of carotid endarterectomy

Introducción: El 80 por ciento de los accidentes cerebrovasculares resulta de tipo isquémico y al menos el 20-30 por ciento está provocado por estenosis de la arteria carótida extracraneal. La endarterectomía carotídea tiene como principal objetivo eliminar las placas de ateroma, que son fuentes de émbolos para el encéfalo, y mejorar el flujo sanguíneo a este órgano. Objetivo: Caracterizar la morbilidad de la endarterectomía carotídea en el Hospital General Docente "Enrique Cabrera" desde 2018 hasta 2021. Métodos: Se realizó un estudio de tipo descriptivo y corte transversal a 32 pacientes, a los cuales se les realizó endarterectomía carotídea. La recolección de los datos se efectuó mediante la revisión de historias clínicas. El período de estudio abarcó desde enero de 2018 hasta enero de 2021. Resultados: Predominó el sexo masculino (65,6 por ciento) y la media de edad fue de 68,8 años. Los factores de riesgo más frecuentes resultaron la hipertensión arterial y el tabaquismo con 75 por ciento y 65,6 por ciento, respectivamente. La enfermedad cerebrovascular con secuela mínima constituyó la forma clínica más frecuente en el 40,6 por ciento de los casos. Se encontró asociación estadísticamente significativa entre diabetes mellitus y formas clínicas, y entre enfermedad arterial periférica y la aparición de complicaciones. La carótida izquierda resultó la más afectada con 53 por ciento y el porcentaje de estenosis, entre 70 por ciento y 99 por ciento, se encontró en el 55,9 por ciento de los pacientes. Con mayor frecuencia se presentaron las complicaciones: lesión de nervios craneales (5,8 por ciento) y hematoma cervical (5,8 por ciento). La endarterectomía por eversión se realizó en el 97 por ciento de los casos. Conclusiones: Se demostró la seguridad y el éxito de la endarterectomía carotídea. La mayoría de los pacientes tuvo una evolución satisfactoria, y se presentaron escasas complicaciones y mortalidad nula(AU)

Introduction: 80 percent of strokes result in ischemic type and at least 20-30 percent are caused by stenosis of the extracranial carotid artery. Carotid endarterectomy has as its main objective to remove atheromatous plaques, which are sources of emboli for the brain, and improve blood flow to this organ. Objective: To characterize the morbidity of carotid endarterectomy at the "Enrique Cabrera" General Teaching Hospital from 2018 to 2021. Methods: A descriptive, cross-sectional study was conducted in 32 patients, who underwent carotid endarterectomy. Data collection was carried out by reviewing medical records. The study period spanned from January 2018 to January 2021. Results: The male sex predominated (65.6 percent) and the mean age was 68.8 years. The most frequent risk factors were high blood pressure and smoking with 75 percent and 65.6 percent, respectively. Cerebrovascular disease with minimal sequelae was the most frequent clinical form in 40.6 percent of cases. A statistically significant association was found between diabetes mellitus and clinical forms, and between peripheral arterial disease and the occurrence of complications. The left carotid was the most affected with 53 percent and the percentage of stenosis, between 70 percent and 99 percent, was found in 55.9 percent of patients. The following complications were the most common: cranial nerve injury (5.8 percent) and cervical hematoma (5.8 percent). Eversion endarterectomy was performed in 97 percent of cases. Conclusions: The safety and success of carotid endarterectomy were demonstrated. Most of the patients had a satisfactory evolution, and there were few complications and zero mortality(AU)

Malformación arteriovenosa epicraneal compleja (aneurisma cirsoideo). Presentación de un caso y revisión de la literatura

RESUMEN Las malformaciones arteriovenosas extracraneales son raras lesiones vasculares que consisten en comunicaciones fistulosas anormales, asociadas a venas de drenajes dilatadas, que crecen a través del tiempo, con tendencia a hemorragias masivas y lesiones de la piel. Se presenta el caso de un paciente masculino de 19 años de edad con diagnóstico de malformación arteriovenosa extracraneal consistente en un aneurisma cirsoideo de gran tamaño y alto flujo que afectaba cuero cabelludo, cara y cuello. El mismo fue seguido por el servicio de Neurocirugía del Hospital "Carlos Manuel de Céspedes" de Bayamo desde el año 2015, evidenciándose crecimiento progresivo de la misma y aumento de tamaño, ocasionando ulceración de la piel suprayacente y hemorragias de gran magnitud por lo que en un primer momento y como medida emergente para salvar la vida se le realizó ligadura de la arteria carótida común izquierda, luego de esto se comprobó disminución de las dimensiones y el flujo intranidal, no obstante persistieron las hemorragias, programándose entonces la excéresis total macroscópica de la lesión, proceder que fue exitoso. Seguidamente, fue sometido a tratamiento reconstructivo por parte de Caumatología con injerto autólogo de piel del muslo sin complicaciones. Actualmente a dos años de estos tratamientos no se evidencian recurrencias.

ABSTRACT Extracranial arteriovenous malformations are rare vascular lesions consisting of abnormal fistulous communications, associated with dilated drainage veins, which grow over time, with a tendency to massive bleeding and skin lesions. We present the case of a 19-year-old male patient diagnosed with an extracranial arteriovenous malformation consisting of a large, high-flow cirsoidal aneurysm that affected the scalp, face, and neck. The same was followed by the Neurosurgery service of the "Carlos Manuel de Céspedes" Hospital in Bayamo since 2015, showing progressive growth of the same and increase in size, causing ulceration of the overlying skin and hemorrhages of great magnitude so that in Initially, as an emergency measure to save life, ligation of the left common carotid artery was performed. After this, a decrease in dimensions and intranidal flow was verified. However, the hemorrhages persisted. Total macroscopic excision of the artery was scheduled. injury, proceed that was successful. Subsequently, he underwent reconstructive treatment by Caumatology with an autologous thigh skin graft without complications. Currently, two years after these treatments, there are no evidence of recurrences.

