No abstract

Occlusion of artery of Percheron is a rare condition caused by a peculiar anatomic variation in cerebral blood supply, leading to a bilateral thalamic infarction. Strokes in artery of Percheron account for 0.1% to 2% of all cerebral infarctions. Thalamic area is supplied by the arteries arising directly from the P1 segment of the posterior cerebral artery. However, in 1/3 of cases the supply is provided by a single trunk referred to as artery of Percheron (AOP). Early diagnosis of stroke in AOP can be very challenging due to an ambiguous clinical presentation and the absence of neurovisualization findings. This article presents two clinical cases of stroke in artery of Percheron observed at Lviv Emergency Hospital. Different clinical progression of a cerebrovascular accident contrasted with a similar neurovisualization pattern was a distinctive feature in these patients. Taking into consideration the rarity of this condition and a characteristic clinical presentation, these clinical cases were retrospectively analyzed and compared. A stroke in AOP should be suspected in all patients with symptoms of interrupted blood supply in the vertebrobasilar territory. The diagnosis primarily depends on clinical features; patients with paramedian bilateral thalamic lesions may develop sudden problems with consciousness, vertical gaze palsy and memory disorders. Early diagnosis of this condition allows for more effective therapeutic interventions and improves patient prognosis.

Objective — to estimate safety and effectiveness of intra-arterial treatment for acute ischemic stroke in the interventional radiology department of multiprofile hospital. Materials and methods. Urgent endovascular treatment was applied at 15 patients with acute ischemic stroke in carotid circulation during 2015–2017. Mechanical intra-arterial therapy with thrombectomy by stent-retrievers and thromboaspiration was used at accordingly six and two recent cases (during 2017); in 7 cases intra-arterial thrombolysis was the treatment option (2015–2016). Results. The article consist brief review of literature about acute ischemic stroke treatment and discussion concerning results of treatment of selected patients. Mechanical thrombectomy or thromboaspiration were effective in 75.0 % of cases with good recanalization rate opposite to 42.9 % at 7 patients treated by either intra-arterial or bridging thrombolysis with rt-PA. Unexpected technical failures of mechanical thrombectomy regarding recent clinical guidelines for ischemic stroke management following are discussed on example of 2 clinical cases. Conclusions. Endovascular treatment of ischemic stroke has a high safety and well-known efficacy. It became evident at our patients that following current management guidelines for thrombectomy with stent-retrievers or thromboaspiration after thrombotic occlusions of extracranial and proximal segments of intracranial arteries allowed attaining in 2017 reperfusion rate 2b/3 Modified Treatment in Cerebral Ischaemia Scale in majority of cases. Intra-arterial thrombolysis contributed to the reperfusion rate 2b/3 on the Modified Treatment in Cerebral Ischaemia scale just in 42.9 % of cases, which indicates its lower effectiveness.

