[Intra-arterial administration of verapamil for prevention and treatment of cerebral angiospasm after SAH due to cerebral aneurysm rupture]

Mechanisms of neuronal cell death in ischemic stroke and their therapeutic implications

Ischemic stroke caused by arterial occlusion is the most common type of stroke, which is among the most frequent causes of disability and death worldwide. Current treatment approaches involve achieving rapid reperfusion either pharmacologically or surgically, both of which are time-sensitive; moreover, blood flow recanalization often causes ischemia/reperfusion injury. However, even though neuroprotective intervention is urgently needed in the event of stroke, the exact mechanisms of neuronal death during ischemic stroke are still unclear, and consequently, the capacity for drug development has remained limited. Multiple cell death pathways are implicated in the pathogenesis of ischemic stroke. Here, we have reviewed these potential neuronal death pathways, including intrinsic and extrinsic apoptosis, necroptosis, autophagy, ferroptosis, parthanatos, phagoptosis, and pyroptosis. We have also reviewed the latest results of pharmacological studies on ischemic stroke and summarized emerging drug targets with a focus on clinical trials. These observations may help to further understand the pathological events in ischemic stroke and bridge the gap between basic and translational research to reveal novel neuroprotective interventions.

[Surgical treatment of patients with cerebral aneurysms in the acute stage of rupture: dynamics of results during 2006-2018]

Treatment of cerebral aneurysms in the acute stage of subarachnoid hemorrhage (SRH) especially on the background of cerebral vasospasm continues to be a difficult task.

OBJECTIVE

Assessment of dynamics of the surgical treatment results of patients with cerebral aneurysms in acute period of SRH.

MATERIAL AND METHODS

A comparative analysis of the results of patients' surgical treatment in NMRCN Burdenko about aneurysm in 1-21 days after hemorrhage was made. The following periods were selected: 2006-2014 (343 patients) and 2015-2018 (356 patients). Most patients had microsurgical operations in both periods. The tactics of choosing the surgery time was the main difference between the periods: particularly in 2015-2018 period the surgery was not postponed at patients with severe.

RESULTS

Analysing the post surgical mortality, it was found that since 2006 there is a consistent trend towards a decrease in the number of patients who died after surgery. When calculating the average post surgical mortality for the studied periods this trend is confirmed - number of lethal cases in 2015-2018 reliably decreased when comparing with 2006-2014 - from 6.8 till 3.2%; p=0.03. At the same time, the number of patients with outcome of vegetative status (from 0.3 till 5%).

CONCLUSION

The tactics of surgical treatment of patients with cerebral aneurysms in the acute period of SRH regardless of severity of patient's condition and time of hemorrhage did not lead to worse treatment. In contrast, post surgical mortality rates show a consistent decline. We associate this fact with a number of changes that have occurred in the management and treatment of patients. In particular, we have high hopes for developing new approaches to the treatment of vasospasm, which remains the leading cause of lethal cases. More definite conclusions will be made at the end of the treatment analysis of the respective patient groups.

Vertebral artery and posterior inferior cerebellar artery aneurysms: Results of microsurgical treatment of eighty patients

Background

The choice of surgical approaches and options for the microsurgical vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms repair remains controversial.

Methods

A retrospective analysis of the clinical, surgical, and angiographic data of 80 patients with VA and PICA aneurysms treated from 2012 to 2018 was performed.

Results

The aneurysms were saccular in 50 cases (62.5%) and fusiform in 30 cases (37.5%). The median suboccipital craniotomy was the most common approach (73.8%). Retrosigmoid craniotomy was performed in 25% of patients. There were the following types of microsurgical operations: neck clipping (61.25%), clipping with the artery lumen formation (13.75%), trapping (10%), proximal clipping (5%), and deconstruction with anastomosis (10%). Fifty-seven (71.3%) patients were discharged without worsening of the clinical signs after surgery. The most common postoperative neurological disorder was palsy of IX and X cranial nerve revealed in 14 (17.5%) patients. No fatal outcomes or patients in vegetative state were identified. The complete occlusion of PICA and VA aneurysms according angiography was in 77 (96.3%) cases.

