[Treatment of patients with a cerebral arterial aneurysm and stenosis of the internal carotid artery]. / Lechenie patsientov s anevrizmami arterii golovnogo mozga i stenozom vnutrennei sonnoi arterii.

AIM: The purpose of this study was to analyse the world literature dedicated to the problem concerning treatment of a combination of internal carotid artery stenosis at the extracranial level and an arterial aneurysm of the brain, as well as to demonstrate own results of surgical treatment of patients presenting with this concomitant pathology of the carotid basin. PATIENTS AND METHODS: From 2013 to 2019, a clinical course of combined pathology of the basin of the internal carotid artery (an intracranial aneurysm and stenosis of the internal carotid artery at the extracranial level) was revealed in 35 of 1638 examined patients. There were ten men and 25 women, with a mean age of 66±7 years. In all the 35 patients, intracranial aneurysms appeared to be asymptomatic and were revealed during diagnosis of an atherosclerotic lesion of the internal carotid artery. Fifteen (43%) of the 35 patients were operated on. A two-stage surgical approach was used in 2 patients with ipsilateral location of the cerebral aneurysm and stenosis of the internal carotid artery: the first stage consisted in clipping of the arterial aneurysm, with stage 2 being carotid endarterectomy. A vascular stage alone (carotid endarterectomy or stenting of the internal carotid artery) was carried out in 9 patients, with a neurosurgical stage alone (clipping of the aneurysm) in 4 patients. RESULTS: The incidence of internal carotid artery stenosis with an arterial cerebral aneurysm, according to our findings, amounted to 2.1%. In the group of surgical treatment, in 1 case (6.7%) after stenting of the symptomatic stenosis of the internal carotid artery a female patient with an ipsilateral asymptomatic aneurysm of the middle cerebral artery intraoperatively developed 'minor' ischaemic stroke. Neither perioperative aneurysmal ruptures nor lethal outcomes were observed in the group of patients subjected to surgical interventions. CONCLUSION: An individual tactical approach to patients presenting with a combination of a cerebral aneurysm and internal carotid artery stenosis at the extracranial level made it possible at this stage of the work to avoid both intracranial haemorrhagic complications and lethal outcomes. The frequency of perioperative ischaemic cerebral events amounted to 6.7%. Further collection of the clinical material is needed to work out an optimal surgical policy in a combined lesion of the extra- and intracranial basin of the internal carotid artery.

[Therapeutic policy in stenosis of the internal carotid artery combined with intracranial vascular malformation]. / Taktika lecheniia stenoza vnutrennei sonnoi arterii v sochetanii s intrakranial'noi sosudistoi mal'formatsiei.

Presented herein is the world experience of surgical treatment and various tactical approaches in a combined lesion of the extracranial and intracranial portions of the internal carotid artery (ICA): a combination of its stenosis or occlusion with vascular malformation of the brain (a cerebral aneurysm, pathological anastomoses, arteriovenous malformations). Also pointed out is the prevalence of the pathology involved, followed by describing various types of surgical policy in this condition: staged and simultaneous interventions, endovascular and standard operative auxiliary techniques. Taking into consideration a low incidence rate of combined pathology of the ICA, there are currently no randomized studies that would make it possible to work out a common tactical approach to management of this cohort of patients. Hence, this vascular and neurosurgical problem appears to require further study.

[Endovascular interventions in treatment of patients with acute impairment of mesenteric blood circulation]. / Éndovaskuliarnye vmeshatel'stva v lechenii bol'nykh s ostrym narusheniem mezenterial'nogo krovoobrashcheniia.