RESUMO As malformações arteriovenosas extracranianas são lesões vasculares raras que consistem em comunicações fistulosas anormais, associadas a veias de drenagem dilatadas, que crescem ao longo do tempo, com tendência a sangramentos maciços e lesões cutâneas. Apresentamos o caso de um paciente do sexo masculino de 19 anos com diagnóstico de malformação arteriovenosa extracraniana constituída por um grande aneurisma cirsoidal de alto fluxo que acometeu couro cabeludo, face e pescoço. O mesmo foi acompanhado pelo serviço de Neurocirurgia do Hospital "Carlos Manuel de Céspedes" em Bayamo desde 2015, apresentando crescimento progressivo do mesmo e aumento de tamanho, causando ulceração da pele sobrejacente e hemorragias de grande magnitude de modo que em Inicialmente, como como medida de emergência para salvar a vida, foi realizada ligadura da artéria carótida comum esquerda. Após isso, verificou-se diminuição das dimensões e fluxo intranidal. No entanto, as hemorragias persistiram. Foi programada a excisão macroscópica total da artéria. lesão, procedimento que foibem sucedido. Posteriormente, foi submetido a tratamento reconstrutivo por Caumatologia com enxerto autólogo de pele na coxa sem intercorrências. Atualmente, dois anos após esses tratamentos, não há evidências de recorrências.

Clinical efficacy and prognosis of 85 patients with extracranial metastatic breast cancer receiving radiotherapy / 中华放射肿瘤学杂志

Objective:To evaluate the clinical efficacy of radiotherapy in the treatment of extracranial metastatic breast cancer, and to investigate the significance and prognostic factors of whole-lesion radiotherapy (WLRT).Methods:Clinical data of 85 patients with extracranial metastatic breast cancer treated with radiotherapy between 2014 and 2019 were retrospectively analyzed. Thirty-six patients were assigned into the WLRT group and 49 in the non-WLRT group. The local control (LC), progression-free survival (PFS) and overall survival (OS) were calculated by Kaplan- Meier method, log-rank test and univariate prognostic analysis. Cox proportional hazards model was used for multivariate prognostic analysis. Results:The median follow-up time was 26.7 months. The 2-year LC, PFS, OS rates were 77%, 26%, 77%, respectively. The 2-year LC (91% vs. 67%, P=0.001), PFS (47% vs. 8%, P<0.001), OS rates (84% vs. 71%, P=0.010) in the WLRT group were significantly higher than those in the non-WLRT group, respectively. Multivariate analysis demonstrated that WLRT was an independent favorable prognostic factor for the LC, PFS and OS. Furthermore, bone metastasis alone was associated with improved LC and positive hormone receptor status was correlated with improved OS. Conclusions:WLRT has the potential to prolong the survival of patients with extracranial metastatic breast cancer. The patients with bone metastases alone obtain better LC, whereas those with negative hormone receptor status has worse OS.

Current perspectives and future directions of the treatment for non acute intracranial artery occlusion / 中国综合临床

Non-acute intracranial artery total occlusion can lead to severe neurological defect and high recurrence rate of stroke.At present, there is no effective treatment recommended by the guidelines.Traditional treatment methods include medical therapy, extracranial-intracranial bypass surgery and minimally invasive endovascular recanalization therapy.In recent years, with the development of microsurgical vascular anastomosis technique and neurosurgical intervention, and the development of interventional materials, the treatment of non-acute intracranial artery total occlusion has become a hot spots.In this paper, the concept of non on-acute intracranial artery total occlusion, medical therapy, extracranial-intracranial bypass surgery and endovascular interventional therapy are reviewed.

Morphological changes in the midface of Beagle dogs treated by trans-sutural distraction / Cambios morfológicos en la cara media de perros Beagle tratados por distracción trans-sutural

Trans-sutural distraction is a biological process that induces the formation of new bone and changes the position of bone by pulling on growing suture under the action of external forces. Currently, therapy to midfacial hypoplasia treated by trans-sutural distraction has been applied. In this study, Beagle dogs were selected as experimental animals, and a traction device designed by ourselves was applied to Beagle dogs to simulate the treatment process of trans-sutural distraction in human face, so as to provide a basis for the subsequent research on the related mechanism of trans-sutural distraction. The objective is that the animal model can provide the basis for the follow-up study of transsutural distraction. 45 month beagle dogs were randomly divided into two groups 3 in experiment group and 3 in control group. Implant nails were implanted as the bone marker in the bilateral zygomatic temporal suture, zygomandibular maxillary suture and palatine transverse suture in experimental group. The traction of the maxilla was carried out by the external cranial traction frame with canine fossa as bearing point, 800g force each side, elastic traction for 15 days. The control group only implanted the implant nail as the bone marker on both sides of the bone suture. The distance between two implant nails was measured by vernier calipers and X-ray examination, compared with preoperative and postoperative changes. X-ray and cephalometric measurements were used to measure change in the cranial basal angle. HE staining was used to observe the width of the bone seams, the morphology and structure of the cells and the tissue of the new bone under the phase contrast microscope. Then descriptive statistical analysis and t-test between two independent samples are carried out for the measurement data. The experimental group had a good retention of the beagle traction frame. In the experimental group, the maxillaries of dogs were protrudent in the process of traction gradually and the occlusal relationship changed to type II malocclusion. When the traction is 15 days, the coverage distance is about 8~9 mm. Before and after the traction, the distance between landmark points indicated that the spacing between the transverse palatine suture was the largest (experimental group: 5.52±0.19 mm control group 1.31±0.06 mm P<0.05), and zygomaticotemporal suture was the second (experimental group: 3.12±0.15 mm, control group 0.73±0.04 mm, P<0.05), and zygomaticomaxillary suture was less (experimental group: 2.60±0.34 mm, control group 0.53±0.05 mm, P<0.05). The cranial basal angle was no change before and after operation (controlgroup: 32.3±1.3°, experimental group: 33.2±1.1° P>0.05. Histology showed that the collagenous fibers in the suture of the control group were denser and the osteoblasts were visible on the edge of the suture, showing osteogenic activity. The experimental group significantly widened suture (experimental group: 1209.388±42.714 µm, control group 248.276±22.864 µm, P<0.05), the number of fibroblasts increased significantly with loose collagen fiber. The direction of cell and fiber arrangement were parallel to the traction force. There were many small blood vessels and marrow cavities, and the bone trabecula around the bone suture was thin (experimental group: 23.684±3.774 mm, control group: 86.810±9.219 mm, P < 0.05), showing active osteogenic activity. The growing beagle dog can be used to establish a suture traction animal model for experimental study. In the experiment, Kirschner wire was used to penetrate the bottom plane of the piriform hole of the maxilla (about the position of the canine fossa at the back) and the traction direction was basically the same as the growth direction, and the maxilla was basically parallel and moved forward.

