[Dynamic functional assessment of internal carotid artery tortuosity in patients with multifocal atherosclerosis]. / Dinamicheskaya funktsional'naya otsenka patologicheskikh izvitostei vnutrennikh sonnykh arterii u bol'nykh s mul'tifokal'nym aterosklerozom. Klinicheskii sluchai.

A personalized approach with attention to anamnesis and specific symptoms is necessary in patients with internal carotid artery tortuosity. Neuroimaging (especially before elective surgery) or functional stress tests following ultrasound of supra-aortic vessels may be necessary depending on medical history and complaints. In addition to standard Doppler ultrasound, these patients should undergo rotational and orthostatic transformation tests. We analyze changes in shape and hemodynamic parameters within the tortuosity area in various body positions. This is especially valuable for patients with concomitant carotid artery stenosis. The article presents a clinical case illustrating the importance of such approach.

[Functional assessment of internal carotid artery tortuosity in patients with multifocal atherosclerosis]. / Vazhnost' dinamicheskoi funktsional'noi otsenki patologicheskoi izvitosti vnutrennikh sonnykh arterii u bol'nykh s mul'tifokal'nym aterosklerozom.

The review is devoted to diagnosis and treatment of internal carotid artery tortuosity. The authors consider modern classification, epidemiology and diagnostic options using neuroimaging or ultrasound-assisted functional stress tests depending on medical history and complaints. In addition to standard Doppler ultrasound, rotational and orthostatic tests are advisable due to possible changes of local shape and hemodynamic parameters following body position changes, especially in patients with concomitant atherosclerotic stenosis. Thus, a personalized approach is especially important for treatment and diagnostics of internal carotid artery tortuosity.

[Treatment and prevention phantom pain syndrome in mine-explosive injuries]. / Analiz ispol'zovaniya sovremennykh metodov lecheniya i profilaktiki fantomnogo bolevogo sindroma pri minno-vzryvnykh travmakh.

Phantom pain syndrome significantly impairs the quality of life and effectiveness of surgical treatment after limb amputations. The authors consider possible strategies for treatment and prevention in elective surgical intervention and mine-explosive injuries.

[Reflexology in patient rehabilitation with postoperative pain. (Literature review)]. / Refleksoterapiya v reabilitatsii patsientov s posleoperatsionnoi bol'yu. (Obzor literatury).

Postoperative pain is a pressing medical problem, as it significantly reduces the quality of life of patients after surgical treatment. Chronic postoperative pain further disables patients and impairs their functional activity. Being a widespread interdisciplinary problem, postoperative pain requires the integration of various pain management methods in complex multimodal pain management in the acute period and treatment programs for its chronicity. The paper examines the possibilities of reflexology methods for the relief of acute and treatment of chronic postoperative pain. Integration of reflex effects from the first days after surgery makes it possible to more effectively and safely solve the problems of acute and chronic postoperative pain.

[Risk factors for neurological complications in the late period after operations on the ascending aortic arch]. / Faktory riska nevrologicheskikh oslozhnenii v pozdnem periode posle operatsii na voskhodyashchem otdele i duge aorty.

OBJECTIVE: To assess the risk factors for unfavorable neurological outcomes in the long-term follow-up periods (after 5 and 10 years) in patients undergoing planned operations on the ascending and arch of the aorta. MATERIAL AND METHODS: The prospective study included 100 patients who were operated on at the FSBSI Petrovsky Russian Research Center of Surgery and were observed over a long period of time (up to 10 years). Patients of group I (n=50) underwent surgery on the aortic arch with antegrade cerebral perfusion and hypothermic circulatory arrest (26 °C). Patients of group II (n=50) underwent prosthetics of the ascending aorta with extracorporeal circulation with moderate hypothermia (32 °C). All patients performed cognitive tests before and after surgery, as well as 5 and 10 years after reconstruction. Possible risk factors were analyzed with respect to 3 expected negative consequences: postoperative delirium, neurocognitive dysfunction and long-term neurological disorders after 5 and 10 years of follow-up. RESULTS: Long-term cognitive impairments were statistically significantly associated with the following predictors: age, baseline presence of mild cognitive impairment, episodes of intraoperative microembolism, episodes of decreased cerebral perfusion, and delirium. The presence of short-term cognitive impairments in the immediate postoperative period was a significant risk factor for detecting impairments 5 and 10 years after surgery. CONCLUSION: For the possibility of preventing long-term unfavorable outcomes of the intellectual sphere, the main attention should be directed to the dynamics of the patient's neurological state in the immediate postoperative period.

