[Surgical treatment of cervical neurovascular bundle tumors]

OBJECTIVE

To determine the main principles of a patient-oriented individual approach to diagnosis and surgical treatment of cervical neurovascular bundle tumors considering the capabilities of neurosurgical hospital.

MATERIAL AND METHODS

There were 92 patients with cervical soft tissue tumors affecting neurovascular bundle. Age of patients ranged from 9 to 81 years (mean 47). There were 65.1% women and 34.9% men. We found chemodectoma (47.4%), neurofibroma (15.8%), neurinoma (13.2%), papillary thyroid cancer (5.3%), salivary gland heterotopia (5.3%), salivary gland adenocarcinoma (5.3%), Hodgkin lymphoma (2.6%), hemangioendothelioma (2.6%) and cavernous lymphangioma (2.6%). Diagnostic algorithm included neurological examinations, Doppler ultrasound of supra-aortic arteries, transcranial ultrasound of cerebral vessels, MRI of cervical soft tissues, CT-AG, MR-AG, CT-perfusion, direct selective angiography.

RESULTS

A total of 94 surgical interventions were performed. All surgeries were performed using surgical optics and neurophysiological monitoring of cranial nerves IX, X, XII. We chose resection technique depending on localization, histological features and blood supply of tumor. En-bloc resection was performed in 46 cases, removal of fragments - in 23 cases, intracapsular resection of tumor followed by resection of the capsule - in 26 cases. Total and subtotal resection was performed in 68 (72%) and 23 (24%) cases, respectively. Three (4%) patients underwent partial resection of infiltrative tumors for carotid artery decompression and histological analysis. In 76% of cases, baseline symptoms of disease regressed after surgery. Persistent moderate bulbar disorders were observed in 16 patients (17%). Ischemic complications with additional surgical interventions were observed in 2 cases.

CONCLUSION

Patients with cervical soft tissue tumors require individual approach regarding choosing the optimal surgical treatment including possible preoperative embolization of tumor, en-bloc or intracapsular resection and carotid artery repair.

[A 20-year experience in surgical treatment of steno-occlusive lesion of craniocervical arteries at the Burdenko Neurosurgical Center]

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.

[Non-coding RNAs as therapeutic targets in spinal cord injury]

Spinal cord injury (SCI) may be followed by persistent motor dysfunction and somatosensory disturbances that negatively influences the quality of life of patients and creates a significant economic burden. Analysis of secondary biological processes associated with changes in genetic expression is becoming increasingly important every day in understanding the pathophysiology of spinal cord injury. The results of international sequencing of the human genome were analyzed in 2004. These data revealed about 20,000 protein-coding genes covering near 2% of the total genomic sequence. The vast majority of gene transcripts are actually characterized as non-coding RNAs (ncRNAs). These RNA clusters do not encode functional proteins and ensure post-transcriptional regulation of gene expression. The clusters may be small (approximately 20 nucleotides) known as miRNAs or the transcripts can enroll over 200 nucleotides defined as long non-coding RNAs (lncRNAs). Some modern studies describe transient expression of microRNA in case of spinal cord injury. These RNAs are associated with inflammation and apoptosis, functional recovery and regeneration. Large-scale genomic analysis has demonstrated the existence of multiple lncRNAs whose expression is associated with some processes of spinal cord injury. lncRNA can be divided into two categories depending on the position in relation to the coding genes: intergenic and intragenic. Intergenic lncRNAs is currently the most studied class. Intragenic lncRNAs can be subdivided depending on the overlap of the coding genes (antisense, intron, etc.). According to recent studies, long non-coding RNAs are abundantly present in the tissues of central nervous system and may be crucial in the pathogenesis of certain diseases of nervous system. At the cellular level, it has been shown that lncRNAs regulate the expression of protein-coding RNAs. Moreover, these molecules are involved into such processes as neuronal death, demyelination and glia activation. This review is devoted to the role of ncRNAs in the pathogenesis of spinal cord injury and their potential use as targets for the treatment of consequences of spinal cord injury.

[Creation of extracranial-intracranial microvascular anastomosis under regional anesthesia (a case report and a review of the literature)]

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.

[Carotid endarterectomy in patients with symptomatic occlusions of the contralateral internal carotid artery]

The main aim of the study was to investigate the effect of carotid endarterectomy on the prognosis of chronic cerebral ischemia in patients with symptomatic occlusions of the contralateral internal carotid artery, assess risks of surgical complications, and substantiate the staged surgical approach for treatment of patients with this pathology. The article analyzes the experience in surgical treatment of 83 patients with symptomatic ICA occlusions who underwent surgery for contralateral carotid artery stenosis. In 40 patients, only carotid endarterectomy (CEA) was performed on the side of hemodynamically significant stenosis (group 1). In 43 (52%) cases, apart from CEA, extracranial-intracranial (EC-IC) bypass was performed at the second stage (23 cases, group 2) or the first stage (19 cases, group 3). A surgical treatment approach was chosen based on clinical symptoms, severity of contralateral carotid artery stenosis, and the magnitude of perfusion deficiency in the territory of carotid occlusion. The conducted analysis revealed that patients with symptomatic occlusions and contralateral carotid artery stenoses represented a heterogeneous group with a different efficacy of carotid endarterectomy and with risks of perioperative complications. As cerebrovascular insufficiency in the territory of carotid occlusion and a related neurological deficit worsen, the risks of complications of contralateral carotid endarterectomy increase, and its clinical efficacy decreases. In these cases, cerebral revascularization on the ICA occlusion side should be performed at the first stage.

