neurosurgeryНейрохирургияRussian journal of neurosurgery1683-32952587-7569Издательский дом "МедИНК"10.17650/1683-3295-2023-25-2-114-129neurosurgery-1380Research ArticleОБЗОР ЛИТЕРАТУРЫLITERATURE REVIEWНизкопоточный экстра‑интракраниальный анастомоз в острейшем и остром периодах ишемического инсульта каротидного и вертебро‑базилярного бассейнов (обзор литературы)Low-flow extra-intracranial bypass in acute carotid and vertebrobasilar ischemic stroke (literature review)https://orcid.org/0000-0003-1870-1270ЩербининА. В.ShcherbininA.  V.

Антон Владимирович Щербинин

195257 Санкт-Петербург, ул. Вавиловых, 14, лит. А

Anton Vladimirovich Shcherbinin

lit. A, 14 Vavilovykh St., Saint Petersburg 195257

antoxia@yandex.ruСПбГБУЗ «Городская больница Святой преподобномученицы Елизаветы»РоссияCity Hospital of the Holy Martyr ElizabethRussian Federation202311072023252114129Copyright © Щербинин А.В., 20232023Щербинин А.В.Shcherbinin A.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.therjn.com/jour/article/view/1380Введение

Введение. Эффективность метода реваскуляризации головного мозга с помощью экстра‑интракраниального микроанастомоза (ЭИКМА) при хронической недостаточности кровоснабжения головного мозга изучена в нескольких рандомизированных мультицентровых исследованиях. Проведен анализ доступных публикаций, посвященных этой методике, за 10 лет при острых инсультах в каротидном бассейне и за 20 лет при ишемических инсультах в вертебробазилярном бассейне.

Цель работы – улучшение результатов лечения ишемических инсультов с помощью экстренных низкопоточных экстра‑интракраниальных анастомозов в острейшем и остром периодах. В 12 публикациях за последние 10 лет, выбранных в поисковой системе PubMed, выявлены 194 случая применения экстренных ЭИКМА в острейшем и остром периодах ишемического инсульта в каротидном бассейне. В 6 публикациях за 20 лет найдено 127 случаев применения экстренных экстра‑интракраниальных анастомозов в острейшем и остром периодах ишемического инсульта в вертебро‑базилярном бассейне. Средний возраст пациентов каротидной группы составил 61,7 года (от 21 года до 96 лет), вертебро‑базиллярной группы – 65 лет (от 30 лет до 81 года). Соотношение между мужчинами и женщинами в обеих группах равнялось 3:1. Критериями выполнения анастомоза в обеих группах были нарастание неврологической симптоматики более 4 баллов по шкале тяжести инсульта Национальных институтов здоровья CША (NIHSS), незначительные ишемические изменения паренхимы головного мозга при нейровизуализации (не менее 8 баллов по шкале оценки начальных изменений на компьютерно‑томографическом (КТ) исследовании при инсульте (Alberta Stroke Program Early CT Score, ASPECTS), признаки грубых атеросклеротических поражений крупных сосудов каротидного и вертебро‑базилярного бассейнах. В 83 случаях в каротидной группе проводили исследование перфузионно‑диффузионного несоответствия в бассейне средней мозговой артерии по данным магнитно‑резонансной томографии или КТ‑перфузии. В 111 случаях каротидной и в большинстве случаев вертебро‑базилярной групп выполнение микроанастомозов было основано на клиникодиффузионных несоответствиях между выраженными клиническим прогрессированием инсульта и незначительными ишемическими изменениями головного мозга при нейровизуализации. В каротидной группе в течение суток после возникновения инсульта выполнено 127 (65 %) микроанастомозов между поверхностной височной артерией и M3–M4 ветвями средней мозговой артерии и 67 (35 %) в течение ближайших 7 дней после манифестации. Благоприятных исходов (0–2 балла по модифицированной шкале исходов Рэнкина – modified Rankin Scale, mRS) оказалось 78 % (151 случай), неблагоприятных (более 2 баллов по mRS) – 22 % (43 случая), летальность составила 3 %. В вертебро‑базилярной группе угнетение сознания до комы и наличие сформированных ишемических очагов в полушариях мозжечка не являлись противопоказаниями к данным операциям. Преобладали (90 случаев) анастомозы между поверхностной височной и верхней мозжечковой артериями. Летальность составила 5 % из‑за осложнений сопутствующей патологии в послеоперационном периоде. Благоприятные исходы (0–2 балла по mRS) зарегистрированы в 97 (76 %) случаях, неблагоприятные – в 30 (24 %) случаях.

Заключение

Заключение. Применение низкопоточного ЭИКМА в остром периоде инсульта каротидного и вертебро‑базилярного бассейнов может улучшить результаты лечения пациентов, у которых внутривенный тромболизис или внутрисосудистые вмешательства оказались неэффективными.

Introduction

Introduction. The effectiveness of the method of revascularization of the brain using extra‑intracranial bypass in chronic insufficiency of blood supply to the brain has been studied in several randomized multicenter studies. The analysis of available publications devoted to this technique for 10 years with acute strokes in the carotid basin and for 20 years with ischemic strokes in the vertebrobasilar basin was carried out.

Aim

Aim. To improve the results of treatment of ischemic strokes with the help of emergency extra‑intracranial low‑flow bypasses in the acute and acute period. In 12 publications over the past 10 years, selected from the PubMed search engine, 194 cases of the use of emergency extra‑intracranial microbypasses in the acute and acute period of ischemic stroke in the carotid basin were identified, 127 cases of emergency extra‑intracranial bypass were found in 6 articles during the last 20 years in the acute phase of vertebra‑basilar area stroke. Middle patient age in carotid group was 61.9 years, and 65 years in vertebral patient’s group. The male / female ratio was 3 / 1. The main indications for the bypass creation were: worsening of neurologic deficit from 4 and more according to the Stroke Severity Scale of the US National Institutes of Health, mini mal or not significant computed tomography (CT) or diffusion‑weighted magnetic resonance imaging (DW‑MRI) ischemia brain changes (not lower than 8 points on the scale of assessment of initial changes in the computed tomographic (CT) examination for stroke Alberta Stroke Program Early CT Score, ASPECTS), signs of significant brachiocephalic arteries atherosclerotic stenosis. In 83 carotid group cases perfusion‑diffusion mismatch was distinguished before bypass creation. In 111 carotid cases and in priority of vertebra‑basilar cases clinic‑diffusion mismatch was the only indication for emergency extra‑intracranial bypass creation. During the first 24 hours 65 % of carotid group bypass were performed, in other 35 % of cases bypasses were performed during 1 week after the stroke onset. There were 78 % of good results (<2 on the Rankin outcome scale, mRS) and 22 % of poor (mRS >2) in carotid stroke group. Mortality was 3 %. In vertebral group, coma was not contraindication for emergence extra‑intracranial bypass creation. In most cases, 70 % of bypass were performed between superficial temporal artery and superior cerebellar artery. Mortality in vertebral stroke group was 5 %, mostly because of somatic pathology worsening. Good results were achieved in76 % of cases.

Conclusion

Conclusion. In some cases of atherosclerotic carotid and vertebrobasilar ischemic stroke, results of recovery can be approved greatly with use of emergency low‑flow extra‑intracranial bypass, if intravenous thrombolysis and endovascular tromboextraction were failed.

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The authors declare that there are no conflicts of interest present.