Endovascular Neuroradiology

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ISSN / EISSN : 23049359 / 26636964
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D.V. Shchehlov, S.V. Konotopchyk, I.N. Bortnyk, O.E. Svyrydiuk, M.Yu. Mamonova
Endovascular Neuroradiology, Volume 30; doi:10.26683/2304-9359-2019-4(30)-79-87

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D.V. Shchehlov, Ya.E. Kudelskyi, O.A. Pastushyn, O.E. Svyrydiuk, O.M. Goncharuk
Endovascular Neuroradiology, Volume 30, pp 23-30; doi:10.26683/2304-9359-2019-4(30)-23-30

Abstract:
Objective – to analyze there sults of treatment of patients with fusiform aneurysms (FA) depending on localization and type of surgery.Materials and methods. In the period from 2007 to 2019 127 patients with intracranial fusiform cerebral aneurysms underwen treatment in Scientific and Practical Center of Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine. 133 fusiform aneurysms were identified. The following neuroimaging methods were used to diagnose FA: magnetic resonance imaging, multispiral computed tomography and cerebral selective angiography according to Seldinger. In this study, patients with fusiform aneurysms are divided according to localization in the FA of the carotid poolsand the FA of the vertebrobasilar basin. Patients with FA of carotid basins were 56 (27 (29 (51.8 %) men and 48.2 %) women). The average age of patients was 45.2 year. 31 (55.3 %) patients were operated. Patients with FA in the vertebrobasilar basin were 71 (43 (60.6 %) men and 28 (39.4 %) women). The average age of patients was 54.5 year. It was operated 48 (67.6 %) patients.Results. It was possible to completely eliminate FA from the bloodstream intraoperative in 16 (51.6 %) patients. In the early postoperative period in this group 5 (16.1 %) patients had a decrease in disease symptoms, in 3 (9.6 %) patients neurological symptoms increased. In other patients the dynamics of neurological manifestations remained unchanged. There were nofatal out comes in either the early or late post operative period. According to the extended Glasgow outcome scale at the time of discharge from the hospital 22 (71 %) patients had > 5 points, 9 (29 %) – 4 points. In the period from 3 to 5 weeks 2 symptomatic thromboses of flow-directingstents were noted, in the form of clinical manifestations of ischemic stroke. In the period from 3 to 6 months 22 (71 %) patients underwent control examination. Angiographically in 19 (86.3 %) revealed a completes hut down of FA from the bloodstream, in 3 (13.7 %) – decrease of volume of FA > 65 %. Clinical symptoms completely regressed in 16 (72.7 %) patients, partially regressed – in 3 (13.7 %), increased – in 2 (13.6 %). In the period from 12 to 18 months 7 (31.8 %) patients underwent control examination. Total FA shut down from the bloodstream was detected in 5 (71.4 %) patients, in 2 (28.6 %) aneurysms decreased by 80 %. Eighteen-month survival was 100 %.It was possible to intraoperatively switch off FA in the vertebrobasilar basin from the bloodstream in 11 (22.9 %) cases. In the early postoperative period a partial regression of neurological symptoms was observed in 7 (14.5 %) patients. In 10 (20.8 %) cases a new or increasing neurological deficit was observed after intracranial stent implantation, which partially regressed against the background of conservative treatment. Four (8.3 %) deaths were recorded in the early postoperative period. The clinical results of 48 patients on the Glasgo woutcome scale at the time of discharge were > 5 points in 27 (56.2 %) patients, 4 points – in 17 (35.4 %) and 1 points – in 4 (8.3 %). In the period from 3 to 6 months 19 (39.5 %) patients underwent control examination. Angiographically in 14 (73.7 %) patients the aneurysm was completely turned off from the blood circulation, in 2 (10.5 %) the decrease in the volume of the aneurysm was > 70 %, in 3 (15.8 %) patients the decrease in the volume of the aneurysm was 47–64 %. Clinical symptoms regressed in 7 (36.8 %) patients, a decrease in neurological deficit was noted in 2 (10.5 %) patients, an increase in neurological deficit in 3 (15.8 %) patients. Three deaths were recorded. In the period from 12 to 18 months, 12 (25 %) patients underwent control examination. Angiographically in 10 (83.3 %) patients FA was excluded totally from the bloodcirculation, in 2 (16.7 %) – the volume of aneurysm was reduced by 80 %. Clinical symptoms regressed in 8 (66.6 %) patients and increased in 1 (8.3 %). During the control period 2 patients died. The 18-month survival rate was 89.5 %, 5 (10.5 %) patients died.Conclusions. Fusiform aneurysms are more common in people of working age, more common in men. A more unfavorable course of the disease occursin patients with symptomatic FA of the vertebrobasilar basin, due to the compression and dysfunction of the brainstem and stem structures. Deconstructive methods for eliminating FA from the bloodstream provide long-termsatis factory treatment results, butrequire careful selection of patients for such in terventions. Endovascular treatment should be considered as the main treatment, asitentails fewer risks for the patient. For aneurysms that cannot be treated with endovascular methods, microsurgical treatments hould be considered. The main forsuccess ful treatment of patients with fusiform aneurysms is th ecareful selection of patients and individual approach to the choice of treatment based on the shape, location and size of the FA.
K.Yu. Polkovnikova
Endovascular Neuroradiology, Volume 30, pp 31-37; doi:10.26683/2304-9359-2019-4(30)-31-37

