Search

Rationale: The prevalence of malformation of internal carotid arteries (ICA) in the population amounts to 46%. In 4 to 16% of the cases, it is associated with clinical manifestations of cerebrovascular insufficiency. Hemodynamic changes in the abnormal arterial vasculature and neurological symptoms are the main indications for surgical intervention. Computed tomography (CT) angiography has shown its high information value in the assessment of ICA occlusions; however, its informativity in the diagnosis of ICA malformations has not been established.Aim: To assess ICA and brain matter in the patients with abnormal tortuosities, both isolated and combined with occlusion, by CT angiography.Materials and methods: We performed a retrospective analysis of medical files of 58 inpatients, who underwent ultrasound examination and CT angiography of extra and intracranial parts of brachycephalic arteries with 256 slice multidetector computer scanner (Philips iCT). CT angiography included native imaging, and contrast-enhanced arterial and venous phases. We assessed the impact of ICA abnormalities on the degree of brain matter lesions in patients with isolated ICA malformations (n=27) and with combination of ICA malformations with its occlusion (n=31).Results: In the group of the patients with isolated ICA malformations, there were no brain focal lesions in 14, small vessel focal lesions and single liquor cysts in 9, and areas and zones of cystic and glial abnormalities in 4. The most frequent in this group were S-like and C-like malformations, together with 2 saccular aneurysms (one of them true and one false). In the group of patients with combination of abnormal ICA tortuosities and occlusions, there were areas and zones of cystic and glial abnormalities in 7, various degrees of small vessel disease and few liquor cysts in 18, and no abnormal brain matter foci in 6. No ICA malformations in combination with true or false aneurysms were found. The patients with combination of ICA malformations and stenosis, the signs of chronic brain ischemia were more advanced, compared to those in the patients with isolated ICA malformations (p=0.012).Conclusion: CT angiography is a highly informative method for the assessment of carotid arteries and brain matter in patients with ICA malformations. The combination with ICA malformations and occlusion is associated with more advanced lesions of brain matter.

Objective: to investigate the informative value of computed tomography (CT) angiography for the evaluation of carotid paragangliomas.Material and methods. Twelve patients with carotid paragangliomas were examined in the Department of X-ray Computed Tomography and Magnetic Resonance Imaging, Vladimirskiy Moscow Regional Research and Clinical Institute, in 2014-2019. Before surgery, we performed ultrasound imaging and CT angiography (Philips iCT 256 slices): non-contrast study, subsequent contrast enhancement (arterial and venous phases) using the intravenous bolus injection of 60 ml of non-ionic iso- or low-osmolar contrast media. The Shamblin criteria were used to evaluate paragangliomas. The extent of changes and the spread of mass tissue were estimated along the carotid artery walls. Surgery was performed in 11 out of 12 patients.Results. Unilateral and bilateral masses were identified in 10 and 2 cases, respectively. Two neoplasms that were characterized by small sizes and minimal involvement of carotid artery walls in the process were assigned to type I in accordance with the Shamblin classification. Type II masses (n = 5) were represented by a partial encasement of the internal and external carotid arteries by paraganglioma. Type III tumors (n = 7) were characterized by large sizes and encasement of all walls of the common, internal and external carotid arteries over a considerable length. No calcifications or necrotic areas were found in the structure of the neoplasms. Multiple small tortuous arterial vessels around the tumor were determined in 12 out of 14 cases. These changes did not match the overall length of the tumor and the degree of carotid artery encasement by the latter. Histological examination confirmed the diagnosis of paragangliomas in all cases. A pathologically altered lymph node was found in 1 case during the subsequent 5-month follow-up.Conclusion. CT angiography can assume the diagnosis of carotid paraganglioma based on its characteristic features and determine the type of tumor according to the Shamblin classification, which allows to plan the optimal surgical intervention.

Background: The main cause of mortality in patients with atherosclerosis of aorta and peripheral arteries of the lower extremities is ischemic heart disease. The presence of peripheral artery atherosclerosis suggests a high probability of simultaneous coronary involvement. To reduce the risk of cardiac complications, these patients are offered myocardial revascularization as the first step of the intervention; however, the choice of a conduit for coronary artery bypass in these patients remains challenging.Case report: A 58-year old man with combined coronary artery stenoses, high occlusion of the aorta and common iliac arteries underwent autoarterial myocardial revascularization with the right internal thoracic artery (ITA) and left radial artery ("off pump”). In the early postoperative period, significant progression of the right leg ischemia was observed, related to partitioning of the main collateral flow between the right ITA and the inferior epigastric artery, that had contributed to blood supply to the right lower extremity. Taking into account the lack of efficacy of medical treatment and progression of the leg ischemia, at day 4 postoperatively the patient underwent resection of the infrarenal aorta with aortobifemoral bypass grafting and restoration of blood supply to the lower extremities and resolution of ischemia.Conclusion: ITA has been recognized as the conduit of choice for surgical treatment of ischemic heart disease; however, its use may result in significant progression of ischemia. When choosing a conduit, ITA at the side of less ischemic lower extremity is preferred. ITA imaging by computed tomography-angiography or by selective ITA angiography can be helpful for assessment of the ITA significance at the side of less ischemic leg. Also, the appearance of retrograde flow in the inferior epigastric artery at Doppler ultrasound examination can be a conditional valuable criterion.

