Clinical efficacy of tirofiban combined with a Solitaire stent in treating acute ischemic stroke

This study explores the safety and effect of acute cerebral infarction treatment by microcatheter injection of tirofiban combined with a Solitaire AB stent and/or stent implantation. Emergency cerebral angiograms showing the responsible vascular occlusion of 120 acute cerebral infarction patients who underwent emergency endovascular thrombectomy were included in the study. These patients were randomly divided into two groups using the random number table method: treatment group (n=60) that received thrombectomy (with cerebral artery stents) combined with intracerebral injection of tirofiban and control group (n=60) that only received thrombectomy (with cerebral artery stents alone). The baseline data, cerebral angiography before and after surgery, hospitalization, and follow-up results of patients in these two groups were compared. Furthermore, the incidence of major adverse cerebrovascular events of these two groups was compared (90-day modified Rankin scale, a score of 0-2 indicates a good prognosis). The difference between baseline clinical data and brain angiography between these two groups was not statistically significant. Patients in the treatment group had a higher prevalence of thrombolysis in cerebral infarction grade 2b/3 than patients in the control group (88.3% (53/60) vs 66.7% (40/60), P=0.036). Moreover, the National Institutes of Health Stroke Scale scores 7 days after surgery and the 90-day prognosis were all better for the patients who received tirofiban (P=0.048 and P=0.024). Mechanical thrombectomy with Solitaire AB stents in combination with the injection of tirofiban through a microcatheter appears to be safe and effective for the endovascular treatment of acute ischemic stroke.

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)

Tratamiento neuroquirúrgico de la isquemia cerebral / Neurosurgical treatment of cerebral ischemia

Introducción: El manejo actual de la isquemia cerebral aguda (IA) contempla el uso de r-tPA y terapia endovascular, mientrasque en la isquemia cerebral crónica (IC) la mejor terapia aún no está definida. La revascularización cerebral microquirúrgicaha sido descrita como tratamiento alternativo para pacientes con IA y contraindicación para r-tPA o terapia endovascular, asícomo para pacientes con IC en quienes la terapia médica ha fracasado. Objetivo: Comunicar la experiencia inicial en cirugíade revascularización cerebral, con énfasis en la utilidad de la embolectomía microquirúrgica y del bypass cerebral comoterapia de rescate en IA, así como del bypass cerebral en IC. Pacientes y Método: Serie prospectiva de 5 pacientes conisquemia cerebral tratados con cirugía de revascularización cerebral en el período 2013 a 2016. Se describe la técnica y resultadosquirúrgicos, así como el estado funcional a los 3, 6 y 12 meses de seguimiento según modified Rankin Scale (mRS)...

Background: Tissue Plasminogen Activator (t-PA) and mechanical thrombectomy are today the best treatment approachfor acute ischemic stroke (AIS). However, the best management for chronic cerebral ischemia (CCI) is still debated. Microsurgicalrevascularization has been described as alternative treatment for patients with AIS and contraindication for t-PA orendovascular therapy, and for patients with CCI and failure of maximal medical therapy. Aim: To describe the effectiveness ofmicrosurgical embolectomy and cerebral bypass as salvage therapy in AIS, as well as cerebral bypass in CCI. Methods: Fivepatients were treated by cerebral revascularization between 2013 and 2016. Surgical and functional results were analyzed.Neurological outcomes were assessed by modified Rankin Scale (mRS) at 3, 6 & 12 months...

Revascularização cerebral na doença de moyamoya / Cerebral revascularization in moyamoya disease

Objetivo: Relatar uma série de casos de doença moyamoya/síndrome de moyamoya (DMM/SMM) tratados por revascularização cerebral no período de 2001 a 2013. Método: Estudo retrospectivo de 12 pacientes portadores de DMM/SMM submetidos à revascularização cerebral. Resultados: Trêspacientes foram operados por meio de by-pass de alto fluxo, três com by-pass de baixo fluxo e seis por revascularização indireta (encefaloarteriossinangiose associada à galeossinangiose). Realizamosdurante o seguimento: análise da ocorrência de novos acidentes vasculares cerebrais (AVC), avaliação funcional (utilizando a Escala de Rankin Modificada) e das complicações cirúrgicas. O tempo de acompanhamento para o grupo de by-pass de alto fluxo foi de quatro a dez anos, para o grupo de baixo fluxo e revascularização indireta de três meses a três anos. Nenhum paciente apresentou outro AVC no hemisfério operado tampouco piora funcional. As taxas de morbimortalidade e de infecção foram nulas. Conclusão: A revascularização cerebral foi efetiva, prevenindo a ocorrência de novos AVC e evitando piora funcional.