[Chronic postoperative pain]. / Problema khronicheskoi posleoperatsionnoi boli.

The problem of chronic postoperative pain has been actualized for the last 20 years all over the world. At least 10-40% of patients suffer from chronic pain after surgery. This review is devoted to the current state of the problem of chronic postoperative pain, risk factors and prediction of chronic pain. The authors emphasize the need for interdisciplinary approach to prevention and treatment of this adverse event.

[Evaluation of immediate complications and 10-years neurological outcomes in patients after reconstructive interventions on the ascending aorta and the aortic arch]. / Otsenka blizhaishikh i 10-letnikh nevrologicheskikh iskhodov u patsientov posle rekonstruktivnykh vmeshatel'stv na voskhodyashchem otdele i duge aorty.

OBJECTIVE: To estimate the frequency of early postoperative neurological complications in patients undergoing planned surgery on the ascending aortic and arch of the aorta, and their long-term outcomes. MATERIAL AND METHODS: The prospective study included 100 patients who were operated on at the FSBSI Petrovsky Russian Research Center of Surgery. In group I (n=50), operations were performed on the aortic arch with hypothermic circulatory arrest (26 °C) and antegrade cerebral perfusion. Patients in group II underwent prosthetics of the ascending aorta with extracorporeal circulation and moderate hypothermia (32 °C). All patients underwent monitoring of cerebral and tissue oxygenation, transcranial Doppler and testing of cognitive functions before and after surgery, and after 5 and 10 years of follow-up. RESULTS: Postoperative stroke in group I was observed in 1 (2%) patient, no cases were observed in group II. Delirium was detected in 14% of patients in group I and 6% of patients in group II, its subsyndromal form was found in 6 and 4%, respectively. Moderate cognitive impairment in the immediate postoperative period was found in 42 and 26%; severe in 8% of group I. After 5 years of follow-up, the number of patients with moderate and severe cognitive impairment was 23.1 and 12.8%, respectively. After 10 years, severe disorders were identified in 37.5 and 21.9% of patients. CONCLUSION: In cardiac surgery patients, intraoperative multimodal monitoring allows dynamic regulation of antegrade cerebral perfusion. Dynamic testing of cognitive functions and early detection of delirium in the immediate postoperative period improve long-term neurological treatment outcomes.

[Differential diagnosis of neurological conditions in cardiac patients on the first day after cardiac, ascending aortic and aortic arch surgery and repair of internal carotid arteries]. / Nevrologicheskii status u patsientov v pervye sutki posle serdechno-sosudistykh operatsii.

The review is devoted to analysis of current trends in interdisciplinary approach to the differential diagnosis of patients' conditions on the first day after cardiac, ascending aortic and aortic arch surgery and repair of internal carotid arteries (neurological disorders, delirium, cognitive dysfunction, psycho-emotional disorders, postoperative sedation). This approach is valuable to determine the prognosis and timely treatment. The basic concepts reflecting the discussion between neurologists, cardiovascular surgeons, anesthetists, radiation diagnostics specialists and rehabilitators are summarized. The authors concluded that timely and correct differential diagnosis of the states on the first postoperative day using current tests and interdisciplinary approach to the treatment of patients with postoperative impaired consciousness or neurological/psycho-emotional dysfunction can improve their quality of life and efficiency of medical care.

[The efficacy of therapeutic nerve blocks in patients with cervicogenic headache]. / Éffektivnost' lechebnykh blokad u patsientov s tservikogennoi golovnoi bol'iu.

