Reconstruction of the Carotid Region Arteries under Conditions of a Neurosurgical Clinic

D.Yu. Usachev, V.L. Lemenev, A.Yu. Lubnin, V.A. Shakhnovich, V.A. Lukshin, A.V. Shmigelsky, O.B. Sazonova, A.A. Ogurtsova, M.V. Churilov

Burdenko Research Institute of Neurosurgery, Russian Academy of Medical Science, Moscow, Russia

 

The goal of the present study was determining indications and methods of surgical treatment of patients with chronic cerebral ishchemia, caused by occluding and stenosing lesions of extra- and intracranial segments of carotid arteries.

Materials and Methods. Reconstructive operations (236) were performed in 181 patients with different versions of stenosing and occluding lesions of carotid arteries in extra- and intracranial segments. All of them were treated in the Burdenko Research Institute of Neurosurgery, beginning with 1999.

Multimodality investigation included examination by different specialists (a neuropathologist, neuroophthalmologist, otoneurologist, neurosurgeon) and instrumental examination (CT and MRI of the brain, color duplex scanning, transcranial Doppler, EEG, CT-angiography, MRI in a vascular mode, selective cerebral angiography).

The main somatic risk factors were as follows: hypertension, ischemic heart disease, smoking and hypercholesterinemia.

The majority of operated cases had sequelae of an ischemic stroke and transitory ischemic attacks, which were watched in 45.3% and 27% of all clinical versions of cerebral ischemia respectively.

All operations were performed under general anesthesia with intraoperative dynamic multimodality neuromonitoring of blood supply, metabolism and cerebral functions. It was carried out mainly in intervention on the carotid region.

Reconstructive operations on extracranial segments of carotid arteries were made in 180 cases (the total number of operations was 236). They were represented by different versions of carotid endarterectomy (126), ICA resection-redressment (28), plasty of ECA opening (22), resection and ICA prosthetics (3) and separation of traumatic carotid-jugular anastomosis (1). In case of ICA occlusion, we performed operations, aimed at creation of extra-intracranial anastomosis (56).

A surgery microscope was used at the main stage of reconstructing arteries of the carotid region (158 reconstructions) in 29.7% of cases. The rest interventions were made with the help of an operating magnifier. Extra-intracranial microanastomosis was created with using a microscope in all patients.

Results. A postoperative period in all the cases was characterized by reduction of signs of cerebral ischemia. A good result was observed in 91.1% of cases. It was considered to be satisfactory in 4.15% of interventions. Development of acute disorder of cerebral circulation in the nearest postoperative period was regarded as a bad result (4.15%).

A total index of early postoperative complications in our series was 6.5% (including postoperative mortality equal to 0.4%). As for severe complications, connected with disorders of cerebral circulation in a postoperative period, they were ischemic (2.3%) and hemorrhagic (0.4%). An operative wound became a cause of complications in 3.4% of cases (paresis of cranial nerves, hematoma of postoperative wound).

Conclusions

  1. Multimodality ultrasonic examination (transcranial Doppler and duplex scanning) is the main method of primary selection of patients for surgical treatment of occluding and stenosing lesions of arteries of the carotid region.
  2. Use of CT (spiral)- and MR-angiography acquires greater significance in diagnosis of stenosing changes in major cerebral arteries; selective cerebral angiograpgy is indicated in case of multifocal lesion of brachiocephalic arteries and necessity of more detailed study of anterior and posterior segments of the Willis circle.
  3. Intraoperative monitoring allows to estimate blood supply and cerebral functions during reconstruction of the carotid region arteries, to determine intraoperative tactics of reconstruction, to detect episodes of cerebral embolism, to control operation of a temporary intraluminal shunt, used in case of necessity, and adequacy of vascular anastomosis just after restoration of blood flow in carotid arteries.
  4. It is expedient to use a surgery microscope at the main stage of reconstruction of carotid arteries.
  5. Reconstructive surgery of arteries of the carotid region is an effective method of treatment of patients with chronic cerebral ischemia.