Objective: To report a case series of moyamoya disease/moyamoya syndrome (DMM/SMM) treated by cerebral revascularization in the period 2001-2013. Method: Retrospective study of twelve patients with DMM/SMM submitted to cerebral revascularization. Results: Three patients were operated through high-flow by-pass, three with low flow by-pass and six with indirect revascularization (encephaloarterio-sinangiosis associated with galeo-sinangiosis). Analyzed during follow-up: the occurrence of new strokes, functional assessment (using the modified Rankin scale) and surgical complications. The follow up to the group of high-flow by-pass was 4-10 years for the group of low flow and indirect revascularization of three months to three years. No patient had another cerebrovascular accident (CVA) in the hemisphere operated nor functional worsening. Rates of morbidity and mortality and infection were nil. Conclusion: Cerebral revascularization was effective, preventing the occurrence of new strokesand preventing functional deterioration.

Entrenamiento en laboratorio de microcirugía para la revascularización cerebral / Microsurgical laboratory training for cerebral revascularization

La idea de llevar más sangre al cerebro para prevenir el infarto y mantener las funciones cerebrales ha estado en la mente de los neurocirujanos por muchas décadas. En el año 1967 el doctor M. G. Yasargil realizo la primera anastomosis microvascular cerebral de la arteria temporal superficial (ATS) a la arteria cerebral media (ACM). Esta cirugía impulso la neurocirugía en un paso agigantado hacia el campo de la microcirugía y la revascularización cerebral. Durante las décadas que siguieron estas técnicas quirúrgicas fueron usadas con tratamiento definitivo y adyuvante para enfermedades vasculares extracraneanas e intracraneanas, tumores de la base del cráneo, aneurismas, fistulas carotido cavernosa, isquemia cerebral aguda, vasoespasmo y la Enfermedad Moyamoya. La cirugía cerebrovascular requiere un entrenamiento extensivo para lograr realizar las diferentes intervenciones de un modo adecuado y seguro. Las técnicas de anastomosis microvascular son muy difíciles de realizar y necesitan de una destreza que se logra obtener con el entrenamiento. Los procedimientos de laboratorios son un buen instrumento para realizar los ejercicios necesarios para obtener la experiencia y realizar la curva de aprendizaje de estos procedimientos quirúrgicos. El entrenamiento de laboratorio se realiza con el uso de microscopio y realizar las diferentes técnicas en material artificial como guantes y tubos de silastico, especímenes muertos, muslo y alas de pollo o cuellos de pavo y en animales vivos entre los cuales se encuentran los conejos, ratas y puercos. En este artículo queremos hacer una revisión de la cirugía de revascularización cerebral y del entrenamiento en laboratorio para poder amaestrar estas cirugías.

The idea of providing additional blood supply to the brain to prevent stroke and maintain neurological function has been present in the mind of neurosurgeons for many decades. In 1967 the first STA–MCA bypass was done by M. G. Yasargil, and an enormous step was made into the field of microneurosurgery and cerebral revascularization. During the decades that followed, this technique was used as an adjuvant or a definitive surgical treatment for occlusive disease of the extracranial and intracranial cerebral vessels, skull base tumors, aneurysms, carotid–cavernous fistulas, cerebral vasospasm, acute cerebral ischemia, and moyamoya disease. Cerebrovascular surgery require extensive training to achieve applying the different interventions in a safe and adequate way. Microneurovascular anastomosis are difficult to do and are a surgical challenge. These procedures needs for the surgeon to obtaining certain skills before mastering the technique. Hands-on laboratory procedures are essential being a learning tool for young surgeons and a daily exercise for the more experienced. Training typically has been done with artificial materials such as silastic tubes and gloves, dead specimens such as chicken wing and turkey neck, or on live animals. In this article we want to review the surgical procedures for cerebral revascularization and the laboratory techniques for mastering these surgeries.

Moya Moya cases treated with encephaloduroarteriosynangiosis.