La distracción trans-sutural es un proceso biológico que induce la formación de hueso nuevo y cambia la posición del éste al tirar de la sutura en crecimiento bajo la acción de fuerzas externas. Actualmente, se ha aplicado la terapia para la hipoplasia de la cara media tratada por distracción trans-sutural. En este estudio, fueron seleccionados perros Beagle como animales experimentales, y un dispositivo de tracción fue instalado a los perros para simular el proceso de tratamiento de la distracción trans-sutural en el rostro humano. El objetivo fue proporcionar una base para la investigación posterior sobre mecanismos relacionados con la distracción trans-sutural. El modelo animal puede proporcionar la base para este tipo de estudio de seguimiento de la distracción trans-sutural. Perros Beagle de 45 meses de edad se dividieron aleatoriamente en dos grupos: 3 en el grupo experimental y 3 en el grupo control. Los clavos de implante se usaron como marcadores óseos en la sutura temporal cigomática bilateral, la sutura maxilar cigomandibular y en la sutura transversal palatina en el grupo experimental. La tracción del maxilar se realizó mediante el marco de tracción craneal externo con fosa canina como punto de apoyo, 800 g de fuerza a cada lado, tracción elástica durante 15 días. En el grupo control solo se implantó el clavo del implante como marcador óseo en ambos lados de la sutura. La distancia entre dos clavos de implante se midió mediante calibradores de vernier y examen de rayos X, en comparación con los cambios preoperatorios y postoperatorios. Se utilizaron mediciones cefalométricas y de rayos X para medir el cambio en el ángulo basal craneal. La tinción con HE se usó para observar el ancho de las suturas óseas, la morfología y la estructura de las células y el tejido del hueso nuevo bajo el microscopio de contraste de fase. Luego se realizó un análisis estadístico descriptivo y una prueba t entre dos muestras independientes para los datos de medición. El grupo experimental tuvo una buena retención del cuadro de tracción del Beagle. En el grupo experimental, los maxilares de los perros sobresalieron gradualmente en el proceso de tracción y la relación oclusal cambió a maloclusión tipo II. Cuando la tracción era de 15 días, la distancia de cobertura fue de aproximadamente 8 ~ 9 mm. Antes y después de la tracción, la distancia entre los puntos de referencia indicaba que el espacio entre la sutura palatina transversal era más grande (grupo experimental: 5,52 ± 0,19 mm, grupo de control 1,31 ± 0,06 mm, P <0,05), y la sutura cigomáticotemporal fue la segunda. (Grupo experimental: 3,12 ± 0,15 mm, grupo control 0,73 ± 0,04 mm, P <0,05), y la sutura cigomaticomaxilar fue menor (grupo experimental, 2,60 ± 0,34 mm, grupo control 0,53 ± 0,05 mm, P <0,05). El ángulo basal craneal no cambió antes ni después de la operación (grupo control 32,3 ± 1,3, grupo experimental, 33,2 ± 1,1 ° , P> 0,05). La histología mostró que las fibras colágenas en la sutura del grupo control eran más densas y los osteoblastos se observaron en el margen de la sutura, mostrando actividad osteogénica. En el grupo experimental se amplió significativamente la sutura (1209,388 ± 42,714 µm, grupo control 248,276 ± 22,864 µm, P <0,05), el número de fibroblastos aumentó significativamente con fibras colágenas dispersas. La dirección de la disposición de la celda y las fibras era paralela a la fuerza de tracción. Se observó gran cantidad de vasos sanguíneos pequeños, cavidades medulares, y trabéculas óseas alrededor de la sutura ósea (grupo experimental: 23,684 ± 3,774 mm, grupo control: 86,810 ± 9,219 mm, P <0,05), que mostró actividad osteogénica activa. El perro Beagle en crecimiento se puede utilizar para estudios experimentales y así establecer un modelo animal de tracción de sutura. En el proceso, se usó alambre de Kirschner para penetrar en el plano inferior del foramen piriforme del maxilar (aproximadamente en la posición de la fosa canina en la parte posterior) y la dirección de tracción fue básicamente la misma que en el crecimiento.

Efectividad y durabilidad de la endarterectomía carotidea a largo plazo / Effectiveness and durability of long-term carotid endarterectomy

Introducción: Los accidentes cerebrovasculares constituyen un problema de salud mundial con tendencia creciente; en la actualidad es la tercera causa de muerte. Objetivo: Describir la efectividad y durabilidad de la endarterectomía carotidea a largo plazo en la enfermedad carotidea extracraneal. Métodos: Se realizó un estudio descriptivo, ambispectivo en 44 pacientes sometidos a un total de 52 endarterectomías carotideas realizadas en el servicio de Angiología y Cirugía Vascular del Hospital Docente Clínico Quirúrgico Hermanos Ameijeiras. A todos se les realizó un seguimiento clínico con ultrasonografía doppler. El período de tiempo analizado fue de ocho años. Se tuvo en cuenta las variables: sexo, edad, factores de riesgo asociados, categoría clínica, localización topográfica de las lesiones, complicaciones tardías, tiempo de permeabilidad y resultados posquirúrgicos. Resultados: Predominó el sexo masculino (68,2 por ciento). Las lesiones carotideas asintomáticas y sintomáticas representaron el 50 por ciento respectivamente. El hábito de fumar y la dislipidemia fueron los factores de riesgo más frecuentes. Hubo predominio de las complicaciones tardías (55,8 por ciento) con relevancia de la restenosis carotidea (n= 21). El tiempo promedio de permeabilidad primaria del sector revascularizado fue de cinco años. El 86,5 por ciento de los pacientes seguidos a largo plazo mostraron resultados posquirúrgicos satisfactorios al no presentar eventos neurológicos isquémicos o lesiones carotideas con repercusión hemodinámica. Conclusiones: La endarterectomía carotidea es un procedimiento seguro con baja morbilidad y mortalidad perioperatorias que garantiza una reducción significativa en las tasas de enfermedad cerebrovascular isquémica en el seguimiento a largo plazo con baja incidencia de complicaciones vasculares y neurológicas tardías(AU)