The authors share herein their experience of treating a total of eight patients with acute impairment of mesenteric blood circulation, describing both technical and instrumental peculiarities of interventions on the superior mesenteric artery. Technical success defined as restoration of the main blood flow through the superior mesenteric artery was achieved in seven (87.5%) patients. Of these, two (25%) patients required laparotomy and intestinal resection, with the scope of resection being significantly reduced in one case after endovascular thrombectomy. A further two (25%) patients developed respiratory distress syndrome as a complication of reperfusion syndrome. There were two (25%) lethal outcomes. A conclusion was drawn that endovascular interventions might be regarded as an independent method of treatment of patients presenting with acute impairment of the mesenteric blood flow in the stage of intestinal ischaemia. Besides, this technique makes it possible in case of the development of intestinal gangrene to dramatically diminish the scope of intestinal necrotic lesion.

[Outcomes of open endovascular operations on the internal carotid artery in acute stage of ischaemic stroke]. / Rezul'taty otkrytykh i éndovaskuliarnykh operatsii na vnutrennei sonnoi arterii v ostroi stadii ishemicheskogo insul'ta.

INTRODUCTION: The authors share their experience in diagnosis and treatment of patients with acute ischaemic stroke. PATIENTS AND METHODS: The study included a total of 33 patients. Of these, 20 patients (Study Group) were operated on at terms ranging from 2 to 7 days after onset of acute cerebral circulatory impairment. The Control Group was composed of 13 patients with ischaemic stroke, having refused surgical prevention of recurrent stroke. Both groups were matched by age, gender, level of neurological deficiency and size of cerebral ischaemic foci. Surgical management in the Study Group consisted in either carotid endarterectomy (n=15) or stenting of the internal carotid artery (n=5). Depending on the severity of coronary artery lesion and the presence of accompanying therapeutic pathology, options of operative treatment with various anaesthesiological support were offered. RESULTS: At discharge, neurological deficit in the Study Group patients was lower - 1.2 points by the NIH Stroke Scale versus 2.7 points in the Control Group, however, this difference was not statistically significant (p=0.45). In the Study Group there were two complications: haematoma of the postoperative injury requiring its revision and a transient ischaemic attack during stenting of the internal carotid artery, having disappeared on the operation table after the distal cerebral protection device was removed. Significantly better results were obtained by the following parameters: in the Study Group the number of patients discharged with no neurological deficit (scoring 0 by the NIHSS scale) was significantly higher compared with the Control Group; 50% vs 7.7% (p<0.001). There were no lethal outcomes in either group. One patient (7.7%) from the Study Group developed recurrent ischaemic stroke, whereas neither intra- nor postoperative stroke was registered in the Control Group patients (p<0.001). CONCLUSIONS: In carefully selected patients with ischaemic stroke (neurological deficit not exceeding 3 points by the Rankin scale and not more than 11 points by the NIHSS, with the size of the ischaemic focus not exceeding 4 cm), surgical prevention of recurrent stroke within 7 days after the onset of an ischaemic event may be performed effectively and safely. Early operation effectively prevents relapsing ischaemic events at the in-hospital stage. Besides, reconstruction of brachiocephalic arteries during an acute stage of stroke in operated patients improves the neurological status in the postoperative period, decreases the degree of motor and sensory disorders and makes it possible in half of patients to completely eliminate neurological deficit present at admission.

[Experience in diagnosis and treatment of combined lesions of the extra- and intracranial portions of the internal carotid artery].

The treatment policy concerning patients with lesions of the extra- and intracranial portions of carotid arteries is currently uncertain. The authors share herein their experience in diagnosis and treatment of 5 patients presenting with lesions of the extracranial portions of the internal carotid artery (stenosis/occlusion/pathological tortuosity) combined with arterial aneurysms and arteriovenous malformations of the brain. Of these, two patients were operated on: the first one was primarily subjected to clipping of the cerebral aneurysm then after several months underwent a reconstructive vascular operation on the ipsilateral side (resection of the internal carotid artery with its readdressing). The second patient with subtotal stenosis of the internal carotid artery who initially underwent clipping of the ipsilateral asymptomatic aneurysm of the middle cerebral artery developed occlusion of the internal carotid artery by the second stage of treatment and was not subjected to vascular operation. There were no is-chaemic cerebral complications or lethal outcomes in the operated patients in peri- and post-operative periods at all stages of treatment.

