[Surgical treatment of pathological kinking of the internal carotid artery].

The study was aimed at improving surgical policy in management of patients presenting with pathological tortuosity of the internal carotid artery. The study comprised a total of 105 patients with pathological kinking of the internal carotid artery undergoing a total of 117 reconstructive operations. In order to determine the indications for the operation the patients were subjected to triplex scanning, transcranial Dopplerography and monitoring of blood flow in the median cerebral artery, contrast-enhanced computed tomography or magnetic resonance tomography. Depending upon the degree of intimal proliferation in the area of the maximal bend («septal tortuosity¼), the patients were divided into two groups: group I - pathological kinking of the internal carotid artery without intimal proliferation - 75 patients, Group II - pathological kinking with intimal proliferation - 30 patients. The indications for the operation were determined depending upon the degree of cerebrovascular insufficiency, haemodynamical significance of pathological tortuosity, the presence of intimal proliferation in the zone of the maximal bend - «septal tortuosity¼. An operation of choice for Group I patients was resection of the internal carotid artery with redressation and reimplantation into the own bed, and all Group II patients underwent resection of the area of kinking of the internal carotid artery with an end-to-end anastomosis in order to remove the septal portion. Immediately after the operation 85% of patients were found to have their cardiovascular insufficiency symptoms relieved and all patients showed improved haemodynamic parameters (p<0.01). Neither postoperative strokes nor lethal outcomes were registered.

A Specialized device designed for eversion carotid endarterectomy.

Carotid endarterectomy (CEAE) is currently considered to be one of the most efficient methods of treatment for chronic cerebrovascular insufficiency and prevention of recurrent acute impairments of cerebral blood supply. Methodically, the manipulation concerned is in the majority of cases carried out by one of two most commonly employed techniques, i. e., classical CEAE from the longitudinal arteriotomy with plasty with a synthetic patch, and the so-called eversion CEAE implying removal of an atherosclerotic plaque (ASP) by means of eversion of the internal carotid artery (ICA). Many Russian and foreign authors point out indisputable advantages of eversion CEAE, consisting in a shorter duration of ICA clamping, no need to use synthetic materials, preservation of the anatomical geometry of the bifurcation of the common carotid artery (CCA), a lower incidence rate of restenoses in the remote period. Along with it, eversion CEAE also possesses certain disadvantages consisting in namely complicated revision of the distal intima of the ICA (the zone wherein the ASP is tapering), the necessity of traction by the ASP, which may might lead to its premature detachment, impossibility of ICA eversion distal to the endarterectomy zone and repeat eversion of the already endarterectomised portion of the ICA. Hence, eversion carotid endarterectomy still remains the area of skilled and experienced vascular surgeons, thus giving prerequisites for further levelling its technical disadvantages shortcomings, which was the objective of the present study. The authors describe herein a new specially designed surgical device intended to facilitate the operation of eversion carotid endarterectomy, as well as the technique of application thereof. Based on a comparative example comprising a total of eighty-six eversion carotid endarterectomic procedures performed both with and without the new device, we demonstrated efficiency of using the proposed technique.

[The effect of carotid endarterectomy on cognitive disturbances in patients with atherosclerotic stenosis of carotid arteries].

Clinical and neuropsychological features of non-dementia cognitive disturbances were studied in 102 patients with atherosclerotic carotid stenosis. Cognitive disturbances were assessed after the carotid endarterectomy (CEAE). Mild cognitive impairment was found in 37 (36,3%) of patients, moderate cognitive impairment was diagnosed in 36 (35,3%)patients. Moderate cognitive impairment was found more often in patients with symptomatic carotid stenosis with structural brain changes confirmed by neuroimaging data and with instable atherosclerotic plaques with the predomination of hypodensity component. It allows to suggest that both the reduction of perfusion and arterio-arterial microemboli may cause cognitive dysfunction in patients with atherosclerotic carotid stenosis. The data on the positive effect of CEAE on cognitive functions have been obtained. The positive changes were more distinct in patients with asymptomatic course of carotid stenosis. However CEAE may have a negative effect on cognitive functions in patients with moderate cognitive impairment of dysmnestic character and symptomatic carotid stenosis.

[Gigantic aneurysm resulting from pathological kinking of the internal carotid artery].

Described in the article is a case report of successful surgical management of a 50-year-old male patient presenting with a gigantic aneurysm of the right internal carotid artery, pathological tortuosity of the right and left internal carotid arteries, successfully treated by resection of the aneurysm of the right internal carotid artery with autovenous prosthetic repair of the right internal carotid artery.

[Normal-pressure glaucoma: a hypothesis of pathogenesis]. / Glaukoma normal'novo davleniia: gipoteza patogeneza.