AIM: To compare the efficacy of 2% articaine solution and 2% lidocaine solution used to perform therapeutic nerve blocks of the large occipital nerve in patients with cervicogenic headache. MATERIAL AND METHODS: A randomized prospective comparative clinical study was conducted in two groups treated with articaine (n=22) or lidocaine (n=21). The therapeutic great occipital nerve blocks were performed on the 1st, 3d and 5th days of treatment. The efficacy of treatment was assessed by the pain intensity measured with the Visual Analogue scale (VAS) and the duration of individual pain paroxysms on the 5th and 10th days. RESULTS: The baseline VAS pain intensity was 6.3±1.2 and 5.9±2.0 centimeters, whereas the duration of individual pain paroxysms was 7.8±2.3 and 9.1±2.8 hours in the articaine group and the lidocaine group, respectively. By the 5th day, there was a more dramatically decrease in VAS pain intensity and duration in the articaine group (up to 3.0±0.8 and 4.3±1.2 centimeters VAS (p<0.05)) compared to the lidocaine group (up to 1.9±0.6 to 4.8±1.3 hours (p<0.05)). By the 10th day, the pain intensity did not differ between groups (1.2±0.5 and 1.7±0.7 centimeters (p>0.05)). The duration of pain episodes was still lower in the articaine group (0.5±0.08 hours) compared to the lidocaine group (2.4±0.8 hours) (p<0.05). CONCLUSION: Therapeutic large occipital nerve blocks with 2% solution of articaine show the significant decrease in pain intensity and duration of pain paroxysms in a short period of time for patients with cervicogenic headache.

[An analysis of blood flow indicators in pathological kinked internal carotid arteries with their orthostatic and rotational positions]. / Analiz pokazatelei krovotoka v patologicheski izvitykh vnutrennikh sonnykh arteriiakh pri ikh ortostaticheskoi i rotatsionnoi transpozitsiiakh.

AIM: To assess the dynamics of blood flow in patients with hemodynamically significant pathological kinked internal carotid arteries (PK ICA) with their orthostatic and rotational positions. MATERIAL AND METHODS: Eighty-six patients, including 35 with PK ICA due to fibromuscular dysplasia (FMD) and 51 with PK ICA due to hypertensive heart disease, and 20 healthy people were examined. All patients underwent Doppler ultrasound scanning. All indicators were evaluated in the position of the patient lying on his back and functional stress tests (orthostatic, rotational). RESULTS: The peak systolic velocity, end diastolic velocity, peripheral resistance index did not differ significantly in patients with PK ICA due to FMD and hypertensive heart disease. The increase of blood flow in bends was significantly higher with S-shaped kinking, regardless of the reason for their formation (p<0.05). In orthostatic position, significant changes of hemodynamic parameters in ICA in healthy people did not occur. Moreover, more frequent formation of turbulent blood flows in the group with hypertensive heart disease (78%) and a decrease in LBFV in the standing position were found in patients with PK ICA due to FMD. Rotational position did not alter the hemodynamics in ICA in healthy people and significantly influenced the values of LBFV in patients with PK ICA. CONCLUSION: Changes in hemodynamic parameters in the area of kinking with orthostatic and rotational positions of ICA demonstrate more significant impairments in patients with PK ICA due to hypertensive heart disease compared to patients with FMD. The rotational position of PK ICA is the most informative for identifying turbulent blood flow and an increase in peak systolic velocity in the area of kinking.

[Early and long-term cognitive disorders after carotid endarterectomy]. / Kognitivnye rasstroistva v rannem i otdalennom periodakh u patsientov posle karotidnoi éndarteréktomii.