Вступ. Дана стаття присвячена вивченню актуального стану проблеми підвищення ефективності лікування хворих із розривами внутрішньочерепних артеріальних аневризм шляхом розробки засобів корекції ускладнень, уточнення показів, термінів і методів хірургічного лікування на підставі аналізу динаміки клінічних, ангіометричних періопераційних показників.Мета. Визначення актуальних питань і напрямів досліджень лікування аневризматичної хвороби головного мозку Методи дослідження. Проведено аналіз літературних джерел за останні 15 років із застосуванням медичних баз MEDLINE, Google scholar, Researchgate, присвячених діагностиці та лікуванню хворих з внутрішньочерепними артеріальними аневризмами і опрацьовано власні проспективні дані, отримані при лікуванні 184 хворих з аневризматичними крововиливами в порожнину черепа.Результати. Ускладненнями в хворих із розривами внутрішньочерепних артеріальних аневризм найчастіше є: ангіоспазм (37,2%); внутрішньомозкові та внутрішньошлуночкові крововиливи (27,6%); вторинна ішемія головного мозку (22,2%); інтраопераційні ускладнення (9,1%); повторний розрив аневризми (6,5%). Вірогідними критеріями прогнозу несприятливого перебігу післяопераційного періоду є проведення операції по виключенню аневризми у хворих з високим ступенем за шкалою Hunt-Hess (>2,7±0,2) і за шкалою WFNS (>2,1±0,2). В гострому періоді (1-14 доба) післяопераційна летальність при транскраніальних втручаннях (16,2 %) різниться порівняно з групою емболізацій (10,2%). Інтраопераційний церебральний ангіоспазм є провідним фактором несприятливого перебігу хірургічного втручання та перебігу захворювання, зумовлюючи зростання летальності при його розвитку до 27,8% та унеможливлюючи успішну операцію у 38,8% випадків. Незалежно від термінів проведення операції, несприятливим критерієм є достовірне (р 0,05) зменшення діаметру середньої мозкової артерії на момент завершення операції порівняно з її початком в середньому на 30,1% на противагу сприятливому перебігу, коли спостерігається недостовірне (p>0,2) звуження артерії в середньому на 8,4%. Рекомендованими є рання госпіталізація хворих із розривами внутрішньочерепних артеріальних аневризм, проведення транскраніальних втручань в термін 10,5-14,3 діб, та ендоваскулярних втручань в першу добу, що дозволяє досягти найкращого клінічного результату. При можливості виконання операції кожним з методів, рекомендованим є проведення ендоваскулярних емболізацій, оскільки середній ліжко-день є статистично вірогідно коротшим (p<0,01), ніж після проведення транскраніальних втручань.

In modern guidelines, the control of intracranial pressure is recognized as an important prerequisite for quality reco-very of brain functions after severe traumatic brain injury (TBI). Among the relatively new approaches to the control of intracranial pressure in severe TBI, a combination drug L-lysine aescinate® is considered. It has endotheliotropic, venotonic, anti-inflammatory, antiplatelet and other effects that allow it to be regarded as a mean for preventing and reducing cerebral edema after TBI. To evaluate the efficacy and effects of L-lysine aescinate®, a multicenter retrospective study was conducted that included 988 patients aged 18 to 65 years with isolated or combined severe or moderate TBI. The median injury severity index was 17 points, i.e. most people had a serious injury. Patients were randomized into two groups, one of which (n = 335) received only standard therapy, while the other (n = 653) — additionally L-lysine aescinate®. L-lysine aescinate® was prescribed on the first day of hospitalization (median — 2.75 hours) and for a course of 2 to 8 days (median — 7 days). Mortality in the intensive care unit (primary endpoint) was 10.3 and 24.2 % in the main and control groups, respectively (difference 13.9 %; 95% confidence interval (CI): 8.93–19.21 %; p < 0.001). Logistic regression method revealed that L-lysine aescinate® was the most important factor influencing patient survival (p < 0.001). Its use increased the chances of survival of a patient with TBI in the intensive care unit by 3.3 times (odds ratio (OR) = 3.311; 95% CI: 2.108–5.200). Similar results were obtained for 30-day hospital mortality. The frequency of recovery of clear consciousness during the hospital stay was 87.0 % in the group of L-lysine aescinate® and 66.0 % in the control group, with a significant difference between them (p < 0.001). Administration of L-lysine aescinate® increased the chances for restoring clear consciousness in a patient with TBI by 3.8 times (OR = 3.823; 95% CI: 2.535–5.765). The results of the study allow us to recommend the inclusion of L-lysine aescinate® in the standard therapy of patients with isolated or combined severe or moderate TBI.