Introduction: Cardiovascular events constitute a global health problem with a growing tendency. Nowadays, they represent the third cause of death. Objective: To describe the effectiveness and durability of long-term carotid endarterectomy in the extracranial carotid disease. Methods: A descriptive, ambispective study was conducted in 44 patients subjected to 52 carotid endarterectomies that were performed in the service of Angiology and Vascular Surgery of Hermanos Ameijeiras Teaching-Clinical- Surgical Hospital. A clinical follow-up was performed with Doppler ultrasonography to all the patients. The period analyzed was eight years. The variables considered were: sex, age, associated risk factors, clinical category, topographical localization of the lesions, late complications, time of permeability and postsurgical results. Results: Male sex predominated (68,2 percent). Asymptomatic and symptomatic carotid lesions represented 50 percent respectively. The smoking habit and dyslipidemia were the most common risk factors. There was predominance of late complications (55,8 percent) being notable the carotid restenosis (n = 21). The average time of primary permeability of the revascularized sector was five years. 86,5 percent of the patients followed in the long term showed satisfactory postsurgical results by not presenting ischemic neurological events or carotid lesions with hemodynamic impact. Conclusions: Carotid endarterectomy is a safe procedure with low morbidity and peri-operative mortality that ensures a significant reduction in ischemic cerebrovascular disease´s rates in long-term follow-up with low incidence of late vascular and neurological complications(AU)

Clinicopathological analysis of extracranial head and neck schwannoma: A case series

Background: Extracranial head and neck schwannomas are rare tumors which are often clinically misdiagnosed. Preoperative diagnosis of these tumors is challenging but imperative for surgeons so as to avoid nerve damage during excision. Materials and Methods: Sixteen patients diagnosed with extracranial head and neck schwannomas over a period of 2 years were retrospectively analyzed. Clinical details including preoperative fine-needle aspiration cytology (FNAC) and/or computed tomography (CT)/magnetic resonance imaging (MRI) findings were retrieved. FNAC smears and formalin-fixed paraffin-embedded sections were evaluated. Results: Among these 16 tumors, 6 (37.5%) were located in the lateral aspect of neck, 4 (25%) in scalp, 2 (12.5%) in orbit, and one each (6.25%) in palate, tongue, submandibular gland and parotid gland. The mean patient age was 31.3 years. FNAC was performed in 14 cases, of which 8 cases (58.3%) showed features of benign nerve sheath tumor (BNST), two cases (14.2%) were inconclusive with possibility of mesenchymal lesion, two cases (14.2%) were inadequate, one case (8.3%) showed features suggestive of schwannoma, and a diagnosis of nerve sheath tumor inconclusive for malignancy was rendered in a single case. The sensitivity of FNAC in diagnosis of BNST was 71.4%. CT or MRI was performed in five cases, of which an accurate diagnosis was rendered only in one case of orbital schwannoma. Conclusion: Imaging has a limited role in the preoperative diagnosis of head and neck schwannomas owing to nonspecific radiological features. Cellular aspirate smears are helpful in accurate diagnosis even at unusual locations

Systemic dissemination of glioblastoma: literature review

SUMMARY INTRODUCTION: Glioblastoma (GBM) is the most frequent primary malignant tumor from the central nervous system in adults. However, the presence of systemic metastasis is an extremely rare event. The objective of this study was to review the literature, evaluating the possible biological mechanisms related to the occurrence of systemic metastasis in patients diagnosed with GBM. RESULTS: The mechanisms that may be related to GBM systemic dissemination are the blood-brain barrier breach, often seen in GBM cases, by the tumor itself or by surgical procedures, gaining access to blood and lymphatic vessels, associated with the acquisition of mesenchymal features of invasiveness, resistance to the immune mechanisms of defense and hostile environment through quiescence. CONCLUSIONS: Tumor cells must overcome many obstacles until the development of systemic metastasis. The physiologic mechanisms are not completely clear. Although not fully understood, the pathophysiological understanding of the mechanisms that may be associated with the systemic spread is salutary for a global understanding of the disease. In addition, this knowledge may be used as a basis for a therapy to be performed in patients diagnosed with GBM distant metastasis.

RESUMO INTRODUÇÃO: Glioblastoma (GBM) é o tumor maligno mais comum do sistema nervoso central em adultos. Entretanto, metástase a distância de GBM é um evento extremamente raro. O presente estudo teve o objetivo de realizar uma revisão da literatura para avaliar os possíveis mecanismos biológicos relacionados com a ocorrência de metástase a distância de pacientes com diagnóstico de GBM. RESULTADOS: Os mecanismos que podem estar relacionados com a capacidade de disseminação sistêmica do GBM são a quebra de barreira hematoencefálica (BHE) frequentemente vista em GBM, seja pela doença, seja por procedimentos cirúrgicos, dando acesso aos vasos sanguíneos e linfáticos, associada à aquisição de características mesenquimais de invasividade, resistência aos mecanismos de defesa do sistema imunológico e adaptação a hostilidades dos meios distantes por meio de quiescência. CONCLUSÕES: As células tumorais necessitam vencer diversos obstáculos até a formação de uma metástase distante. Apesar de não totalmente esclarecido, o entendimento fisiopatológico dos mecanismos pelos quais podem estar associados à disseminação sistêmica do GBM é salutar para a compreensão global da doença. Além disso, esse conhecimento pode servir de base para a terapia a ser empregada diante do paciente com diagnóstico de GBM com metástase a distância.

An anatomic study of superficial temporal artery to anterior cerebral artery bypass using ipsilateral parietal branch of superficial temporal artery as graft / 中华显微外科杂志

Objective Revascularization of the distal segment of the anterior cerebral artery (ACA) using extracranial donors requires long interposition grafts.A novel bypass procedure which uses the two main branches of the superficial temporal artery (STA) to reach the A3 segment of the anterior cerebral artery with a single skin incision was designed.Methods Ten cadaveric specimens were dissected through a single skin incision to harvest the frontal and parietal branches of the STA from June,2017 to September,2017.An anterior interhemispheric approach provided access to the middle internal frontal artery (MIFA).The parietal STA was used as an interposition graft between the frontal STA and MIFA.Lengths and calibers of the distal branches of STA and MIFA were measured at the anastomotic sites.All data was statistical analysis by t-test.Results The average caliber of MIFA was (1.4±0.2) mm,which matched the caliber of both frontal and parietal branches of STA.The mean distance for an end-to-side bypass from STA to MIFA was (144.5±7.4) mm and the average harvested donor-graft complex length was (203.1±27.9) mm.This bypass construct provided around 140％ donor graft length.Conclusion Using the parietal branch of the STA as an interposition graft enabled a successful tension-free STA-MIFA bypass.The advantages of this technique over existing approaches include sufficient graft length,caliber match and relative technical ease.