AIM: To identify correlation of carotid endarterectomy with neurocognitive function and psycho-emotional state changes. MATERIAL AND METHODS: There were 120 patients with internal carotid arteries (ICA) stenoses for the period from September 2013 to December 2016. The main group consisted of 100 patients undergoing carotid endarterectomy for internal carotid artery stenosis, control group - 20 patients who refused surgery in 2014-2016. Cognitive function and psycho-emotional state were assessed preoperatively, after 24 hours, 7 days and 3, 6 months postoperatively using the Mini Mental State Examination (MMSE), Frontal assessment battery (FAB), Information-Memory-Concentration Test, Clock Drawing Test and Schulte`s test, Luria Memory Words Test, Hospital Anxiety and Depression Scale (HADS) and Covi Anxiety Scale. RESULTS: Moderate preoperative cognitive impairment was observed in 39 (39%) patients of the main group. De novo postoperative cognitive dysfunction occurred in 65 patients on the 1st day after surgery (65%). Disturbances were noted after 1 week in 26%, after 3 months - in 15%, after 6 months - in 10% of patients. Improved status was noted in 31 (31%) patients of the main group within 1 day after surgery. Improved results were observed after 7 days in 52 (52%) patients, after 3 months - in 67 (67%), after 6 months - in 78 (78%) patients. Mean values of psycho-emotional testing in the main group were high before surgery and significantly decreased on the 1st day after operation. However, advanced anxiety and aggravation of depression occurred in 14% of patients (n=14) that affected cognitive sphere (p<0.01). Progressive cognitive impairment was noted in the control group. CONCLUSION: Carotid endarterectomy has a positive long-term effect on initially impaired neurocognitive functions (3 and 6 months) (p<0.05). There were no significant differences in cognitive testing data in subgroups of eversion and classical procedures (p>0.05). Early postoperative depressive disorders significantly increase the risk of postoperative cognitive dysfunction.

[ANAESTHETIC MANAGEMENT OF RECONSTRUCTIVE SURGERY ON THE AORTIC ARCH: THE NUANCES OF ORGAN PROTECTION].

UNLABELLED: Aortic arch reconstruction is one of the most difficult surgical procedures. Therefore the aims of our study were: to choose appropriate flow rate for antegrade cerebral perfusion and assess its adequacy in relation to cerebral metabolic demands; to evaluate safety of temperature settings during the surgery; to assess the effectiveness of chosen protocol for brain and visceral organ protection during aortic arch reconstruction surgery. Our study included 67 patients. Patients of the first group (n = 33) underwent aortic arch reconstruction with antegrade cerebral perfusion and hypothermic circulatory arrest (target core temperature 26 °C). The second group (n = 34) underwent ascending aorta repair using cardiopulmonary bypass with modest hypothermia (target core temperature 32 °C). Cerebral and tissue oxygenation monitoring was performed in all patients. In the first group transcranial Doppler monitoring and jugular venous bulb catheterization were performed. Target core temperature during rewarming was 36 °C. In the first group air-warming device in addition to fluid warming was used. In all patients cognitive function was assessed before and after surgery. The multimodal monitoring allowed to dynamically adjust flow rate of antegrade cerebral perfusion. As a result cerebral SO2 and linear velocity were maintained in acceptable range, while flow rate varied significantly from 5.8 to 16.5 ml/ kg/min (average rate 13.4 ± 3.69 ml/kg/min). CONCLUSION: Combined use of cerebral oximetry and transcranial Doppler monitoring allows assessing how oxygen delivery meets metabolic demands of the brain during antegrade cerebral perfusion. This method allows to maintain the proper flow rate of antegrade cerebral perfusion and to choose an appropriate modification of perfusion (unilateral vs bilateral). Multichannel monitoring of core temperature and combined use of air- and fluid warming techniques are required for effective temperature management.

[The results of early neurocognitive and neuropsychological testing in patients after ascending aorta and aortic arch surgeries].

It was investigated 30 patients after reconstructive ascending aorta and aortic arch surgeries. Neurocognitive testing was performed 2-3 days before surgery, through 24 hours and 10 days after surgery. Neurocognitive tests included Psychiatric Rating Scale, test "Information-Memory-Consideration Concentration", frontal dysfunction battery and test of clock drawing. Neuropsychological testing was performed by using of hospital scale of anxiety and depression evaluation and Covey scale. The observed moderate decrease of cognitive sphere in 24 hours after surgery has recovered by 10 days of postoperative period. Depressive disorders also were revealed in all stages of postoperative period. Inverse correlation between depressive and intellectual-mental disorders in examined patients was presented. It was suggested introduction of compulsory neurocognitive and psycho-emotional testing for improvement of surgical treatment results.