Conclusion

Microsurgical treatment is an effective method for VA and PICA aneurysms. The majority of VA and PICA aneurysms do not require complex basal approaches. A thorough preoperative planning, reconstructive clipping techniques, and anastomoses creation, as well as patient selection based on the established algorithms and consultations with endovascular surgeons, may reduce the number of complications and increase the rate of complete microsurgical occlusion in VA and PICA aneurysms.

[Microsurgical treatment of aneurysms of vertebral and posterior-lower cerebellar arteries: surgical approaches, exclusion options, treatment results]

Aneurysms of vertebral (VA) and posterior inferior cerebellar arteries (PICA) are relatively rare pathologies and account for 3.4% of the total number of intracranial aneurysms.

MATERIAL AND METHODS

The experience of microsurgical treatment of 67 patients with VA and PICA aneurysms in N.N. Burdenko National Medical Research Center for Neurosurgery of the RF Ministry of Health from 2012 to 2017 is presented.

RESULTS

Most patients underwent reconstructive microsurgical interventions: clipping of the aneurysm neck in 42 (62.7%) patients and complex clipping with the formation of arterial opening - in 10 (14.9%). Exclusion of the aneurysm together with the carrier artery (trapping, proximal clipping) was performed on 10 (14.9%) patients. In 5 (7.5%) patients, deconstruction of the carrier artery of the aneurysm was performed after creating local anastomoses. The radical exclusion of aneurysms in the studied group was 95.5%. Postoperative dysfunction of the caudal group of cranial nerves was detected in 11 (16.4%) patients. There were no lethal outcomes, or cases with vegetative status outcomes.

CONCLUSION

Microsurgical intervention is an effective way to treat VA and PICA aneurysms, subject to the principles of patient selection based on existing treatment algorithms as well as adherence to an interdisciplinary approach.

[Intracisternal administration of verapamil for the prevention and treatment of vasospasm in patients after microsurgical treatment of cerebral aneurysms in the acute period of hemorrhage]

The first results of intracisternal administration of verapamil for the prevention and treatment of cerebral vasospasm (CVS) in patients in the acute period of subarachnoid hemorrhage (SAH) after microsurgical clipping of cerebral aneurysms are presented.

OBJECTIVE

Safety assessment of the method of prolonged intracisternal infusion (PII) of verapamil.

MATERIAL AND METHODS

Over the period from May 2017 to December 2018, 42 patients were included in the study, who underwent clipping of aneurysm of the anterior segments of the Willis circle. Most patients (78.6%) were operated during the first 6 days after SAH. For each patient, a thin silicone catheter was installed, through which verapamil was infused. A prerequisite was the installation of external ventricular drainage and opening of the lamina terminalis. The daily dosage of verapamil varied from 25 to 50 mg of the drug diluted in 200-400 ml of isotonic sodium chloride solution. The indication for the use of the PII method was the presence of one of the following factors: a score on the Hunt-Hess scale from III to V, 3 or 4 points on the Fisher scale, confirmed angiographically by the CVS before the operation.

RESULTS

The PII procedure was performed from 2 to 5 days. The average dose of verapamil was 143.5±41.2 mg additionally, in the presence of an angiographically confirmed CVS accompanied by clinical manifestations, 14 (33.4%) patients received intra-arterial injection of verapamil in several stages, with individual selection of the drug dose. The formation of new cerebral ischemic foci of vasospastic genesis was observed in only 1 (2.4%) patient. No infectious intracranial complications were noted. The average follow-up period was 297.6±156.1 days. Long-term treatment outcomes, assessed by a modified Rankin scale from 0 to 2 points, were observed in 83.3% of patients. There were no outcomes such as vegetative status and no deaths. The frequency of liquorodynamic disorders, as well as epileptic syndrome did not exceed that among patients with SAH according to the literature.

CONCLUSION

The study has confirmed the safety of prolonged PII. The efficacy of the method, compared with other methods for CVS treatment requires further investigation. The first results look quite promising: the observation shows a low percentage of new foci of cerebral ischemia and the absence of deaths associated with it. In patients with severe CVS, the efficacy of the PII method is increased when combined with intra-arterial administration of verapamil.