[Simultaneous reconstruction of the carotid and vertebral arteries using a temporary intraluminal shunt (a clinical case)]

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.

An anastomosis between the internal carotid and vertebral arteries in the treatment of a patient with bilateral carotid arteries occlusions

The article presents a case of successful surgical treatment of a patient with progressive chronic cerebral ischemia due to occlusions of both internal carotid arteries combined with occlusion of the vertebral artery in the first and second segments. We describe a surgical technique that includes an auto arterial carotid-subclavian bypass in the third segment of the vertebral artery, with an extracranial portion of the occluded internal carotid artery (after preliminary thromboendarterectomy) being used as a shunt. Previously, the patient had undergone surgery for creating bilateral EICMA. We analyzed the indications for each phase of the surgery with allowance for the peculiarities of compensatory collateral circulation and possible complications of the surgical treatment.

Criteria of the efficacy of surgical brain revascularization in patients with chronic cerebral ischemia

PURPOSE

The article analyzes results of surgical revascularization in patients with symptoms of chronic cerebral ischemia caused by occlusion of the carotid arteries.

MATERIAL AND METHODS

We analyzed 404 surgeries for placement of extra-intracranial microvascular anastomoses (EICMAs) performed in 376 patients between 2000 and 2015. All patients underwent detailed neurological and neuropsychological examinations before surgery and throughout the follow-up period using the neurological deficit scale (NIHSS). Additionally, the medical history data, technical features of surgery, and results of instrumental tests were recorded. For a more detailed study of the cerebral circulation, a SCT perfusion examination was conducted in 58 patients before and after placement of EICMA.

RESULTS

All patients were divided into 3 groups, depending on the surgical treatment outcomes: improvement (53%), without significant changes (43%), and worsening of clinical symptoms (4%). A statistical analysis revealed that the efficacy of EICMA surgery ranged from 22 to 79% and was reliably confirmed by hemodynamic and anamnestic factors as well as by technical details of surgery.

CONCLUSION

When determining the indications for surgical revascularization in patients with ischemic stroke consequences, the patient's age, occlusion duration, location and size of ischemic lesions should be considered. Also, the choice of the acceptor artery and blood flow through the created anastomosis are of great importance.

[Combined surgical treatment of cavernous internal carotid artery pseudoaneurysm]

We describe a clinical case of surgical treatment of a cavernous internal carotid artery (ICA) pseudoaneurysm that developed due to damage to the artery during transsphenoidal resection of pituitary adenoma. Clinically, the aneurysm presented with episodes of profuse epistaxis that required tight nasal packing. Given the presence of an open circle of Willis, the patient underwent staged surgery that included the creation of a high-flow extra-intracranial anastomosis, subsequent endovascular ICA occlusion at the pseudoaneurysm level using balloon-assisted coiling, and endoscopic debridement of the nasal cavity. The combined surgical treatment of this rare complication successfully excluded the pseudoaneurysm from the bloodstream, which led to complete regression of nasal bleeding.

[Perfusion criteria of the EICMA efficacy in patients with symptomatic occlusion of the internal carotid artery]

AIM

To investigate changes in cerebral perfusion in patients with unilateral internal carotid artery occlusion before and after surgical revascularization of the brain, depending on the clinical efficacy of surgical treatment.

MATERIAL AND METHODS

The study included 60 patients with unilateral ICA occlusions who underwent placement of an extra-intracranial microvascular anastomosis (EICMA). All patients underwent a CT perfusion study before and after cerebral revascularization. In addition, the degree of neurological deficit was evaluated before surgery and during follow-up (3 and 8-10 months) using the NIHSS score.

RESULTS

All patients were divided into 3 groups, depending on the results of surgical treatment: objective improvement (43 patients), no changes (14 patients), and worsening of clinical symptoms (3 patients). In each group, the absolute and relative perfusion parameters (MTT, CBV, and CBF) were analyzed to identify the perfusion criteria for the EICMA efficacy. A significant relationship between the clinical efficacy of EICMA and a baseline perfusion deficit and its change after anastomosis placement was found.

CONCLUSION

Placement of EICMA is effective treatment for patients with symptomatic ICA occlusions and an increase in the blood transit time in the hemisphere ipsilateral to occlusion by more than 40% compared to that in the opposite side provided that perfusion is recovered in more than one area of the MCA territory (in accordance with the ASPECTS scale).

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.

The case of simultaneous use of direct and endovascular techniques for the reconstruction of occluded brachiocephalic trunk

The article provides an example of successful surgical treatment of progressive chronic cerebral ischemia due to occlusion of the brachiocephalic trunk and critical stenosis of the right internal carotid artery (more than 85%). We describe a hybrid method of surgical treatment, which include direct access to the neurovascular bundle, retrograde endovascular recanalization following angioplasty and stenting of the brachiocephalic trunk during temporary occlusion of the distal internal carotid artery and carotid endarterectomy. We provide an analysis of indications for each phase of operation considering the features of compensatory collateral circulation in the basin of the occluded brachiocephalic trunk and the possible complications of 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.

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.