[Epidural blockades use in low back pain treatment].

MATERIALS AND METHODS: We studied 90 patients with radicular acute pain syndrome of lumbosacral localizations in the Petrovsky Russian Research Center of Surgery from 2009 to 2013. The patients were divided into two groups. We assessed an effectiveness of epidural blockades in complex therapy. CONCLUSION: The treatment of radicular pain syndrome with intensity over 5 points according to visual analog scale should be started with epidural blockade with local anesthetics and small doses of steroids.

[Possibilities for the instrumental monitoring of neuralgia therapy].

AIM: To study the possibility of using a paired (test) H-reflex recovery test in the expert assessment of the intensity of acute pain syndromes and in the control of performed therapy. SUBJECTS AND METHODS: The authors analyzed 40 patients treated for radicular pain syndrome (RPS) caused by disk protrusion or herniation at the lumbar spine with the pain intensity of up to 9 points on digital rank scale of pain. As a clinical model they used a pathogenetically sound therapeutic blockade method including glucocorticosteroids for the therapy of acute neuralgia and basic medical therapy with Arcoxia 120 mg/day. Investigations were conducted to study the specific features of early recovery of test H-reflex caused in pair with a conditioning H-reflex in both healthy volunteers and patients with obvious RPS. RESULTS: There were different features of paired H-reflex recovery in healthy individuals and patients with RPS during different treatment options. Recovery of test H-reflex in the range of 150-200 msec can be a criterion for a pain state. CONCLUSION: The clinical test reflex recovery technique may be used in the diagnosis and monitoring of the performed therapy of acute pain syndromes, as well as in the expert examination of pain states.

[Local invasive treatment of chronic pain].

The literature on methods of invasive local treatment of chronic pain was analyzed. We reviewed 14 publications including meta-analyses and systematic reviews. The use of regional anesthesia conducted by anesthesiologists in pain clinics demonstrated the evidence based efficacy of different types of peridural injections of local anesthetics with steroids in patients with root pain syndromes at cervical and lumbar levels. Therapeutic blockades of the occipital nerve is effective method of treatment of cervicogenic and cluster headache as well as occipital nerve neuralgia. There are clear indications of the efficacy of local injections in primary chronic cephalgia (migraine and headache of tension). The possibility of the abortion of the pain information flow in peripheral nociceptive pathways and, as a consequence, breaking the vicious circle is emphasized. Issues on the efficacy of local injections at trigger points in the treatment of chronic pain are highlighted.

[Treatment of myofascial pain syndrome].

OBJECTIVE: To study different methods of treatment of patients with myofascial pain syndrome (MFPS). MATERIAL AND METHODS: We evaluated the efficacy of complex treatment in 152 patients with chronic tension-type headache (СЕЕР) and 96 patients with facial MFPS. The treatment included standard methods (reflex therapy of СЕЕР and local injections of a combination of local anesthetics with small doses of steroids in trigger points in patients with facial MFPS. To assess the efficacy of tizanidine, patients were randomized into two comparable groups. The duration of the study was 12 weeks. RESULTS AND CONCLUSION: The combined therapy, including reflex action and tizanidine, speeds recovery from pain and ensures the stability of results.

[Odontogenic pain syndrome: integrated approach in analgesia].

The article deals with the study of 96 patients (69 women and 27 men) with odontogenic facial pain syndrome. All patients received complex neurodentist examination with radiological assessment of maxillofacial area and additional functional methods. Patients were divided into two groups, 48 patients in each group. All patients received usual therapy; mouth cavity sanitation, selective grinding of teeth, drug therapy (anticonvulsants, B vitamins) and physiotherapy. Patients in group 2 received corporeal acupuncture. Efficacy of the therapy was assessed by changes of basic subjective and objective significatives on 10th, 30th and 60th day of treatment. Reflective anaesthesia techniques using allowed to stop the pain faster and decreased the dosage of drugs in patients of group 2.