Rationale: Carotid endarterectomy is a surgical procedure to prevent acute ischemic cerebrovascular accidents. Neurologic complications can occur after surgery. Multidetector computed tomography (MDCT) is used for their diagnosis in severely ill patients.Aim: To evaluate the potential of MDCT in the diagnosis of neurologic complications after carotid endarterectomy.Materials and methods: We analyzed the results of radiologic assessments in 15 patients with early postoperative neurologic complications which occurred after surgery for internal carotid artery occlusion (595 patients underwent surgery). In stable patients, brain magnetic resonance imaging (MRI) was performed (T1, T2, FLAIR, DWI modes) with non-contrast MR angiography. In critically ill patients, brain computed tomography, computed tomographic angiography and perfusion computed tomography were performed.Results: Ischemic neurologic complications were found in 11 patients. One patient had no clinical manifestation of an ischemic stroke, and acute stage signs were found in his routine brain MDCT. In 9 patients with acute brain ischemia, MDCT (n = 6) and MRI (n = 3) results were specific for this diagnosis, with no diagnostic problems. There were problems with the diagnosis of the hyperacute ischemia in 1 patient. In this patient, the complication occurred against a background of abnormal carotid blood flow before surgery, therefore, differential diagnosis between the hyperperfusion syndrome on the intervention side and the hyperacute phase of ischemic insult on the opposite side was performed. Hyperperfusion syndrome and hemorrhagic strokes were observed in 4 patients.Conclusion: The most difficult for diagnosis by MDCT is the hyperacute phase of brain ischemia. Further studies are necessary in the area of diagnosis of postoperative complications, with the search for potential specific diagnostic criteria.

Objective – to optimize dedicated assessment of carotid arteries in case of occlusive disease with computed angiography (CTA).Material and methods. During 2015–2016 years 65 patients underwent ultrasound examination and computed tomography examined before carotid surgery.Results. Aortic arc branching variants were observed in 26% cases. In 51% combined steno-occlusive process in common, internal carotid arteries and subclavian arteries was confirmed. In 29% of cases atherosclerotic plagues were detected in upper parts of common carotid arteries and such data changed surgical strategy. Patients included in study has internal carotid artery (ICA) stenosis more than 50% NASCET. Detailed assessment was used for cervical ICA distal to stenosis. In 62% of patients with carotid subocclusion narrowing in upper segments were detected. In 3 cases ascending pharyngeal artery arose from affected carotid artery and these findings change surgical approach. All patients underwent carotid surgery. Degree of ICA stenosis detected with CTA was conformed. CTA data for carotid plague extension were less informative – intraoperative plague length exceeded CTA results.Conclusion. CTA is high informative study that allows detailed assessment of occlusive carotid disease for carotid surgery.

Background: Stenoses of the brachiocephalic arteries (BCA) are ones of the main causes of ischemic defects of cerebral circulation. From the end of the former century to the current time, the surgical cerebral revascularization in steno-occlusive BCA disturbances occupies the topical place in prevention of acute brain circulation defects. Carotid endarterectomy (CEAE) remains till now a basic method of surgical revascularization. As a result of chronic hypoperfusion, autoregulation of the cerebral circulation can be disturbed with a persistent capillary dilatation which enables development of hyperperfusion syndrome after surgical intervention. Aim: A quantitative assessment of the cerebral tissue perfusion disturbances depending on the variants of the brachiocephalic vessels lesions before and after surgical reconstructions as well as revealing possible prerequisites for hyperperfusion syndrome development during preoperative multislice computed tomography (MSCT) perfusion. Materials and methods: The results of examination and treatment of 65 patients (mean age 64.2±5.0 years) with chronic cerebrovascular IV stage insufficiency were analyzed as well as the hemodynamically significant lesion of the inner carotid arteries. CEAE was planned for all patients. All patients underwent cerebral MSCT angiography and MSCT perfusion in preoperative and early postoperative periods. Results: The majority of patients in preoperative period showed decrease of perfusion parameters at the side of the most expressed defects. The mean circulation deficiency varied from 12 to 15%. Improvement of circulation at the side of surgical intervention formed, on the average, about 12%. The best outcome was noted in patients with bilateral stenoses of the inner carotid arteries (ICA). In one case, in critical unilateral ICA stenosis in preoperative period, MSCT perfusion demonstrated persisting dilatation of the small cerebral arteries of the disturbed hemisphere which led to autoregulation defects of these arteries with a high risk of hyperperfusion syndrome development. On the second day of the postoperative period, the said hyperperfusion syndrome developed but was successfully arrested using hypotensive therapy. Conclusion: CEAE provides circulation improvement in patients with ischemic stroke. MSCT perfusion favors circulation improvement in ischemic stroke patients. MSCT perfusion allows revealing patients with high risk of hyperperfusion syndrome development in postoperative period.