Correlation between the hemodynamic parameters of extracranial vertebral artery and the severity and location of intracranial vertebral artery stenosis / 中华超声影像学杂志

Objective To analyze the effects of the degree and location of intracranial vertebral artery (VA) lesions on the hemodynamic parameters of extracranial VA.Methods A total of 275 consecutive patients who were diagnosed as posterior circulation ischemic stroke or transient ischemic attack (TIA) with unilateral intracranial VA stenosis or occlusion in the Department of Neurology and Neurosurgery of Capital Medical University Xuanwu Hospital from January 2015 to December 2017 were enrolled.All patients were examined by head and neck vascular ultrasound,CT angiography (CTA) and/or digital subtraction angiography (DSA) within one week.According to the results of DSA or CTA,the patients were divided into mild stenosis group (53 patients),moderate stenosis group (62 patients),severe stenosis group (58patients) and occlusion group(102 patients).The inner diameter (D),peak systolic velocity (PSV),end diastolic velocity (EDV),and resistance index (RI) of the extracranial segment (V2 segment) of the VA were recorded and analyzed.Results The PSV and EDV in the severe stenosis group and the occlusion group were significantly lower than those in the mild stenosis group and the moderate stenosis group (P =0.000),and the PSV and EDV in the occlusion group were significantly lower than those in the severe stenosis group[(31 ± 10) cm/s vs (46 ± 12)cm/s,(5 ± 4)cm/s vs (15 ± 7)cm/s;all P =0.000],RI was significantly higher than the other three groups (0.85 ± 0.12,0.70 ± 0.10,0.66 ± 0.07,0.64 ± 0.06,respectively;all P =0.000);RI in the severe stenosis group were not significantly different from those in the mild to moderate stenosis groups (P =0.044,0.223).There were no significant differences in the inner diameter,PSV,EDV and RI between the subgroups in the severe stenosis group before or after the PICA (posterior inferior cerebellar artery) (P =0.130,0.322,0.865,0.227).However,the EDV decreased and RI increased in the occlusive subgroup before the PICA when compared the subgroup after the PICA (all P =0.000).Conclusions The location and degree of intracranial VA lesions directly affect the changes of blood flow velocity and vascular resistance of extracranial VA,and the changes of low-speed and high-resistance hemodynamics of extracranial VA may indicate the existence of occlusive lesions in intracranial VA.

Association between Serum Alkaline Phosphatase and Carotid Atherosclerosis in a Chinese Population: A Community-based Cross-sectional Study / 生物医学与环境科学（英文）

OBJECTIVE@#This study aimed to investigate the relationship between alkaline phosphatase (ALP) and common carotid intima media thickness (IMT), carotid plaque, and extracranial carotid artery stenosis (ECAS).@*METHODS@#A total of 3,237 participants aged ⪖ 40 years were recruited from Jidong community in 2013-2014. Participants were divided into five quintile groups based on their serum ALP levels. Carotid atherosclerosis was assessed using ultrasound. Abnormal IMT, carotid plaque, and ECAS were defined as IMT > 0.9 mm, IMT > 1.5 mm, and ⪖ 50% stenosis in at least one extracranial carotid artery, respectively.@*RESULTS@#Common carotid IMT values and the prevalence of carotid plaque increased across serum ALP quintiles. Higher ALP quintiles were correlated with an increased risk of abnormal IMT [fourth quintile: odds ratio (OR) 1.78, 95% confidence interval (CI) 1.13-2.82, P = 0.0135; fifth quintile: OR = 1.82, 95% CI: 1.15-2.87, P = 0.0110] and ECAS compared to the lowest quintile (fifth quintile: OR = 1.47, 95% CI: 1.09-1.97, P = 0.0106). The association between ALP and prevalence of carotid plaque became insignificant after adjustment for confounders.@*CONCLUSION@#Serum ALP levels were independently associated with abnormal common carotid IMT and ECAS. These conclusions need to be further corroborated in future prospective cohort studies.

Correlation between the hemodynamic parameters of extracranial vertebral artery and the severity and location of intracranial vertebral artery stenosis / 中华超声影像学杂志

Objective@#To analyze the effects of the degree and location of intracranial vertebral artery(VA) lesions on the hemodynamic parameters of extracranial VA.@*Methods@#A total of 275 consecutive patients who were diagnosed as posterior circulation ischemic stroke or transient ischemic attack (TIA) with unilateral intracranial VA stenosis or occlusion in the Department of Neurology and Neurosurgery of Capital Medical University Xuanwu Hospital from January 2015 to December 2017 were enrolled. All patients were examined by head and neck vascular ultrasound, CT angiography (CTA) and/or digital subtraction angiography (DSA) within one week. According to the results of DSA or CTA, the patients were divided into mild stenosis group(53 patients), moderate stenosis group(62 patients), severe stenosis group(58 patients) and occlusion group(102 patients). The inner diameter (D), peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) of the extracranial segment (V2 segment) of the VA were recorded and analyzed.@*Results@#The PSV and EDV in the severe stenosis group and the occlusion group were significantly lower than those in the mild stenosis group and the moderate stenosis group (P=0.000), and the PSV and EDV in the occlusion group were significantly lower than those in the severe stenosis group[ (31±10) cm/s vs (46±12)cm/s, (5±4)cm/s vs (15±7)cm/s; all P=0.000], RI was significantly higher than the other three groups (0.85±0.12, 0.70±0.10, 0.66±0.07, 0.64±0.06, respectively; all P=0.000); RI in the severe stenosis group were not significantly different from those in the mild to moderate stenosis groups (P=0.044, 0.223). There were no significant differences in the inner diameter, PSV, EDV and RI between the subgroups in the severe stenosis group before or after the PICA (posterior inferior cerebellar artery)(P=0.130, 0.322, 0.865, 0.227). However, the EDV decreased and RI increased in the occlusive subgroup before the PICA when compared the subgroup after the PICA (all P=0.000).@*Conclusions@#The location and degree of intracranial VA lesions directly affect the changes of blood flow velocity and vascular resistance of extracranial VA, and the changes of low-speed and high-resistance hemodynamics of extracranial VA may indicate the existence of occlusive lesions in intracranial VA.