OBJECTIVE: To study neurological outcome of Moya Moya disease treated surgically with Encephaloduroarteriosynengopsis (EDAS). DESIGN: Prospective observational study. SETTINGS: Community and General with tertiary care facility. SUBJECTS: Eight children diagnosed with Moya Moya disease by Magnetic Resonance Angiogramover 4 years of period were selected for EDAS. Children who were not able to sustain surgery excluded from study. METHODS: Treatment modality selected were surgery in form of EDAS. After surgery subjects were followed up for minimum of 2 year period to know neurological out come. Outcome was reported as poor, fair, good and excellent. No statistical analysis performed due to small sample size. RESULTS: After surgery no episode of stroke or TIA was observed in any patient during 2 year follow up period and all patients are living without any new neurological deficit. CONCLUSION: Long term outcome of EDAS is promising.

Symptomatic non-atherosclerotic bilateral extracranial vertebral artery occlusion treated with extracranial to intracranial bypass: case report / Oclusão sintomática não-aterosclerótica da artéria vertebral extracraniana tratada com bypass: relato de caso

Posterior fossa ischemia is not a very frequent situation. It is responsible for about 25 percent of all ischemic strokes, and the vast majority of the cases are related to atherosclerotic stenosis of the vertebral and/or basilar arteries. Acute ischemia can also occur in the setting of vertebral artery dissection, traumatic or spontaneous. Recently, blunt trauma has been increasingly recognized as a cause for craniocervical artery injury. The management options for both traumatic and atherosclerotic lesions of the posterior fossa are still under debate. We present a case of a delayed onset of hemodynamic ischemic symptoms due to bilateral vertebral artery occlusion probably related to remote trauma to the head and neck in a 55-year-old-man treated successfully with extracranial to intracranial bypass.

Acidentes vasculares cerebrais (AVC) isquêmicos no sistema vertebro-basilar não são frequentes. Representam cerca de 25 por cento dos AVCs isquêmicos, e a maioria é relacionada com aterosclerose das artérias vertebrais e/ou basilar. Isquemia aguda pode também ser resultado de dissecções da artéria vertebral, traumáticas ou espontâneas. Recentemente, traumatismos fechados têm sido cada vez mais reconhecidos como causa de lesão das artérias craniocervicais, podendo ou não resultar em sintomas isquêmicos. O tratamento para estas lesões, sejam traumáticas ou ateroscleróticas, ainda é motivo de debate. Relatamos o caso de um homem de 55 anos com sintomas isquêmicos, hemodinâmicos, tardios, devido a oclusão bilateral das artérias vertebrais, provavelmente relacionada a lesão traumática das artérias vertebrais, tratada com sucesso com bypass extra-intracraniano.

Técnicas de anastomoses microvasculares em ratos no laboratório de microcirurgia / Microvascular anastomosis techniques in rats at the microsurgical laboratory

As técnicas de revascularização cerebral são um importante elemento no tratamento de complexas patologias vasculares ou naquelas que envolvem a base do crânio. Dessa forma, o treinamento de técnicas microvasculares no laboratório de microcirurgia é o primeiro passo para os neurocirurgiões que desejam tratar estas doenças. Neste estudo realizaram-se anastomoses término-terminais nas artérias carótidas de 15 ratos albinos pesando em média 25o gramas, sendo realizado previamente treinamento em artérias e veias selecionadas presentes na face fetal de 7 placentas. Realizou-se um total de 30 anastomoses término-terminais. Os resultados foram os seguintes: das 30 anastomoses término-terminais, 25 apresentaram patência e 5 não apresentaram fluxo sanguìneo distal à região da sutura, o qual foi testado realizando-se manobras específicas logo após o tpermino da sutura. Foram revisados os fatores envolvidos no sucesso de microanastomoses vasculares, bem como os passos no laboratório para realização de exercícios de microcirurgia

Aspectos tecnicos e resultados do bypass de alto fluxo com veia safena para aneurismas complexos / Saphenous vein high-flow bypass for complex aneurysms: technical aspects and surgical results

A tecnica de reconstrucao vascular com ponte venosa de alto fluxo para aneurismas cerebrais complexos é apresentada. As indicacoes, complicacoes e resultados de uma serie de 27 pacientes operados no periodo de 1992 a 1997 sao discutidos. Do total de pacientes 71 por cento possuiam aneurismas gigantes da arteria carotida interna intracavernosa. Cinco pacientes foram submetidos a pontes venosas como medida de profilaxia contra isquemia transoperatoria (bypass profilatico) no tratamento de aneurismas gigantes supraclinoideos. Obtivemos 75 por cento de patencia nos enxertos apos controle angiografico. Nossos resultados mostraram-se bons em 85,7 por cento dos pacientes; nossa morbidade isquemica foi de 3,6 por cento e nossa morbidade nao-isquemica de 7,1 por cento a mortalidade na serie foi de 3,6 por cento.