[Chronic cerebrovascular diseases and neuroprotection: the clinical efficacy of meldonium (Mildronat)]. / Khronicheskie formy narushenii mozgovogo krovoobrashcheniya i neiroprotektsiya: klinicheskaya effektivnost' primeneniya mel'doniya (Mildronat).

OBJECTIVE: To evaluate the efficacy of meldonium (mildronat) in patients with chronic cerebral vascular disease (CVD). MATERIAL AND METHODS: An open comparative study of the clinical efficacy of meldonium (mildronat) in patients with chronic CVD caused by arterial hypertension and atherosclerosis was conducted. The main group included 30 (60%) patients who were prescribed meldonium (mildronat) at a dose of 1000 mg per day in addition to routine basic therapy. The control group was consisted of 20 (40%) patients who received routine basic therapy only. The duration of the study was 60 days. To evaluate the clinical efficacy of the meldonium (mildronat), the main subjective clinical symptoms, neurological, psychoemotional and cognitive status, quality of life were assessed when patients were included in the study (before treatment), on the 11th and 60th days from the start of treatment. To assess the meldonium (mildronat) effect on the endothelium vascular wall, asymmetric dimethylarginine (ADMA), tissue plasminogen activator (tPA), plasminogen activator inhibitor-1 (PAI-1) and endothelin-1 were determined in the blood when patients were included in the study, on the 11th and 60th days from the start of treatment. RESULTS: Meldonium (mildronat) has a positive therapeutic effect on the main clinical symptoms and cognitive functions which appears in increasing the quickness of mental activity, improving short-term and operative memory, increasing the resistance of mental processes and memory traces to interfering influences, and improving cognitive evoked potentials P300 results. Meldonium (mildronat) therapy leads to the decrease in the level of state and trait anxiety. The quality of life of patients treated with meldonium (mildronat) increases due to the physical and mental components. The effect of meldonium (mildronat) on the decrease in endothelin-1 and PAI-1 levels, which indicates the antitrombogenic effect of the drug, has been identified. CONCLUSION: Nootropic, anxiolytic and antitrombogenic effects of meldonium (mildronat) in patients with chronic CVD are demonstrated that makes it possible to recommend this drug for widespread use by specialists in clinical practice.

[Predictors of acute cerebral embolic lesions during carotid artery stenting]. / Prediktory ostrykh tserebral'nykh émbolicheskikh povrezhdenii pri stentirovanii sonnoi arterii.

The authors carried out a prospective study aimed at revealing predictors of acute embolic lesions of cerebral vessels during angioplasty with stenting of the internal carotid artery. The study enrolled a total of 54 patients who between May 2015 and December 2018 underwent carotid angioplasty with stenting performed at the Department of Vascular and Endovascular Surgery of the Research Centre of Neurology. The procedure of internal carotid artery stenting may be accompanied by intraoperative acute embolic lesions. In order to reveal intraoperative acute embolic lesions of cerebral vessels all patients before and 24 hours after the intervention were subjected to diffusion-weighted magnetic resonance imaging. Thirty-six patients received classical carotid stents (Xact and Acculink) and 18 patients received Casper stents. The patients of both groups were comparable by 24 characteristics studied, including the incidence of intraoperative acute cerebral embolic lesions (18/36 for the classical stents and 10/18 for the Casper stent), which made it possible to unite them into one group in order to increase the power of the study. All acute embolic lesions detected by the diffusion-weighted magnetic resonance imaging (prior to stenting and 24 hours thereafter) were clinically, asymptomatic with no perioperative stroke observed. In order to reveal predictors of intraoperative acute embolic lesions of cerebral vessels we analysed 22 characteristics of the patients, with the obtained findings demonstrating the following signs: a low-intensity (below 20 dB) ultrasonographic signal reflected from fragments of an atherosclerotic plaque during ultrasound examination prior to stenting (p=0.001) - a sign strongly associated with acute embolic lesions (sensitivity - 75%, specificity - 92%); symptomatic stenosis according to the anamnestic data (p=0.02) - a sign significantly associated with acute embolic lesions; female gender (p=0.06) - a sign moderately associated with acute embolic lesions; a history previously endured (according to the anamnestic data) operations on coronary and/or carotid arteries (p=0.09) - a sign weakly associated with acute embolic lesions. Based on the obtained findings we proposed a prognostic scale to assess the risk of acute embolic lesions of cerebral vessels during internal carotid artery stenting. Knowing the factors associated with intraoperative acute embolic lesions will allow the endovascular surgeon to single out the patients at increased risk of acute embolic lesions.