Accidente cerebrovascular bulbar lateral con trayecto extracraneal de la arteria cerebelosa póstero-inferior / Lateral medullary stroke with extracranial course of the postero- inferior cerebellar artery

Presentamos dos casos de accidente cerebrovascular en sujetos con trayecto extracraneal de la arteria cerebeloso póstero-inferior. Caso 1: varón de 21 años, quien presentó ataxia y dismetría derecha luego de un traumatismo cervical en un partido de rugby. Caso 2: mujer de 56 años, quien inició con vértigo y hemiparesia izquierda luego de esfuerzo físico intenso. En ambos casos, los estudios angiográficos mostraron un trayecto extracraneal de la arteria cerebelosa póstero-inferior. Este vaso raramente se origina por debajo del foramen magno, en relación cercana con las primeras tres vértebras cervicales y la articulación atlanto-axial. En este nivel, está expuesta a daño mecánico causante de disección, como por ejemplo trauma directo, manipulación cervical abrupta o extensión cefálica prolongada. Por lo tanto, en pacientes con accidente cerebrovascular de región lateral de bulbo y trayecto extracraneal de la arteria cerebelosa póstero-inferior se debería considerar esta asociación.

We present two cases of lateral medullary stroke in subjects with extracranial trajectory of the postero-inferior cerebellar artery. Case 1: a 21-year-old male who presented ataxia and right dysmetria after cervical trauma in a rugby match. Case 2: 56-year-old woman, who started with vertigo and left hemiparesis after intense physical effort. In both cases, the angiographic studies showed an extracranial trajectory of the posterior inferior cerebellar artery. This vessel rarely originates below the foramen magnum, in close relationship with the first three cervical vertebrae and the atlanto-axial joint. At this level, it is exposed to mechanical damage causing dissection, such as direct trauma, abrupt cervical manipulation or prolonged cephalic extension. Therefore, this association should be considered in patients with stroke of the lateral region of the bulb and extracranial trajectory of the posterior-inferior cerebellar artery.

Anatomy and clinical importance of the extracranial clivus and surrounding structures / Anatomía e importancia clínica del clivus extracraneal y las estructuras circundantes

The aim of this study was to reveal the clinical importance of measurements taken from the pharyngeal tubercle (PT) to various anatomical structures around the extracranial clivus. Twenty-six adult dry Anatolian skulls were examined. The extracranial clivus and PT were used as landmarks from which various distances were measured using a digital caliper accurate to 0.01 mm. The following mean distances from the PT were observed; foramen lacerum (FL) (L: 17.15 mm, R: 17.4 mm) ; medial external margin of the carotid canal (CC) (L: 26.7 mm, R: 27.5 mm); anterior tip of occipital condyle (OC) (L: 16.4 mm, R: 16.3 mm); anterior margin of foramen magnum (FM) (10.8 mm); foramen ovale (FO) (L: 25.9 mm, R: 29.1); medial margin of the jugular fossa (JF) (L: 25.4 mm, R: 25.7 mm); medial external margin of the hypoglossal canal (HC) (L: 20.0 mm, R: 19.9 mm). Mean bilateral distances were: LFO-RFO: 45.34 mm; LFL-RFL: 20.1 mm; LCC-RCC: 52.1 mm; LOC-ROC: 17.6 mm; LJF-RJF: 45.2 mm; LHC-RHC: 33.5 mm. The following mean distances were observed from the FM: FM-OC (L: 8.3 mm, R: 9.3 mm); FM-HC (L: 17.8 mm, R: 17.4 mm). Also the mean distance of OC-HC were observed (L: 11.7 mm, R: 11.4 mm). Present measurements suggest that the PT can be used as an anatomical landmark during surgery involving clival pathology. However, the anatomy and variations of the extracranial clivus and surrounding structures must be taken into consideration.

El objetivo de este estudio fue revelar la importancia clínica de las mediciones tomadas desde el tubérculo faríngeo (TF) a diversas estructuras anatómicas alrededor del clivus extracraneal. Veintiséis cráneos, secos adultos, de Anatolia, fueron examinados. El clivus extracraneal y TF se utilizaron como puntos de referencia a partir de los cuales se midieron varias distancias con un calibrador digital con una precisión de 0,01 mm. Se observaron las siguientes distancias medias del TF: foramen lacerum (FL) (L: 17.15 mm, R: 17,4 mm); margen externo medial del canal carotídeo (CC) (L: 26,7 mm, R: 27,5 mm); parte anterior del cóndilo occipital (OC) (L: 16,4 mm, R: 16,3 mm); margen anterior del foramen magnum (FM) (10,8 mm); foramen oval (FO) (L: 25,9 mm, R: 29,1); margen medial de la fosa yugular (FY) (L: 25,4 mm, R: 25,7 mm); margen medial del canal hipogloso (CH) (L: 20,0 mm, R: 19,9 mm). Las distancias bilaterales medias fueron: LFO-RFO: 45,34 mm; LFLRFL: 20,1 mm; LCC-RCC: 52,1 mm; LOC-ROC: 17,6 mm; LJFRJF: 45,2 mm; LHC-RHC: 33,5 mm. Se observaron las siguientes distancias medias de la FM: FM-OC (L: 8,3 mm, R: 9,3 mm); FMCH (L: 17,8 mm, R: 17,4 mm). También se observó la distancia media de OC-CH (L: 11,7 mm, R: 11,4 mm). Las mediciones actuales sugieren que el TF puede ser utilizado como un hito anatómico durante la cirugía que involucra la patología clival. Sin embargo, se deben tener en cuenta la anatomía y las variaciones del clivus extracraneal y las estructuras circundantes.