Normal pressure glaucoma (NPG) is a heterogeneous pathology of the optic nerve and retina. Besides, primary open-angle glaucoma (POAG) with high pressure belongs equally to the heterogeneous group. The risk factors and pathogenesis stages of NPG and those of POAG do not coincide completely. A considerable number of the NPG cases can be attributed to the glaucoma of pseudo-normal pressure. The individual norm of the intraocular pressure (IOP) does not coincide with the statistical standards. At the same time, POAG with high pressure has, to a more or less extent, the specific features peculiar to NPG. This is especially characteristic of POAG with moderately high IOP. The NPG specific features peculiar to a majority of the examined patients were related with an insufficient cerebral blood circulation caused by occlusive processes in the great and small vessels of the brain, by the nature of the collateral blood circulation and by a dysfunction of the vascular endothelium due to an exhaustion of the cerebral perfusion reserve. The latter is formed mainly at the cost of the vertrebobasilar basin. The mentioned basin supplies blood to the visual tract, as well as to the cerebral centers of the visual analyzer and of the midbrain. Ischemia of the upper corpus bigeminum and of the optic nucleus of the corpus geniculate laterale reduces the formation and supply of neurotrophines (in particular, of BNDF) with the axonal transport to the retinal ganglionic cells, which leads to their apoptosis. Cavernous dystrophy of the optic nerve is a factor preconditioning the occurrence of excavation of the optic nerve head. The mechanic factor related with excavation cannot be ruled out, either. NPG patients often have a relatively large size of the optic nerve disk (OND), therefore, their disk area is equally large. The pressure exerted on the OND is proportional not only to an IOP value, it is also proportional to a disk area. Consequently, provided the IOPs are identical, the mechanical forces exerted on the OND would differ with direct dependence on a disk area. There is every reason to suggest that a considerable share of NPG cases are preconditioned by the cerebrovascular pathology and, therefore, not only the ophthalmologist but also the neurologist must be involved in the diagnostics and treatment of such patients.

[Role and place of ophthalmological methods in the diagnosis of lesions of the main vessels of the brain]. / Rol' i mesto oftal'mologicheskikh metodov v diagnostike porazhenii magistral'nykh sosudov golovnogo mozga.

The study was aimed at detecting changes in visual functions and organ of vision in patients with involvement of the main vessels of the head and injuries to this vessels in patients with expressed ischemic diseases of the organ of vision. Twenty-four patients with occlusive disorders of the carotid arteries and 22 with retinal and ocular nerve diseases with the ischemic component were examined. The share of carotid artery abnormalities in the second group was 27.3%. Total efficacy of ophthalmological methods of diagnosis in the group with carotid artery involvement was 89.4%, this demonstrating high efficacy of ophthalmological methods for the diagnosis of involvement of the main cerebral vessels. Static quantitative perimetry proved to be the most effective method. It permits reliable detection of the slightest changes and assess the efficacy of surgical treatment.

[An evaluation of the hemodynamic efficacy of an extra-intracranial microanastomosis in unilateral occlusion of the internal carotid artery]. / Otsenka gemodinamicheskoi éffektivnosti ékstra-intrakranial'nogo mikroanastomoza pri odnostoronnei okkliuzii vnutrennei sonnoi arterii.

The physicians of the A. N. Bakulev Institute for Cardiovascular Surgery examined 64 patients with unilateral atherosclerotic occlusion of the internal carotid artery (ICA). TCDG and angiography were employed before and after establishment of EICMA. TCDG proved highly informative in assessment of collateral circulation (sensitivity 95.6%). Indications to EICMA should be based on overall account of initial stage of cerebrovascular insufficiency and collateral circulation. EICMA is indicated for patients with compensated and relatively compensated cerebrovascular insufficiency (transient ischemic attacks, minor apoplexy, dyscirculatory encephalopathy), residue sequelae of ischemic apoplexy stroke, baseline poor collateral circulation. Differentiated approach to EICMA establishment allows improved outcomes of the surgery and revision of common among angio-neurosurgeons attitude to the above surgery in ICA occlusion.

[Surgical treatment of combined extra- and intracranial lesions of the carotid arteries]. / Khirurgicheskoe lechnie sochetannykh ékstra- i intrakranial'nykh porazhenii sonnykh arterii.

The results of surgery for extra- and intracranial lesions of the carotid arteries in 108 patients are analysed. Application of non-invasive methods of examination parallelled with angiography provided a positive estimate of collateral circulation in unilateral occlusion of the internal carotid artery. Long-term postoperative studies showed best results in patients with transitory ischaemic attacks, minor stroke, dyscirculatory encephalopathy, and minor sequelae of ischaemic stroke. Surgery is contraindicated in moderate to severe poststroke neurological defect and does not have an advantage over conservative treatment.