Objective ‒ to determine the dependence of unfavourable treatment outcomes of spontaneous intracerebral hematomas (ICH) on the peculiarities of microstructural changes in the perihematomal area.Materials and methods. A prospective study was conducted that included 68 patients with haemorrhagic stroke and chronic arterial hypertension, as well as signs of ICH. Patients’ clinical condition and treatment outcomes were assessed. The brain data of five patients who died at different stages after the haemorrhagic stroke were analysed using the method of optical microscopy of autopsy material. Results. Patients’ age ranged from 38 to 59. At the time of hospitalization, the Glasgow Coma Scale score was 8 to 15. The inpatient period was less than 1 day for three patients with stem and medial ICH, and 10 and 34 days in case of subarachnoid haemorrhage (in the latter cater, there was an aneurism re-rapture 3 days before death). Blood in the ventricular system was observed in all patients. Gross examination data during the autopsy showed that the cortical layer above the affected area is thin; after 12‒24 hours, the perihematomal area is swollen, with small dotted, and sometimes coalesced haemorrhaging; after 3 and more days, it increased to 4–5 mm and turned reddish-brown. During histologic examination: brain tissue with signs of the swelling, perihematomal area is cell-like with nerve cells – ranging from minor changes to extreme dystrophia and coagulative necrosis (nuclei with signs of pyknosis, rhexis, lysis), homogenous eosinophilic cytoplasm, apparent pericellular swelling, cell shaft formed by lymphocytes, leukocytes, macrophages, hemosiderophages, and reactive increase in oligodendrocytes and astrocytes.Conclusions. Perihematomal area has been found to be not just a «perihematomal swelling» as described in the literature. The unfavourable course of the ICH of different localization (basal, stem) can be explained by a complex of pathomorphological changes in this area: reactive inflammatory activation of glia, dystrophic nerve cell changes, pericellular swelling. As seen from our observations, early development of these processes – as early as on the 1st day – and their progressing indicate the presence of common mechanisms of unfavourable outcome regardless of haemorrhagic stroke localisation.

Objective – to establish the value of non-invasive monitoring of central hemodynamics during the acute period of polytrauma and its impact on systemic respiratory and circulatory parameters and intensive care treatment using the estimated Continuous Cardiac Output (esCCO), a non-invasive continuous measurement technique of central hemodynamics, which was integrated into the Life Scope monitor (Nihon Kohden, Japan). module.Materials and methods. The study included 170 patients with polytrauma who were treated in our intensive care unit. Patients with severe polytrauma (ISS 20–30 points) were included in the group 1 (n = 70), with an average age of (41.9 ± 2.4) years. The group 2 (n = 100) consisted of patients with moderate polytrauma (ISS 10–19 points), the average age of the patients in this group was (38.7 ± 2.5) years. In sub-groups 1А and 2А adequate circulating blood volume measurement and subsequent support was performed using the esCCO. In subgroups 1B and 2B, the analysis of systemic hemodynamics such as ECG and blood saturation was performed using standard multifunction monitors.Results. Hemodynamic disorders in the form of arterial hypotension < 70 mm Hg on admission occurred in 14.3 % of patients in group 1, and was not observed in patients within the group 2. The normalization of systemic hemodynamics was observed after 24 hours of intensive care therapy, in particular in subgroup 1А a marked increase in the systemic blood pressure and subsequent termination of tachycardia was observed. Normalization of cardiac output and cardiac index in subgroup 1А was observed after 3–6 h of infusion therapy (IT), in the subgroup 2А – after 12 h IT. In the subgroup 1А the infusion volume during the first day differed significantly, 8.9 % less if compared to the infusion volume used in subgroup 1B. In moderate-severity polytrauma, the infusion volume was significantly smaller than in severe polytrauma, and in the subgroup 2А it was significantly lower by 8.6 %, compared to the infusion volume used in the subgroup 2B. The confirmation of the effectiveness of the balanced IT was the normalization of the urine output. Namely: on day 2 in the subgroup 1А the diuresis increased significantly compared to day 1, and in the subgroup 1B it did not change significantly. Intergroup differences in mean daily diuresis in the group 2 were significant after 12 h of IT.Conclusions. Carrying out monitor-controlled infusion and respiratory therapy with the usage of the esCCO monitoring technique allowed to achieve an early normalization of central and systemic hemodynamics during the intensive care of polytrauma patients with a significantly smaller volume of infusion, contributed to the elimination of hypoxia, and was accompanied by a significant reduction, namely by 21.1 %, in the duration of mechanical ventilation in severe polytrauma.