Abstract:
Objective – to evaluate of diagnostic informativeness of сopeptin serum values in determining the risk of complications in patients with subarachnoid hemorrhage.Materials and methods. A prospective cohort study of 82 patients (40 men and 42 women) with spontaneous (non-traumatic) subarachnoid hemorrhage (SAH) from the age of 23 to 72 years (average age – (49,6 ±1,3) year) was conducted.Results. Complications were recorded in 31 (74.20 %) patients with a serum level of copeptin ≥ 0.605 ng/ml on the third day of the SAH, which was in 9.49 times higher (95 % CI 3.60–24.80, р ˂0.0001) than in patients with a serum level of copeptin < 0.605 ng/ml. When determining the cumulative risk of developing complications of SAH, the values ​​of positive and negative predictive values ​​of serum levels of copeptin on third day of SAH were 74.19 % and 92.20 % respectively, the accuracy of prediction (the sum of correctly classified observations) was 85.39 %.Conclusions. ROC-analysis suggests that the serum level of copeptin on third day of SAH ≥ 0.605 ng/ml is characterized by an optimal ratio of sensitivity and specificity in assessing the cumulative risk of developing such SAH complications as secondary ischemia combined with cerebral angiospasm.
Yu.V. Cherednichenko
Endovascular Neuroradiology, Volume 30, pp 68-78; doi:10.26683/2304-9359-2019-4(30)-68-78

