[A 20-year experience in surgical treatment of steno-occlusive lesion of craniocervical arteries at the Burdenko Neurosurgical Center]. / Dvadtsatiletnii opyt khirurgicheskogo lecheniya stenoziruyushchei i okklyuziruyushchei patologii brakhiotsefal'nykh arterii v FGAU «Natsional'nyi meditsinskii issledovatel'skii tsentr neirokhirurgii im. akad. N.N. Burdenko¼.

INTRODUCTION: Surgical treatment of cerebral ischemia at the Burdenko Neurosurgical Center for the period from 1999 to 2019 is analyzed in the paper. The details of the treatment strategy in patients with steno-occlusive lesion of craniocervical arteries followed by cerebral ischemia developed over 20 years are discussed in the article. We have analyzed the features of surgical interventions on the major craniocervical arteries in a neurosurgical clinic and the results of this treatment. OBJECTIVE: To demonstrate management of various lesions of major cerebral arteries in modern neurosurgical vascular hospital. MATERIAL AND METHODS: In total, there were 3098 interventions on the major cerebral arteries in 2527 patients for this period. Mean age of patients ranged from 1.5 to 91 years (58±14 years). Interventions included open reconstructions of the carotid arteries (2031 surgeries), reconstructions of the vertebrobasilar arteries (135 surgeries), brain revascularization (658 surgeries), excision of the tumors of neurovascular bundle on the neck compressing carotid arteries (51 interventions). Endovascular interventions were performed in 223 cases and consisted of angioplasty and stenting of the extracranial segments of craniocervical arteries (185 surgeries), stenting of the intracranial arteries (30 surgeries) and endovascular thrombextraction (8 cases). Staged surgeries were performed in 541 patients (22.3%). RESULTS: Favorable outcomes were obtained in 87.6% of cases, satisfactory results - in 9% of patients. Clinical deterioration due to long-term postoperative complications and recurrent strokes occurred in 2.9% of cases. Postoperative morbidity rate was 4.6%, persistent neurological deficit developed in 2.6% of cases. Mortality rate was 0.5%. CONCLUSION: Surgical treatment of stenotic and occlusive lesion of the major cerebral arteries is an interdisciplinary problem. Solution of this issue is closely associated with technological progress, new discoveries in normal and pathological physiology, as well as clinical researches. Individualized choice of surgical approach is one the main modern trends of neurosurgical approach to this problem. At the same time, own surgical experience is the most important factor determining the results of arterial reconstructions.

[Monitoring of adverse event triggers as a tool for managing the medical care quality at a neurosurgical clinic. Invitation to the discussion]. / Monitoring triggerov neblagopriiatnykh sobytii kak instrument upravleniia kachestvom meditsinskoi pomoshchi v neirokhirurgicheskoi klinike. Priglashenie k diskussii.

Management of the healthcare quality and safety is one of the priorities of state policy for protecting health of Russian citizens. We describe modern technologies for managing the quality of medical care and patient safety based on a systematic approach. Potential applications of these technologies in neurosurgical practice are defined. Quantitative, qualitative, and basic indicators are proposed for evaluation of outcomes (results) as part of implementation of an integrated quality management system in neurosurgical practice.

[Simultaneous reconstruction of the carotid and vertebral arteries using a temporary intraluminal shunt (a clinical case)]. / Odnomomentnaia rekonstruktsiia sonnoi i pozvonochnoi arterii s ispol'zovaniem vremennogo vnutriprosvetnogo shunta (klinicheskoe nabliudenie).

The article describes a case of one-stage surgical treatment of a patient with progressive chronic cerebral ischemia caused by combined steno-occlusive lesions of the carotid and vertebral arteries. The disease was complicated by intolerance to temporary occlusion of the carotid artery due to an incomplete circle of Willis. We performed extra-anatomic carotid-vertebral artery bypass with subsequent ipsilateral carotid endarterectomy. A temporary intraluminal shunt was used at the main stage of reconstructive surgery. We use this clinical case to analyze the issues of surgical treatment for combined lesions of the carotid and vertebral arteries and the techniques for prevention of associated ischemic complications.

[Creation of extracranial-intracranial microvascular anastomosis under regional anesthesia (a case report and a review of the literature)]. / Sozdanie ékstra-intrakranial'nogo mikrososudistogo anastomoza v usloviiakh regionarnoĭ anestezii (klinicheskoe nabliudenie i obzor literatury).

