RESUMEN
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.
Asunto(s)
Isquemia Encefálica , Estenosis Carotídea , Aneurisma Intracraneal , Accidente Cerebrovascular , Anciano , Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/cirugía , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/cirugía , Constricción Patológica , Femenino , Humanos , Aneurisma Intracraneal/complicaciones , Aneurisma Intracraneal/diagnóstico , Aneurisma Intracraneal/cirugía , Masculino , Persona de Mediana EdadRESUMEN
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.