Abstract:
Case of endovascular treatment of a patient with tandem left internal carotid artery (ICA) and middle cerebral artery (MCA), which was a complication of carotid endarterectomy, are presented. The rupture at the location of the suture in the bulb of the ICA during endovascular intervention required implantation of a graft-stent and subsequent removal of the hematoma in the neck soft tissues.A 51 year old man in the residual period of ischemic stroke in the left carotid basin with elements of sensory speech disorders, with subtotal stenosis in the bulb of the left ICA, stenosis 35 % in the bulb of the right ICA and severe hypoplasia of the A1-segment of the left anterior cerebral artery underwent left-side carotid endarterectomy. The next morning after surgery, 1 hour after awakening, a right-sided hemiparesis progressing to hemiplegia, total aphasia. The level of consciousness deteriorated to the sopor. A computer tomography was performed immediately. New ischemic lesions were not identified. Cerebral angiography revealed the occlusion from the mouth of the left ICA, occlusion in the M1-segment of the left MCA. Thrombospiration from MCA and ICA was performed with Sofia Plus distal approach catheter. The MCA was recanalized in one pass (mTICI 3), but the patency of the left ICA was not recovered. The anti-embolic device SpiderFX was introduced and opened in the C2-segment of the left ICA. Then, a slow inflation of the Submarine 5 × 20 mm balloon catheter was performed in the left ICA bulb. At a pressure of 4.0 atm, the balloon opened like an hourglass, indicating a rough rigid stenosis in the ICA bulb. At a pressure of 4.5 atm, the balloon fully opened. Immediately after balloon deflation, intense contrast extravasation is determined at the level of the ICA bulb. Inflation of the balloon at a pressure of 4 atm was performed again. Intubation of the trachea of ​​the patient was performed. Intravenous administration of 300 mg acetylsalicylic acid was initiated. The balloon catheter is deflated and withdrawn from vessels, the carotid stent Protégé 8–6×40 mm was implanted into the left ICA bulb and the left common carotid bifurcation segment. The bloodstream above the stent is not determined, but extravasation through the stent cells at the level of the former defect is determined. Stent graft Graftmaster 4×15 mm was implanted into the carotid stent at the level of the defect in the ICA. Stent graft was additionally opened in its lower part by a 5×20 mm balloon-catheter. Thrombaspiration from the left ICA was performed again. Patency of the ICA and intracranial arteries was totally restored – mTICI3, stenosis in the left ICA bulb was completely eliminated. The patient’s neurological status was restored to baseline. A large hematoma in the soft tissues of the neck to the left was determined. Only “old” ischemic foci in the left temporal lobe were determined on brain CT, a large hematoma laterally and anteriorly to the carotid artery was determined in the soft tissues of the left side of the neck on computer tomography. Ticagrelor was added to aspirin therapy. Hematoma was removed surgically. The postoperative period was unremarkable. The patient was discharged from the clinic in good condition with an level modified Rankin scale 1.In the presented case, the friendly work of different profiles specialists avoided the devastating consequences of such a relatively rare complication of carotid endarterectomy as cerebral arteries tandem thrombosis. The availability of graft-stents in access to interventional neuroradiologists is extremely important in such cases.
Yu.R. Yarotskyi, L.M. Yakovenko, M.Yu. Orlov, A.G. Lugovskyi, V.V. Moroz, I.I. Skorokhoda
Endovascular Neuroradiology, Volume 30, pp 38-48; doi:10.26683/2304-9359-2019-4(30)-38-48