[Modern approach to diagnosis and treatment of acute mesenteric ischemia].

It was proposed the medical and diagnostic tactic in patients with acute mesenteric ischemia on basis of efficiency results of modern laboratory markers and instrumental methods. Positive laboratory D-dimer-test with computed tomography of abdominal organs or abdominal aorta and its branches CT-angiography led to diagnose thrombosis or embolism of mesenteric arteries at early terms and to reduce preoperative period. The authors presented the variant of isolated endovascular intervention in case of superior mesenteric artery thrombosis. This technique may be regarded as the method of choice in the treatment of patients with acute mesenteric ischemia.

[Possibilities of endovascular surgery in treatment of acute arterial impairment of mesenteric blood circulation].

The authors demonstrate herein their experience (3 clinical case reports) in endovascular interventions in the basin of the superior mesenteric artery, performed for its thromboembolism (2 patients) and thrombosis (1 patient). Rheolytic thrombectomy from the superior mesenteric artery turned out inefficient in one patient and he was operated on in the scope of laparotomy, vast resection of the small intestine and the right half of the large intestine and indirect embolothrombectomy from the superior mesenteric artery. Aspiration thrombectomy had only a partial effect in the second patient presenting with thromboembolism of the proximal segment of the superior mesenteric artery: the major blood flow through the artery was restored and the scope of intestinal resection was reduced to 20 cm of the jejunum. Finally, the third patient underwent combined endovascular (rheolytic and aspiration) thrombectomy performed in an isolated manner, with neither laparotomy nor intestinal resection employed. In the last two cases, endovascular thrombectomy was supplemented by selective administration of platelet glycoprotein IIb/IIIa receptor inhibitors injected into the basin of the mesenteric artery. Endovascular intervention is an operation of choice in patients presenting with acute impairment of mesenteric blood circulation at the stage of intestinal ischaemia.

[Venous thromboembolic complications in patients with intracranial hemorrhage and tumors of the central nervous system].

It was analyzed the results of diagnosis and prevention of venous thromboembolic complications in 248 patients with intracranial hemorrhages of different etiology (hemorrhagic stroke, subarachnoid hemorrhage, craniocerebral injury, hemorrhages in the tumors of brain and spinal cord). The overall frequency of venous thrombosis in the vessels of the inferior vena cava pool was 24.6% (in 61 patients), the majority of patients had the asymptomatic thrombosis. The crural veins were the main localization of venous thrombosis. Also it was the main origin of thromboembolic complications (60.7%). Surgical treatment in different amount was an independent predictor of venous thromboembolic complications in neurosurgical patients according to the multivariate variance analysis. The frequency of thrombosis was significantly higher in the group of operated patients in comparison with non-operated group (37.1 vs. 17.6% (p=0.008). Early prevention by geparin (the use of direct anticoagulants for 2-4-th day of the founding of an intracranial hematoma) did not reduce the frequency of venous thrombosis in operated patients, but significantly reduced the frequency of fatal pulmonary embolism: 0 vs. 9.1% (p=0.002). Patients with intracranial hemorrhage are the one of the most unfavorable groups in terms of their venous thromboembolic complications.

[Organ-preserving method in the surgical treatment of the spleen injuries].

The authors have experience in organ-preserving operations for spleen rupture with the splenic artery ligation in 156 casualties. They consider that such operations let to preserve the spleen, to avoid the postoperative rebleeding and ischemia of pancreas tail and body. Also it is accompanied by the low indications of lethality and postoperative complications. The authors consider that this operation is alternative to splenectomy and other techniques of organ-preserving operations in case of spleen trauma.

[The organ-preserving surgical treatment of the splenic rupture after the blunt abdominal trauma].