[Relation between ultrasonographic and morphological characteristics of atherosclerotic plaques of carotid sinus]. / Sviaz' ul'trazvukovykh i morfologicheskikh kharakteristik ateroskleroticheskikh bliashek karotidnogo sinusa.

The authors revealed relation between the structure of an atherosclerotic plaque (ASP) and intensity of the ultrasound signal reflected form the ASP. Our prospective pilot study included a total of 90 patients (71 men and 19 women aged from 47 to 79 years, with the median age 62 years) presenting with atherosclerotic stenosis of the carotid sinus (CS) and undergoing treatment at the Research Centre of Neurology (Moscow) from April 2015 to March 2016. All patients underwent ultrasonographic examination followed by morphological study of the structure of the plaques removed during carotid endarterectomy (CEA). It was revealed that intensity of the ultrasound signal from an ASP depended on the morphological structure of the ASP components: the foci of atheromatosis were associated with an ultrasound range of 1.1-5.6 dB, those of fibrosis - with the range 23.1-30.5 dB, and those of calcinosis - with the range 42.3-44.7 dB (presented are the values from the 15th to 85th percentiles). It was determined that an increase of intensity of the ultrasound signal reflected from the foci of atheromatosis and fibrosis in the ASP was associated with the presence of small calcificates therein, and a decrease of intensity of the ultrasound signal from the portions of fibrosis in the ASP - with large accumulation of lipophages or newly formed vessels in these portions.

[Carotid revascularization in type 2 diabetes mellitus. Significance of chronic hyperglycaemia]. / Karotidnaia revaskuliarizatsiia u bol'nykh sakharnym diabetom 2 tipa. Znachenie khronicheskoi giperglikemii.

Patients with type 2 diabetes mellitus (type 2 DM) are typically prone to the development of cerebral atherosclerosis. Presented herein are the results of examination of patients suffering from ischaemic cerebrovascular diseases on the background of type 2 DM subjected to open surgical or endovascular interventions. In patients with cerebrovascular pathology and type 2 DM, atherosclerosis progresses on the background of chronic hyperglycaemia combined with dyslipidaemia, leading to increased incidence of the development of cerebral circulatory impairments and detection of the indications for carrying out angioreconstructive operations on the internal carotid arteries. The presence of type 2 DM is associated with increased risk for the development of ischaemic lesions of the brain matter while performing carotid endarterectomy and endovascular interventions which are associated with higher values of glycaemia (8.0 mmol/l) and glycated haemoglobin (7.8-8 %) prior to the operation.

[Prediction of ischaemic lesions of the brain in reconstructive operations on internal carotid arteries]. / Prognozirovanie ishemicheskikh povrezhdenii golovnogo mozga pri rekonstruktivnykh operatsiiakh na vnutrennikh sonnykh arteriiakh.

The present study was undertaken to examine the relationship between the level of the intensity of the ultrasonic signal reflected from atherosclerotic plaques (ATP) of carotid arteries and the risk for formation of an ischaemic lesion in the brain matter, detected during diffusion-weighted magnetic resonance imaging (DW-MRI) performed 24 hours after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS). Our prospective study included a total of 78 patients presenting with stenosis of the sinus of the interior carotid artery. Of these, 42 patients were subjected to CEA and 36 subjects endured CAS. All patients in the preoperative period underwent ultrasonographic examination with determination of the degree of heterogeneity of ATPs and registration of the values of the intensity of acoustic characteristics of the signal. The condition of the brain matter before and 24 hours after the intervention was assesses by the findings of DW-MRI. None of the patients after the reconstructive intervention during the postoperative period demonstrated any evidence of acute cerebral circulation disorders. DW-MRI carried out 24 hours after the operation revealed acute ischaemia foci (AIF) in 9 (21.4%) patients after CEA and in 18 (50%) patients after CAS (p=0.05). It was revealed that the postoperative occurrence of AIF was related to the intensity of the ultrasonographic signal prior to the operation: in the CEA group patients the postoperative ischaemic foci were associated with high-intensity ultrasonographic signals (more than 25 dB), whereas in the CAS group patients, vice versa - with low-intensity signals (less than 25dB). For CEA, sensitivity and specificity of the preoperative ultrasonographic method of predicting postoperative embolic lesions of the brain appeared to be similar, amounting to 100% each (with the cut-off point of high- and low-intensity signals equaling 25 dB), and for CAS, sensitivity of the method turned out to be 75% and specificity - 100% (with the same cut-off point of 25 dB). A conclusion was drawn that quantitative characteristics of the intensity of an ultrasonographic signal from fragments of atherosclerotic plaques of the sinus of the internal carotid artery made it possible with high probability to predict the risk for the development of AIF in the brain matter after both CEA and CAS and may therefore serve as a reliable criterion for appropriate therapeutic decision-making with the lowest risk of inflicting lesions in a particular case. The threshold cut-off points of high- and low-intensity ultrasonographic signals, as well as their clinical significance are yet to be specified and verified with the growing number of cases.

