Vol 15, No 4 (2021)

The aim of this study was to analyse the inpatient and long-term results of hybrid surgery, incorporating percutaneous coronary intervention (PCI) and different types of carotid endarterectomy (CEA).

Materials and methods. A prospective, open-label cohort comparison study was conducted in 2018–2020 and included 363 patients with atherosclerosis of both the internal carotid artery (ICA) and coronary artery, who underwent hybrid revascularization of the brain and myocardium. All patients were divided into four groups based on the revascularization strategy: group 1 (n = 107; 29.5%) — PCI + eversion CEA; group 2 (n = 98; 27%) — PCI + classic CEA with patch angioplasty; group 3 (n = 72; 19.8%) — PCI + glomus-sparing CEA according to R.A. Vinogradov; and group 4 (n = 86; 23.7%) — PCI + glomus-sparing CEA according to A.N. Kazantsev. The follow-up period was 20.8 ± 8.0 months.

The patient received a loading dose of clopidogrel (300 mg) before the PCI, and the procedure was then performed in an endovascular operating room. A radial artery catheter was inserted, and the patient received 10,000 IU of intravenous heparin before the procedure. After the PCI, the patient was taken to the vascular operating room, where they underwent the CEA. The patient received 5,000 IU of intravenous heparin before artery clamping. Glomus-sparing CEA according to A.N. Kazantsev was performed as follows: an arteriotomy was conducted along the internal edge of the external carotid artery (ECA), adjacent to the carotid sinus and 2–3 cm above the ostium, and extending to the common carotid artery (CCA) (also 2–3 cm below the ECA ostium), depending on the size of the atherosclerotic plaque. The ICA was transected in the area bound by the ECA and CCA walls. Eversion CEA of the ICA was performed, followed by open CEA of the ECA and CCA. The ICA was implanted in its previous position in the preserved area.

Results. No mortality was recorded during the inpatient follow-up period. All cases of myocardial infarction occurred after eversion and classic CEA: 3 in group 1 (2.8%) and 1 in group 2 (1.02%); р = 0.2. No ischaemic stroke was recorded only in patients who underwent CAE according to A.N. Kazantsev (р = 0.66); however, ischaemic stroke occurred in two patients in group 1 (1.8%), in two patients in group 2 (2.04%) and in one patient in group 3 (1.38%). The highest number of cardiovascular events occurred in group 1, due to carotid glomus injury, which led to poorly controlled hypertension during the inpatient stay. This tendency influenced the composite endpoints (death + myocardial infarction + ischaemic stroke), which were highest in group 1 (5 or 4.6%) compared to 3 (3.06%), 1 (1.38%) and 0 in groups 2–4, respectively (р = 0.18). The groups were comparable in the frequency of long-term complications. However, the incidence of ICA restenosis was lowest and no ECA thrombosis/occlusion was observed after glomus-sparing CEA according to R.A. Vinogradov and A.N. Kazantsev.

Conclusion. A hybrid PCI + CEA for brain revascularization should be glomus-sparing. CEA according to A.N. Kazantsev was characterized by lack of procedural arteriotomy complications. This procedure enables blood pressure monitoring in the postoperative period, thus minimizing the risk of cardiovascular complications.

Study aim. To analyse the surgical outcomes in patients with haemorrhagic stroke depending on the timing of surgery.

Materials and methods. We performed a retrospective analysis of 500 patients (335 (67%) men and 165 (33%) women), who underwent surgical treatment of hypertensive intracranial hemorrhages at the N.V. Sklifosovsky Research Institute for Emergency Medicine between 1997 and 2020. The mean patient age was 53.1 ± 12.2 years. The mean time until surgery was 3.3 ± 2.6 days. Outcomes were assessed on day 30 from disease onset using the modified Rankin Scale (mRS).

Results. In the total sample, outcomes as measured by the mRS were as follows: type 0 — 84 (16.8%) patients, type 1 — 37 (7.4%), type 2 — 46 (9.2%), type 3 — 38 (7.6%), type 4 — 43 (8.6%), type 5 — 142 (28.4%) and type 6 — 110 (22.0%). Treatment results were better when surgery was delayed (χ² = 64.4; p < 0.00001). Mortality was 36.4% after surgery conducted in the first day after haemorrhage, while mRS scores of 0–2 made up 18.6%. Mortality was 20.4% after surgery conducted on the second or third day, and mRS scores of 0–2 made up 29.6%. Mortality was 17.4% after surgery conducted on day 4–7, and mRS scores of 0–2 outcomes were present in 49.0% of subjects. Mortality was 8.8% when surgery was performed on day 8 or later, and favourable outcomes were present in 48.5% of patients.

Conclusion. Intracerebral haematoma excision on day 2–3 leads to better outcomes in patients with reduced levels of alertness up to sopor, while surgery after day 3 leads to better results in alert patients and those with obtundation.

This systematic review describes primary progressive aphasia (PPA) variants and includes the authors' own clinical observations. Over 20 genes have now been identified, with mutations that are directly involved in the development of the behavioural variant of frontotemporal dementia, as well as other forms of PPA. Pathomorphological markers of Alzheimer's disease were identified in 76% of cases of logopenic PPA, while signs of frontotemporal dementia associated with TDP-43 were identified in 80% of cases of the semantic variant, and those associated with TDP-43/tau were identified in 64% of cases of agrammatic PPA. The clinical diagnosis of PPA is based on a history of long-term, progressive speech disturbances and identifying a particular variant: agrammatic, semantic or logopenic. The primary variant of the speech disorder cannot be identified in approximately 30% of cases. The focus should be on the main and additional clinical signs (presence of agrammatism, object naming, word comprehension, preserved repetition), as well as neuroimaging (presence of asymmetrical frontal and/or temporal lobe atrophy).

The article also provides key aspects of differential diagnosis of the PPA variants, and puts forth a stepwise diagnostic algorithm. It examines features of PPA progression, with possible development of corticobasal syndrome, illustrated by a clinical case. A dissociation between neuroimaging findings and clinical disease variant is also demonstrated to be possible. Different neuropsychological assessments of patients with aphasia and methods of determining the severity of speech dysfunction are presented. Standardized aphasia assessment tools and the adapted PPA severity scale are provided.

Minor atrial septal defect (ASD) may be one of the pathways of paradoxical embolism in the brain. Few scientific papers have investigated the relationship between ASD (excluding patent foramen ovale) and the occurrence of ischemic stroke. There is no definite opinion as to how functionally important such shunts are and how the shunt changes with age. The review analyzes modern ideas about the probability of paradoxical embolism in small ASDs from the viewpoint of pathophysiology, and also demonstrates the technological capabilities of assessing the functional significance of such shunts based on our own clinical observations.

Hashimoto encephalopathy is a rarely diagnosed autoimmune neurological disorder, associated with the presence of antithyroid antibodies. The variability of clinical presentation, rarity of the disease, and absence of specific diagnostic markers make timely diagnosis very complicated. This article describes a clinical case of a female patient with Hashimoto encephalopathy and discusses diagnosis, differential diagnosis and treatment approaches. We emphasize the importance of establishing a timely diagnosis, considering high efficacy of targeted treatment.