The outcomes of 383 cases of heavy combined traumas (n=273) and isolated (n=110) closed injuries of the abdomen with spleen damage were analyzed. The overall mortality was 11.74% (n=45), whereas the mortality rate during the first day after admission was 7.83% (n=30). Removal of a spleen was executed at 228 patients. The spleen-preserving operation with ligation of splenic artery, was performed in 155 patients. The optimal level of the splenic artery ligation proved to be in its proximal and median parts. The postoperative CT-angiogarphy and Doppler US scanning together with the three-dimensional reconstruction confirmed that blood supply of the body and tail of the pancreas was satisfactory thanks to the natural collateral blood circulation. The dramatic decrease in lethality and of postoperative complication rates allows to consider spleen-preserving resections to be a good alternative to spleenectomy.

[Sural sinus as the main source of postoperative venous thromboembolic complications in neurosurgical patients].

The authors analysed the results of diagnosis and treatment of venous thromboembolic complications in a total of 239 patients presenting with various-aetiology intracranial haemorrhage and tumours of the central system. The total incidence of venous thromboses in the system of the inferior vena cava amounted to 25.1%. Thromboembolism of pulmonary artery complicated the course of the underlying disease in 3.3% of cases. Operative treatment of the underlying disease resulted in an increased incidence rate of thromboses of deep veins from 18.5 to 36.4% (p=0.015) and that of pulmonary artery thromboembolism from 2.7 to 4.5% (p=0.5). The most frequently encountered localization of thromboses in the postoperative period turned out to be the sural veins of the crus. The level of consciousness (p=0.0001), operative treatment (p=0.002), putaminal and thalamic intracranial haematomas (p=0.01), as well as dislocation syndrome (p=0.05) according to the findings of the univariate analysis were the risk factors for the development of venous thromboses in patients with haemorrhagic stroke. Independent predictors of the development of venous thromboembolic complications in patients with haemorrhagic-type acute impairments of cerebral circulation according to the data of the univariate analysis were the level of consciousness by the Glasgow coma scale scoring 4-5 points (p=0.01) and deep-seated localization of the intracerebral haematoma (p=0.01). Patients with intracranial haematoma having endured operative treatment are a cohort of patients running the highest risk for the development of postoperative venous thromboembolic complications.

[The possibilities of laser Doppler flowmetry for the estimation of the intestine resection volume by the acute mesenteric ischemia].

The results of the surgical treatment of the acute mesenteric ischemia in 2 groups of patients were comparatively analyzed. The control group (n=52) experienced the traditional way and criteria of detecting the volume of intestinal resection (color and peristaltic activity, arterial pulsation). For the main group (n=57) the intraoperative estimation of the intestinal viability was performed with the help of laser Doppler flowmetry. As a result, the postoperative intestinal gangrene rate was 9.1% among patients of the main group, whereas the complication was registered among 48.6% of the control group. The main group of patients demonstrated the overall lower rate of postoperative complications in comparison with the control group: 67.6 and 40.9% (p=0.01), respectively. The same picture was for the lethality rate: 76.9 and 52.6% (p=0.03), respectively.

[Computed tomography and CT angiography in diagnosis of acute disorders impairment of mesenteric circulation].

Presented herein is the first experience in using two instrumental methods (remote contrast- free computed tomography and CT angiography) in a total of twenty-one patients suspected of having acute mesenteric ischaemia. Contrast-free computed tomography allowed of making a correct diagnosis of acute mesenteric ischaemia in 6 of 7 patients (with sensitivity of 85.7% and specificity amounting to 90%). Thrombosis of mesenteric vessels was revealed in all cases on CT angiography, with both sensitivity and specificity of the method equalling 100%. Also described herein is the incidence rate of various CT signs of intestinal lesions depending on aetiology and the stage of the disease. Minimally invasive nature, high spatial resolution of these two methods, high sensitivity and specificity make it possible to recommend them as the first step for instrumental diagnosis of acute mesenteric ischaemia.

[Safety and efficacy of various regimens of heparin-mediated prevention of venous thromboses in patients with intracranial haemorrhage].