The article describes a case of successful surgical treatment of an 81-year-old male patient with symptomatic occlusion of the internal carotid artery that led to severe impairment of cerebral hemodynamics and was accompanied by severe gait and equilibrium disorders. Given the patient's age and his positive medical history, he underwent surgery for the creation of an extracranial-intracranial microvascular anastomosis under regional anesthesia, with spontaneous breathing and a baseline level of consciousness being maintained. In the postoperative period, the patient achieved a marked clinical effect in the form of complete regression of syncopal conditions and gait disorders associated with recovery of cerebral perfusion in the right MCA territory. The article discusses the indications for surgical treatment and the technical details of surgery for the creation of an extracranial-intracranial microvascular anastomosis under regional anesthesia.

[Surgical management of patients with pathological deformities of carotid arteries].

Surgical management of pathological deformities of the internal carotid arteries, a cause of chronic brain ischemia, is discussed. This pathology is very common and is found in 25% of all individuals who underwent preventive medical examination according to the ultrasonography data. Most deformities do not pose any threat to patients, while some of them may cause ischemic stroke and chronic brain ischemia. The study included 165 patients with the known follow-up history who had been operated on at the N.N. Burdenko Neurosurgical Institute since 2001. A total of 196 reconstructive interventions of carotid arteries were analyzed. The indications for surgical management of pathological deformities based on clinical symptoms and identification of the signs of vascular wall dysplasia are thoroughly discussed. The local and cerebral hemodynamics during pre- and postoperative period are analyzed. The results of pathomorphological examination of the resected fragments of the deformed arteries are presented; they show that the changes are identical to those in patients with fibromuscular dysplasia. The follow-up history of the patients was recorded; it showed a sustained regression of transitory ischemic strokes and cerebral symptoms in most cases (69%). For proper indications for surgical management, reconstructive surgical interventions are a reliable and effective method for treating chronic brain ischemia and preventing recurrent ischemic strokes in patients with deformities of carotid arteries.

[Carotid endarterectomy in patients with high surgical risk].

Aim of the study to examine the risk factors for carotid endarterectomy (CEA) and their effect on the results of surgical treatment in patients with chronic cerebral ischemia. The study included 340 patients who were operated in the institute from 2007 to 2011. All patients underwent CEA in various modifications. Based on the classification of surgical risk CEA proposed by Sundt, patients were divided into 4 groups. In the following analysis, we evaluated perioperative outcomes of surgical treatment in the third and fourth groups, respectively, compared the frequency of the installation of temporary intraluminal shunt (TIS) during the surgery, depending on the severity of angiographic risk factors and neurological anamnesis. Perioperative ischemic complications in the third group was 4.2%, 6.4% in the fourth respectively. In both groups, TIS required in 15% of operations. In patients undergoing surgery under regional anesthesia, shunts were used two times less frequently than in patients under general anesthesia (8.8% vs. 19.8%). Correlation between the severity of angiographic risk factors and tolerance to hypoperfusion of the brain, caused by a temporary clamping of the ICA revealed. In case occlusion of the contralateral ICA temporary shunts have been installed in 40%, with contralateral stenosis in 15% and without angiographic and risk factors in 80% of cases. The findings coincide with the results of similar studies published in the literature. Taking into account our and foreign data should be noted that CEA in patients with high surgical risk by Sundt is accompanied by an increased incidence of perioperative ischemic complications and requires more differentiated approach to the tactics of surgical treatment, and choice of the method of neurophysiological monitoring during surgery.

[Surgical treatment of patients with chronic cerebral ischemia due to occlusion of the common carotid arteries].

The paper contains information about surgical occlusion of the common carotid arteries--one of the causes of chronic cerebrovascular ischemia. For the period from 2003 to the present time have been treated 25 patients with a clinical picture of cerebral ischemia due to occlusion of the common carotid artery. Performed a total of 48 surgical procedures among which subclavian-external carotid and common carotid bypasses, retrograde carotid thromboendarterectomy. In 7 cases revascularization of the brain was performed as a second stage. Choice of reconstruction type based on preoperative investigation results and intraoperative data. No persistent complications or mortality were observed. Positive clinical dynamics was noted in 80% of cases. Crossability of reconstruction area at the annual catamnesis was 84%. Prosthetic vascular graft thrombosis occurred most often (up to 40%) in patients with type 2 occlusion and in the presence of severe collateral perfusion. In patients with 1st type of occlusion of the common carotid artery reconstructive surgery have shown to be a reliable and effective treatment for chronic cerebral ischemia and prevention of recurrent ischemic stroke.