Abstract:
Objective – to optimize the results of surgical treatment of the cerebral arteriovenous malformations (AVM) with a torpid clinical course of the disease.Materials and methods. The results of combined surgical treatment of cerebral AVMs of 36 patients without a history of AVM rupture were analyzed (this variant of clinical course was defined as «torpid»). Patients were treated in the departments of vascular neurosurgery at the Romodanov Neurosurgery Institute NAMS of Ukraine during the period from 2010 till September 2019. Among the patients there were 18 (50 %) men and 18 (50 %) women. The average age of patients was 28.1 years (10–47 years). Clinical, neurological, laboratory, instrumental, functional and morphological methods of examination were used as well as neuroimaging evaluation and follow-up investigation.Results. The «torpid» course of disease in patients with AVM was presented as heterogeneous epileptiform manifestations in 24 (66.7 %) cases. One (2.8 %) patient had seizure that were combined with internal hydrocephalus, 9 (25 %) patients had different severity cephalalgic syndrome (according to the International classification of headache – 3β). Progressive neurological deficit was detected in 2 (5.55 %) patients. The distribution of AVMs according Spetzler–Martin scale (1986) was as follows: grade I – in 2 (5.55 %) patients, grade II – in 10 (27.8 %), grade III – in 13 (36.1 %), grade IV – in 9 (25.0 %), grade V – in 2 (5.55 %). In most cases (94.44 %), AVMs were supratentorial, and in 2 (5.55 %) cases they were subtentorial. The average AVM size in the largest dimension was 3.7 cm (2.8–6.7 cm). Intranidal aneurysms in the AVM structure were diagnosed in 8 (22.2 %) patients, fistulas – in 7 (19.4 %) cases. In all cases, at the first stage, endovascular embolization (EE) of AVM was performed. All 36 patients underwent 64 endovascular procedures. Curative treatment after 1 stage was performed in 16 (44.4 %) patients, after 2 stages – in 13 (36.1%), after 3 stage – in 6 (16.66 %), and after 4 stage in 1 (2.77 %) patient. In 36 (56.25 %) cases, embolization was performed with Onyx composition (eV3), in 24 (37.5 %) – with n-butylcyanoacrylate, and in 3 (4.7 %) – with their combination. In 1 (1.56 %) patient, the fistula was excluded from the blood flow using detached balloon-catheter. Embolization was supplemented with radiosurgical treatment (RST) in 30 (83.3 %) cases, microsurgical removal – in 2 (5.55 %), radiotherapy – in 2 (5.55 %) patients. In 1 (2.77 %) case EE was combined with shunting procedure and RST. One (2.77 %) patient after EE with RST suffered hemorrhagic stroke with intracerebral hematoma formation. An operation was performed for hematoma removal and partially functioning AVM resection. In 7 (10.9 %) cases after EE of AVM, patients developed motor deficits. At the time of discharge, they regressed completely in 6 patients, and partially in 1 patient. In (1.5 %) case homonymous hemianopsia had occurred. After RST, total obliteration of AVM was achieved in 17 (58.6 %) patients, in 5 (17.2 %) – subtotal (repeated RST was recommended). In 7 (24.1 %) cases, positive signs of AVM obliteration was noted, and the timing of radiation exposure did not reach the recommended ones. In 2 (3.1 %) patients after microsurgical resection, the AVM was removed completely, which was confirmed by cerebral angiography. After radiotherapy, decreasing of the AVM size and a positive neurological dynamics were noted. There were no fatal outcomes. According to the modified Rankine scale, patients were distribution to group 0 (33 (91.7 %)) and group I (3 (8.3 %)).Conclusions. The obtained data indicate the promising result of combined surgical treatment of cerebral AVM with a torpid type of clinical manifestations. The leading technique in the applied staged combined surgical treatment of AVM was EE. Its successful use is due to the effectiveness of its impact on all components of the «complex» AVM.
N.M. Nosenko, D.V. Shchehlov, M.Yu. Mamonova, Ya.E. Kudelskyi
Endovascular Neuroradiology, Volume 30, pp 49-58; doi:10.26683/2304-9359-2019-4(30)-49-58

Abstract:
There are some imaging methods for the diagnosis of left ventricular hypertrophy. Such as echocardiography, computed tomography, magnetic resonance imaging. These methods help to identify changes at different stages, evaluate the prognosis, stratify the risk and differential diagnosis.The left ventricle hypertrophy is a condition that may be due to physiological adaptation due to overload. For example, in patients with arterial hypertension, in athletes, and so on. Left ventricle hypertrophy may also be associated with a change in the actual structure: for example, with hypertrophic cardiomyopathy.Signs of left ventricle hypertrophy by echocardiography are a very significant predictor of mortality in patients with arterial hypertension in the general population. The presence of left ventricle hypertrophy by echocardiography is a high cardiovascular risk for the patient.It is important to diagnose diseases with a high risk of sudden cardiac death on time. One of these diseases is hypertrophic cardiomyopathy. A clinical diagnosis of hypertrophic cardiomyopathy is impossible without visualization. Therefore, the European Association of Cardiovascular Imaging recommends a multimodal approach in examining patients with hypertrophic cardiomyopathy.Сomputed tomography, echocardiography, and magnetic resonance imaging are used to diagnose which patient’s hypertrophy is pathological or physiological. The choice of which method to use depends on the diagnostic task, and also on the specific advantages and disadvantages of the method. Different visualization methods should be considered complementary, not competing. It is also important to choose a particular imaging technique given its diagnostic value, availability, benefits, risks and costs.
D.V. Shchehlov, O.E. Svyrydiuk, A.V. Naida, Yu.M. Samonenko, O.V. Slobodian
Endovascular Neuroradiology, Volume 30, pp 14-22; doi:10.26683/2304-9359-2019-4(30)-14-22