Analysis of radiotherapy curative effect and prognostic factors in 164 patients with extracranial oligometastases / 中华放射肿瘤学杂志

Objective To investigate the efficacy of radiotherapy,as well as the prognostic factors of survival in patients with extracranial oligometastases. Methods A total of 164 patients who underwent intensity-modulated radiotherapy ( IMRT ) of the extracranial oligometastases, from January 2013 to December 2016, were enrolled in the study. The short-term efficacy, local control rate, overall survival, progression free survival and adverse effects of treatment were observed. Results Short-term efficacy was assessed within the first 1-3 months after the end of radiotherapy. The objective response rate (CR+PR) was 78. 7% and the short-term efficacy is mainly related to the T stage of primary tumor ( P＝0. 004).Until the last follow-up,all patients with 1-,2-and 3-year LC were 89. 8%,82. 5% and 74. 9% respectively.Univariate analysis showed that the influencing factors of LC include tumor size and gross tumor volume dose ( all P＜0. 05),multivariate analysis found no significant influence factors. The 1-,2- and 3-year OS were 83. 4%, 69. 6% and 54. 6% respectively. Univariate and multivariate analysis showed that the primary tumor sources, metastasis organs,whether synchronous or adjuvant chemotherapy and short-term efficacy were independent prognostic factors in patients of OS ( P＜0. 05 ).Main toxicity-associated events were grade 1-2 acute reactions,with only 6 patients experiencing grade 3 toxicity;no grade≥4 toxic reactions or treatment-related deaths occurred. Conclusions Radiation therapy for the treatment of extracranial oligometastases can achieve good curative effect,is well-tolerated and has low toxicity.

Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke / 대한뇌졸중학회지

Atherosclerosis is a major cause of ischemic stroke that can be effectively prevented with appropriate lifestyle modifications and control of cardiovascular risk factors. Medical advances in recent years along with aggressive cardiovascular risk factor modifications have resulted in decreased recurrence rates of atherosclerotic stroke. Non-statin lipid-lowering molecules have recently shown clinical benefit and are recommended for very high-risk patients to reduce their risk of stroke. Aggressive hypertension treatment is crucial to reduce atherosclerotic stroke risk. Advances in antithrombotic treatments include combinations of antiplatelets and new antiplatelet agents in the acute phase post-stroke, which carries a high risk of recurrence. Intensive medical treatment has also limited the indications for carotid interventions, especially for asymptomatic disease. Intracranial atherosclerotic disease may provoke stroke through various mechanisms; it is increasingly recognized as a cause of ischemic stroke with advanced imaging and is best managed with lifestyle modifications and medical therapy. The diagnostic search for the vulnerable culprit atherosclerotic plaque is an area of intense research, from the level of the intracranial arteries to that of the aortic arch. Ultrasonography and novel magnetic resonance imaging techniques (high-resolution vessel-wall imaging) may assist in the identification of vulnerable atherosclerotic plaques as the underlying cause in cryptogenic or misdiagnosed non-atherosclerotic ischemic stroke. Vertebrobasilar atherosclerotic disease is less common than carotid artery disease; thus, high-quality data on effective prevention strategies are scarcer. However, aggressive medical treatment is also the gold standard to reduce cerebrovascular disease located in posterior circulation.

Meningioma extradural de oído medio: reporte de un caso y revisión de la literatura / Extradural meningioma of middle ear: reporting a case and literature review

Los meningiomas son los tumores no gliales más comunes del sistema nervioso central constituyendo el 24%-30% de los tumores intracraneales y el 25% de los tumores de médula espinal. Se originan de células de la aracnoides y en general presentan un comportamiento benigno. Existe un subtipo llamado meningioma extracraneal primario o extradural que es poco frecuente y afecta principalmente el área de cabeza y cuello. Debido a su baja prevalencia y síntomas poco característicos son a menudo diagnosticados por fortuna, siendo la inmunohistoquímica fundamental. Se presenta el caso de una mujer adulta con una lesión tumoral en oído medio diagnosticada inicialmente mediante una biopsia incisional como un granuloma de colesterol. Luego del tratamiento quirúrgico y estudio de inmunohistoquímica se concluye el diagnóstico definitivo de meningioma extradural de oído medio. Se analiza la literatura al respecto y se discute sobre su epidemiología, clínica, estudio y manejo.

Meningiomas are the most common non-glial tumors of the central nervous system constituting 24-30% of intracranial tumors and 25% of spinal cord tumors. They originate from arachnoid cells and generally exhibit benign behavior. The subtype primary extracranial meningioma or extradural meningioma that is uncommon and affects the head and neck area. Due to their low prevalence and uncharacteristic symptoms are often diagnosed by fortune, being the immunohistochemistry fundamental. We present the case of an adult woman with a tumor lesion in the middle ear initially diagnosed by an incisional biopsy such as a cholesterol granuloma. After the surgical treatment and immunohistochemical study, the definitive diagnosis of extradural meningioma of the middle ear is concluded. The literature on this subject is analyzed and its epidemiology, clinical practice, study and management are discussed.

Caracterización de las variantes quirúrgicas realizadas en dos años a pacientes con enfermedad cerebrovascular extracraneal / Characterization of surgical varians performed in patients with extracranial cerebrovascular diseases in two years

Objetivo: Caracterizar las variantes quirúrgicas realizadas a los pacientes ingresados con enfermedad cerebrovascular extracraneal en un período de dos años. Métodos: Estudio descriptivo prospectivo en 27 pacientes, sin distinción de edad y sexo, operados por enfermedad cerebrovascular de origen extracraneal. Se tuvieron en cuenta los criterios de cirugía, además del estadio clínico, enfermedad cerebrovascular extracraneal que motivó la operación, localización de la lesión carotidea, variantes quirúrgicas realizadas, la permeabilidad de estas y las complicaciones poscirugía. Los pacientes fueron seguidos en consulta externa por dos años. Resultados: Se encontró que el 44,4 por ciento tuvo un ataque transitorio isquémico. Fueron más frecuentes las lesiones unilaterales (85,2 por ciento) y las de la carótida derecha (48,1 por ciento). Se halló una asociación significativa entre el sexo masculino con el estadio clínico y la localización de las lesiones carotideas. La endarterectomía por eversión fue la variante quirúrgica más realizada (44,4 por ciento). El 96,3 por ciento de las intervenciones se mantuvo permeable hasta los 18 meses poscirugía, mientras que tres pacientes presentaron reestenosis a los 24 meses. El 40,7 por ciento no desarrolló complicaciones, y entre estas el sangrado fue la de mayor frecuencia (33 por ciento). Conclusiones: Las variantes quirúrgicas realizadas se caracterizaron por altos porcentajes de permeabilidad durante el tiempo de estudio, con un mínimo de complicaciones posquirúrgicas(AU)