Analysed in the article is the incidence rate of the development of venous thromboembolic complications in a total of 79 patients presenting with various-aetiology intracranial haemorrhage in different regimens of heparin-mediated prevention. The authors have revealed that early (on day 2-4 after the onset of the disease) administration of preventive doses of heparin in patients with intracerebral and intracranial haematomas is a safe and efficient regimen, since it decreases the rate of venous thromboses in the system of the vena cava inferior and fatal thromboembolic complications as compared with a later term (on day 5 and more) of initiating heparin-mediated prevention.

[Major intestinal resections and short-bowel syndrome in patients with the acute mesenterial thrombosis].

The study represents the retrospective analysis of major intestinal resections (the length of the left in olace bowel less then 200 sm) and non-major resections in 52 patients operated on the acute mesenterial thrombosis. Major bowel resection was performed in 30 patients (57.7%). 66.7% of those patients (20 of 30) died soon after the operation. Whereas lethality rate among patients with non-major resections was 54.5% (12 of 22). All 10 survived patients demonstrated the short-bowel syndrome during the follow-up period (the median follow-up time was 25 months).

[The ileal and colic microcirculation by the thrombosis and thromboembolism of mesenterial arteries].

Quantitative and functional parameters of regional intestinal blood circulation were intraoperatively investigated with the use of laser Doppler flowmetry. The first group consisted of patients with necrotized parts of the intestine, while the second (control) group consisted of flowmetry data from intact intestine. Such indexes, as basal circulation, variation coefficient, blood oxygen perfusion saturation index, maximal perfusion amplitude of endothelial, neurogenic and myogenic oscillations in the intestinal volume, were showed to be valuable for the intestinal viability assessment. Thus, the method of the intraoperative laser Doppler flowmetry can be useful for determining the volume of intestinal resection.

[Intestinal microcirculation in health and in acute impairment of mesenteric blood flow].

The authors attempted to determine instrumental criteria for vitality and non-vitality of the intestine with the help of laser Doppler flowmetry and absorption spectroscopy. The material used was subdivided into two study groups: in group one, the indices of microcirculation of the viable small and large intestine were determined during elective cavitary operations; group two comprised 20 portions of resected necrotised segments of the large and small intestine, wherein we registered the indices of microcirculation of the non-viable devitalized intestine. We thus obtained instrumental indices of microcirculation of various intestinal portions in health, as well as in the setting of acute impairment of intestinal blood circulation and intestinal gangrene. Statistically significant differences were revealed only for the parameter of microcirculation and the coefficient of variation of the "viable" and necrotized intestine; blood oxygen saturation and volumetric blood filling of tissue between the two groups did not differ significantly. The instrumental criteria for intestinal vitality and non-vitality of may be used while making a decision as to the scorife of resection of the intestine affected which would thus make it possible to decrease the rate of progression of intestinal necrosis in the postoperative period. We believe that this would make it possible to substantially improve the outcomes of surgical management and to decrease lethality in patients presenting with acute impairment of mesenteric circulation.

[Treatment and prevention of thromboembolism in patients with intracranial hemorrhage].

Frequency of venous thromboses and thromboembolic complications was retrospectively analyzed in 95 patients with intracranial hemorrhage of various etiology. Thrombosis of inferior caval vessels was registered in 19 (20%) patients; of them 3 patients had thromboembolism of a pulmonary artery, lethal in one case. The high frequency of venous thromboses indicates the necessity of early use of anticoagulants in treatment dosages and importance of the prophylaxis measures. Cava-filter implantation for pulmonary artery thromboembolism prevention should be considered only in patients with strong contraindications for anticoagulant therapy.

[Programmed relaparotomy in treatment of upper mesenteric artery acute occlusion].

Results of surgical treatment and frequency of intestinal necrosis in 44 patients with acute mesenterial circulation failure were analyzed. Instrumental method of detecting the border of necrosis by the infracted intestine should allow refuse programmed relaparotomies in treatment of such patients and perform a sole operation with intestinal resection and anastomosis.