Abstract:
Objective – to evaluate long-term results of treatment of patients with arteriovenous malformations AVM of the spinal cord. Materials and methods. A retrospective analysis of clinical and angiographic data of the results of treatment of patients with spinal AVM for the period from 2005 to 2019 was conducted. In SO «Scientific-Practical Center of Endovascular Neuroradiology NAMS of Ukraine» 47 patients were operated on endovascular method. The age of patients ranged from 11 to 62 years (middle age is 45.3 years). There were 29 men (61.7 %), 18 women (38.3 %). Liquid cyanoacrylate embolizant was used for endovascular intervention. The operations were performed with transfemoral access. Accoding the classification proposed by Anson and Spetzler in 1992 patients with type I were 31 (65.9 %), with ІІ type – 8 (17.0 %), with ІIІ type – 5 (10.6 %), with IV type – 3 (6.4 %). Magnetic resonance tomography and spinal angiography were used for diagnostics AVM.Results. Total exclusion of AVM from the bloodstream was achieved in 22 (46.8 %) cases. Out of the 31 (65.9 %) patients with type I AVM, 17 (54.8 %) had an early transient deepening of the neurological deficit. In this group, complete dissection of arteriovenous fistula was achieved in 16 (51.6 %) patients. In 8 (17.0 %) patients with type II AVM, complete exclusion of AVM was achieved in 5 (62.5 %) cases. In this case, 6 (75.0 %) patients were observed early postoperative deepening of neurological symptoms. In 5 (10.6 %) patients with type III AVM, total exclusion was achieved in 1 (20.0 %) case. Transient deepening of neurological deficit was noted in 3 (60.0 %) patients. In 3 (75.0 %) patients with type IV AVM, total embolization was achieved in 1 (33.0 %) observation. Neurological impairment occurred in 1 (33.0 %) patient. In all groups there were no fatalities.Conclusions. Angiography is the gold standard of diagnosis and dynamic monitoring of patients with spinal cord AVM. The use of endovascular treatment of AVM can stop the further progression of neurological deficits, which, however, is not always associated with the total exclusion of AVM. The best neurological improvement and total exclusion were achieved in patients with type I AVM. Radicality, efficacy and deepening of neurological deficiency depend on angioarchitectonics of AVM. The main condition for carrying out embolization is to achieve a safe level of catheterization of the afferent.
I.V. Altman
Endovascular Neuroradiology, Volume 30, pp 59-67; doi:10.26683/2304-9359-2019-4(30)-59-67

Abstract:
Objective – to determine the role of endothelial vascular growth factor (VEGF) in the formation, progression of arteriovenous malformations (AVM), the occurrence of relapses of this disease and to justify the need to study the level of VEGF in blood plasma in patients with AVM.Materials and methods. The analysis of 15 sources of scientific and medical literature on the etio-logy and pathogenesis of AVM. Recent data of studies of the role of VEGF in the formation, progression of AVM, occurrence of relapses of this disease have been systematized. The own results of the study of the level of VEGF in blood plasma in 19 patients with AVM of different localization are presented.Results. The important role of increasing the level of VEGF in the formation, progression of AVM, both according to scientific and medical literature and according to own research, has been proved. The necessity to study the level of VEGF in blood plasma in patients with AVM in the perioperative period to improve the effectiveness of complex treatment of such patients is substantiated.Conclusions. Endothelial vascular growth factor plays an important role in the formation, progression of arteriovenous malformations. Increased level of VEGF in blood plasma in patients with AVM was noted. Increased levels of VEGF in blood plasma after surgical or endovascular treatment may cause relapses of the disease. Changes in the level of VEGF in blood plasma after surgical or endovascular treatment have not been studied at present. Studying the level of VEGF in blood plasma before and after surgical and endovascular treatment opens new possibilities for the use of drugs that block the action of VEGF as a neoadjuvant therapy for the prevention of recurrence or regression of stroke.
D.V. Shchehlov, O.A. Pastushyn, O.E. Svyrydiuk, S.V. Konotopchik, A.V. Naida
Endovascular Neuroradiology, Volume 29, pp 54-62; doi:10.26683/2304-9359-2019-3(29)-54-62