Objective: To characterize the surgical variants performed in hospitalized patients with extracranial cerebrovascular diseases in two years. Methods: Prospective and descriptive study of 27 patients, regardless of age and sex, who had been operated on from cerebrovascular disease of extracranial origin. Surgical criteria, clinical condition, extracranial cerebrovascular disease that required surgery, location of the carotid lesion, surgical variants, their permeability and the post-surgery complications were all taken into account. The patients were followed-up in the outpatient service during two years. Results: It was found that 44.4 percent of patients had had a transient ischemic attack. Unilateral lesions (85.2 percent) and right carotid lesions (48.1 percent) were the most common. Significant association was found between the male sex and the clinical staging and the location of carotid lesions. Eversion endarterectomy was the most performed surgical technique (44.4 percent). In the study, 96.3 percent of operations were kept permeable up to 18 months after the surgery whereas three patients presented with re-stenosis after 24 months. In the study group, 40.7 percent did not develop complications, being bleeding the most frequent one (33 percent). Conclusions: The surgical variants performed in the study time were characterized by high percentages of permeability and minimal postsurgical complications(AU)

Características de la enfermedad cerebrovascular extracraneal en el municipio de arroyo naranjo / Characteristics of the extra-cranial cerebrovascular disease in Arroyo Naranjo municipality

Introducción: La enfermedad cerebrovascular extracraneal en Cuba está subdiagnosticada, de ahí que se desconoce su prevalencia en población general. Objetivo: Determinar las características de la enfermedad cerebrovascular extracraneal en el municipio de Arroyo Naranjo. Métodos: Se realizó estudio descriptivo en las 26 personas diagnosticadas con enfermedad carotidea de una muestra de 200 individuos obtenida por método aleatorio simple de los 208 554 residentes del municipio Arroyo Naranjo. La enfermedad se confirmó por eco-doppler carotideo. Las variables fueron: edad, sexo, porcentaje de estenosis, localización, tipo de placa, factores de riesgo y grosor íntima-media carotideo. Resultados: La prevalencia de la enfermedad fue de 12,5 x 100 000 habitantes, mayor en las mujeres (10,1) y en los mayores de 60 años (9,1). Se confirmó el diagnóstico en el 80,8 por ciento de las personas y más del 45 por ciento mostró estenosis no significativa en ambas carótidas. Predominaron las placas heterogénea (46,2 por ciento) localizadas fundamentalmente en: bifurcación carotidea y bulbo. El tabaquismo (80,8 por ciento), la hipertensión arterial (73,1 por ciento), y la enfermedad arterial periférica (65,1 por ciento) fueron los factores de riesgo más frecuentes; el 69,2 por ciento presentaba más de tres factores. Más del 75 por ciento de los mayores de 60 años, independiente del sexo, tenían valores patológicos del grosor íntima-media carotideo. Conclusiones: La prevalencia de enfermedad cerebrovascular extracraneal en el municipio es elevada. Alta incidencia de factores de riesgo. El diagnóstico precoz de dicha enfermedad en un alto porcentaje permitió remitir a sus áreas de salud a aquellas personas que requerían de un tratamiento oportuno(AU)

Introduction: Extracranial cerebrovascular disease is a problem of health internationally, in Cuba it is sub-diagnostician without knowing its prevalence in the general population. Objective: To determine the characteristics of the extracranial cerebrovascular disease in the Arroyo Naranjo municipality. Methods: a descriptive study was conducted in 26 people diagnosed with carotid disease of a sample of 200 people obtained by a simple random method of the 208 554 residents of the municipality of Arroyo Naranjo. The disease was confirmed by carotid doppler ultrasound. The variables were: age, sex, percent stenosis, location, type of plate, risk factors and thickness intima-media carotid. Results: The prevalence of the disease was 12,5 x 100 000 inhabitants, higher in women (10,1) and older adults (9,1). The diagnosis was confirmed in 80,8 percent of people, where more than 45 percent showed a non-significant stenosis in both carotid. The types of plates were the heterogeneous (46,2 percent) and the echogenic (38,6 percent), located in: carotid bifurcation, bulb, and internal carotid. Smoking (80,8 percent), hypertension (73,1 percent), and peripheral arterial disease (65,1 percent) were the most frequent risk factors, noting that 69,2 percent had more than three factors. More of the 75 percent of those older than 60 years, independent of sex, showed pathological values of the thickness intima-media carotid. Conclusions: The prevalence of the extracranial cerebrovascular disease in the municipality is high; and too the incidence of the risk factors. Early diagnosis of the disease in a high percentage allowed referring to their areas of health to those persons requiring prompt treatment(AU)

Study on the correlation between intracranial and extracranial artery stenosis in patients with ischemic stroke / 中国综合临床

Objective To determine whether there is correlation between intracranial and extracranial arterial stenosis in patients with ischemic stroke,and to understand the difference of the main risk factors between them.Methods One hundred and sixty-eight patients with symptomatic ischemic stroke were selected in order to analyze the correlation and risk factors of intracranial arterial stenosis and extracranial arterial stenosis.Results In the 168 cases,123 patients(73.2%)were with abnormal artery(include intimal thickening)and 100 patients(59.5%)were diagnosed with artery stenosis,including 33 cases of intracranial artery stenosis,48 cases of extracranial artery stenosis and 19 cases of intracranial and extracranial stenosis.The rate of extracranial artery stenosis(39.9%)was higher than that of intracranial artery stenosis(31.0%),but there was no significant difference between them(χ2 =2.93,P=0.11).There was no definite correlation between them(χ2 =0.35,P=0.61)and there were statistically significant differences in age and arterial pressure between patients with intracranial and mean extracranial artery stenosis(t=1.98,P=0.05;t=5.42,P<0.001),but the gender,blood pressure,blood glucose and dyslipidemia rate showed no significant difference (χ2 =1.15,3.41,0.43,0.81,P>0.05).Conclusion Extracranial arterial stenosis may not predict the possibility of intracranial arterial stenosis,and extracranial arterial stenosis may be more likely to cause ischemic stroke.