[Ischaemic lesions of cerebral after carotid stenting].

Carotid angioplasty with stenting is a reliable method of primary and secondary prevention of ischaemic stroke in patients with stenosing lesions of the internal carotid artery. However, carrying out such operations is sometimes associated with risk for the development of intraoperative impairments of cerebral circulation due to arterioarterial embolism in cerebral arteries, as well as vasospasm. Presented herein are the results of following up a total of 64 patients with pronounced atherosclerotic lesions of internal carotid arteries (>70%) - "symptomatic" and "asymptomatic", undergoing carotid stenting. Acute foci of ischaemia in the brain after stenting according to the findings of diffusion-weighted magnetic resonance tomography were revealed in 40% of cases, and in only 6% of patients they manifested themselves by symptoms of acute cerebral circulatory impairment. We revealed a direct correlation between the number, size of infarctions in the brain, and the appearance of neurological symptomatology. Intraoperative monitoring of blood flow in the middle cerebral artery during stenting makes it possible to predict the appearance of acute foci of cerebral ischaemia, to specify the genesis of perioperative stroke, as well as to evaluate clinical significance of vasospasm and material microembolism. The obtained findings should concentrate neurologists' attention on active postoperative follow up of patients subjected to carotid angioplasty with stenting in order to perform adequate personified neuroprotective correction, including preventive one.

[Intraoperative monitoring of cerebral blood-flow and condition of cerebral at open and endovascular interventions in carotid system].

The aim of our research is to study hemodynamic and embolic situation during the carotid endarterectomy (CEA), carotid angioplastic and stenting (CAS), and to reveal the prognostic significance of the data provided by intraoperative monitoring of the brain blood flow in exposing acute ischemic lesions in brain. Intraoperative monitoring of blood flow in artery ophthalmic vas carried out with 60% of patients, in the middle cerebral artery-with 40% during the main stages of CEA, and with 64 patients in the middle cerebral artery during CAS. The comparison of the data of intraoperative monitoring of blood flow in middle cerebral artery with the result of brain diffusion-weighted magnetic resonance imaging (DW-MRI) 24 hours after the operation shows, that solid microembolic signals and vasospasm are prognostic signals (sensibility and specifics make up 95%) in the development of acute ischemic cerebral lesions. The monitoring of blood flow in artery ophthalmic is of the greatest diagnostic value in estimation of the hemodynamic situation, but it is of the lowest practical value in detecting microembolic signals. According to the data of the intraoperative blood flow monitoring in middle cerebral artery in group CEA the development of acute ischemic cerebral lesions were predicted with 11,1% of patients and the cause of postoperative stroke, developed by 2,9% of the patients, was specified. According to the result of DW-MRI, acute ischemic cerebral lesions were diagnosed with 21% of patients, that is, 18% of ischemic cerebral lesions were asymptomatic. In group CAS ischemic cerebral lesions were prognosed with 30% of patients, actually they were later detected with 40,6% of cases by means of DW-MRI. According to the data of intraoperative of blood flow monitoring the cause of the development of postoperative stroke was specified in 6,2% of cause; in 34,4% of cause the acute ischemic cerebral lesions were asymptomatic.