Abstract:
In the period from 2013 to 2019 at the Scientific and Practical Center for Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine, implantation of flow-diverter in the acute period of aneurysmal intracranial hemorrhage was performed in six patients (4 (66.7 %) men and 2 (33.3 %) women. The average age was 50 years). Hemorrhage was diagnosed using multispiral computed tomography, aneurysm was verified using cerebral subtraction angiography according to Seldinger. In 3 cases the aneurysm was located on the internal carotid artery, in 2 cases – on V4-segment of the vertebral artery, in1 case – on A1-segment of the anterior cerebral artery. Five patients received a loading dose of double antiplatelet therapy before implantation of a flow-diverter (300 mg clopidogrel and 300 mg acetylsalicylic acid). One patient received dual antiplatelet therapy (75 mg clopidogrel and 75 mg acetylsalicylic acid) in five days before stent implantation. All patients after implantation of a flow-diverter received double antiplatelet therapy in a standard dose (75 mg clopidogrel and 75 mg acetylsalicylic acid). In five cases a FRED (Microvention - Terumo) flow-diverter was used and in one case – Pipeline (Medtronic). The diameter and length of the stent depended on the angioantomy of the aneurysm and the bearing artery. In two cases the implantation of a flow-diverter was accompanied by the implantation of micro coils into the cavity of the aneurysm, in four cases – as a single endovascular treatment technique. There were no complications in the early or late postoperative period. At the time of discharge on the Glasgow modified exit scale (GOSE) five patients had more than 5 points, one patient died (1 point) for reasons not related to the underlying disease. A control examination in the period from 6 to 12 month after implantation passed three patients, in all cases of aneurysm from the blood circulation is totally excluded.
T.V. Kolesnyk, Alla Nadiuk, H.A. Kosova
Endovascular Neuroradiology, Volume 29, pp 46-53; doi:10.26683/2304-9359-2019-3(29)-46-53

Abstract:
Objective – to determine the level of anxiety and depression, to investigate cognitive functions and the status of physical activity in patients with hypertension, depending on age.Materials and methods. We examined 67 patients with hypertension I–III stage (atherosclerotic plaque and/or myocardial infarction in history). According to age classification (WHO, 2012) patients were randomized into 3 groups: group I – 25 middle-aged patients, group II – 22 elderly patients, group III – 20 patients of senile age. The highest level of education, the total number of education years; duration of arterial hypertension; anthropometric data and the office blood pressure were assessed. We used an individual approach to determine the target level of blood pressure according to the recommendations ESC/ESH 2018. Cognitive functions were evaluated using the MoCA-test and the Clock Drawing Test. The level of anxiety and depression was determined by the results of the Hospital scale of anxiety and depression.Results. According to the data obtained, a statistically greater degree of depression was recorded among eldery patients in comparison with other groups. Only in this group, a higher level of depression was associated with less time that patients spent for regular exercise during the week. Among middle-aged patients with arterial hypertension, the absence of anxiety and depression was detected in 56.0 %. At the same time, in the group of senile age, 75.0 % of patients were diagnosed with manifestations of anxiety and depression of varying severity. It is important to notice that in the group of senile age the median level of anxiety was higher, although nonsignificantly, in comparison with other groups and met the criteria for subclinical anxiety. Results of multivariate correlation analysis showed that a high level of anxiety in middle-aged patients was associated with an earlier age of arterial hypertension verification, as well as with waist circumference increase and the waist/hip circumference ratio. Among elderly patients, a higher level of anxiety was determined in the presence of physical inactivity and among patients of senile age, an increase in anxiety level was associated with a shorter duration of education and a decrease in cognitive functions. Conclusions. The highest level of depression was diagnosed among people of senile age, which was associated with the presence of physical inactivity. The groups did not differ statistically in level of anxiety, however, an increase in its severity in the middle-aged group was associated with an earlier age of hypertension verification and an increase in the degree of abdominal obesity, among elderly patients – with hypodynamia, and in the group of senile age – with a low level of education and the presence of cognitive dysfunctions.
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