Ìåòà. Äîñë³äèòè âçàºìîçâ'ÿçîê ´àçîòðàíñì³òåðà îêñèäó àçîòó òà êèñëèõ ³ ëóaeíèõ ôåðìåíò³â ðèáîíóêëåàç ó ïàö³ºíò³â ³ç òÿaeêîþ ÷åðåïíî-ìîçêîâîþ òðàâìîþ òà âñòàíîâèòè îñîáëèâîñò³ äèíàì³êè ¿õ çì³í ïðîòÿãîì ïåð³îäó ë³êóâàííÿ. Ìàòåð³àë ³ ìåòîäè. Ó ðîáîò³ äîñë³äaeóâàëèñü äàí³ ä³àãíîñòèêè òà ðåçóëüòàòè ë³êóâàííÿ 72 ïàö³ºíò³â ³ç òÿaeêîþ ÷åðåïíî-ìîçêîâîþ òðàâìîþ â³êîì 18-76 ðîê³â (ñåðåäí³é â³ê 42,26±15,02 ðîêè), ÿê³ áóëè ïîãðó-ïîâàí³ íà ÷îòèðè ãðóïè çà øêàëîþ íàñë³äê³â Ãëàçãî: "Ñìåðòü", "Çíà÷íà ³íâàë³äèçàö³ÿ", "Ïîì³ðíà ³íâàë³-äèçàö³ÿ", "³äíîâëåííÿ". Ðåçóëüòàòè é îáãîâîðåííÿ. Äîâåäåíî çíà÷íå äîñòî-â³ðíå çðîñòàííÿ ïîêàçíèêà îêñèäó àçîòó â ïàö³ºíò³â ³ç íåáëàãîïîëó÷íèìè íàñë³äêàìè (ÿê³ â ïîäàëüøîìó ïîìåðëè ÷è çàëèøèëèñü îñîáàìè ç ³íâàë³äí³ñòþ) òà çíèaeåííÿ éîãî ç ÷àñîì ë³êóâàííÿ äëÿ ãðóï ïàö³ºíò³â ³ç â³äíîñíî áëàãîïîëó÷íèìè íàñë³äêàìè ë³êóâàííÿ (ïî-ì³ðíîþ ³íâàë³äèçàö³ºþ òà â³äíîâëåííÿì). ijà´íîñòè÷íèìè ìàðêåðàìè ïîäàëüøîãî íåñïðèÿòëèâîãî íàñë³äêó äëÿ aeèòòÿ ìîaeóòü áóòè íà ïî÷àòêó ë³êóâàííÿ (ïåðøà äîáà) ð³âåíü îêñèäó àçîòó â ñå÷³ íèae÷å 1,1 ìêìîëü/ë òà ð³âåíü ÐÍÊàç ìåíøå 25 ìÎ/ìë. Äîâåäåíî ïðÿìèé êîðåëÿö³éíèé âçàºìîçâ'ÿçîê çíà÷åíü ð³âíÿ îêñèäó àçîòó òà ð³âíÿ ÐÍÊàç íà 1, 3, 7 ³ 9-é äí³ ë³êóâàííÿ (ð<0,05). Âèñíîâêè. Ðåçóëüòàòè ðîáîòè áóäóòü âàaeëèâèìè äëÿ îïåðàòèâíî¿ îö³íêè ñòàíó ïàö³ºíòà òà ïðèéíÿòòÿ ð³øåííÿ ñòîñîâíî ìåòîä³â ë³êóâàííÿ, ùî äîçâîëèòü ì³í³ì³çóâàòè åôåêò â³ä îòðèìàíî¿ òðàâìè é ñïðî´íîçóâàòè éìîâ³ðí³ íàñë³äêè ÷åðåïíî-ìîçêîâî¿ òðàâìè.