The article presents a clinical case of 2 patients with heart arrhythmias of the sick sinus syndrome type, who were implanted electriccardiac pacemakers in the acute period of cerebrovascular accidents. There were no cardiac complaints in the clinical manifestation, however, a comprehensive assessment confirmed the diagnosis of sick sinus syndrome.

Background: At present, efficacy of carotid endarterectomy for prevention of cerebrovascular accidents has been convincingly proven. Its results in patients with a history of an ischemic stroke depend on multiple factors.Aim: To study results of reconstructive interventions on internal carotid arteries in patients with post-stroke cerebral cysts.Materials and methods: We analyzed data from 210 patients who had undergone an intervention (159 men and 51 women, aged 61 ± 2.7 years) with occluding lesions of the internal carotid artery and a history of an ischemic stroke. Depending on the size of a post-stroke lesion, patients were divided into 5 groups: patients from group 1 had a lesion of more than 5 cm in diameter, from group 2, from 2 to 5 cm, from group 3, ≤ 2 cm, patients from group 4 had a lacunar cysts and patients from group 5 had no focal lesions.Results: A clear positive correlation between the size of a post-stroke cyst and the degree of hemodynamic abnormalities in internal carotid arteries was found. The most prominent asymmetry of blood flow in the middle cerebral artery (on average, 34.1%) was seen in patients from the group 1. Patients from the group 1 more often had low and critical brain tolerance to ischemia (42.9%). In patients with large post-stroke cysts (group 1) mean Barthell index was 69 ± 8.1, and NIHSS score 8.2 ± 1.6. In patients from other groups neurological deficiency was less pronounced: 80 ± 6.8 and 7.6 ± 1.9 in the group 2, 82 ± 5.7 and 4.1 ± 1.3 in the group 3, 94 ± 4.6 and 3.2 ± 1 in the groups 4 and 5. The differences between groups in the rates of postoperative complications were not statistically significant (p > 0.5). However, signs of hyperperfusion without any clinical manifestations were more often observed in patients from the group 1 (19%). Assessment of changes in neurological status at 1 year after the intervention, depending on the size of post-stroke lesions, showed that in patients with large cysts the regression of neurological deficiency was less obvious, than in other groups (NIHSS 7.5 ± 1.7, Barthell index 76 ± 7.7). The best restoration of impaired neurological functions was seen in patients with small cysts (NIHSS 2.2 ± 0.7, Barthell index 91 ± 3.4).Conclusion: In patients with large and intermediate post-stroke cerebral cysts surgery is associated with a higher complication rate, and, first of all, of hyperperfusion syndrome. However, the risk of these complications is significantly smaller than the probability of repeated acute cerebrovascular accidents.

Background: Aortic aneurysm is characterized by high incidence, polymorphic clinical features and sudden onset of severe complications.Aim: To develop a standard multidetector computed tomography (MDCT) protocol for aortic aneurysm examination and image analysis for detection the signs of aortic wall instability.Materials and methods: The data of 279 patients with aortic aneurysm who underwent MDCT examination during 2009–2014 was analyzed to identify aortic wall instability signs.Results: Complicated course of aortic aneurysm was observed in 100 cases (36%). The most common sign of aortic wall instability was aortic dissection. According to our results, a new definition of aortic aneurysm complications was elaborated. It included signs of aortic wall instability with incomplete and/or complete disruption of aortic wall layers. A scheme of the most common patterns of aortic wall abnormalities was proposed, allowing a radiologist to reach high accuracy in characterizing this pathology.Conclusion: A dedicated MDCT protocol for aortic aneurysm detection and image analysis can increase quality of radiologic assessment of aneurysm wall allowing to approach to the level of histological accuracy.

Rationale: Carotid endarteractomy is a surgical intervention that is performed for prevention of cerebrovascular accidents, up to 80% of them being of ischemic origin, in the presence of a marked stenosis and occlusion of carotid arteries. A detailed description of specifics of postoperative changes in carotid arteries depending on the type of surgical intervention has not been published.Aim: To evaluate internal carotid arteries in the early postoperative period by means of multidetector computed tomography (MDCT) and to match the changes detected with the type of surgical intervention.Materials and methods: In 2014, 23 patients with atherosclerotic stenoses of internal carotid arteries were assessed in the Department of Roentgenology of MONIKI. As a part of preoperative work-up, the patients underwent ultrasound examination (USE) of the neck vasculature and MDCT with bolus contrast enhancement. Postoperative monitoring also included USE and MDCT. The data obtained were matched against the type of surgical intervention.Results: After the eversion procedure (15 patients), there were 14 cases of expected (normal) postoperative changes and 1 case of changes that required a follow-up. After an open (classic) carotid endarterectomy (3 patients) there was 1 case of expected postoperative changes and 2 cases requiring a follow-up. Among 5 patients who underwent a resection of internal carotid artery and its prosthetic replacement, 2 patients had expected changes, 2 patients had changes that required a follow-up and 1 patient had a complication after surgery.Conclusion: The postoperative use of MDCT for assessment of reconstructed arteries allows for identification of various types of postoperative changes, for detection of symptoms of severe complications and borderline conditions that require subsequent targeted diagnostics and monitoring.