RU2408300C2 - Method of treating cerebral ischemia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: supposed (claimed) invention relates to field of medicine, namely to neurosurgery. Method includes formation of cutaneous aponeurotic flap, craniotomy, isolation of donor vessel of frontal and parietal branches of superficial temporal artery (STA), isolation of recipient vessel, preparation of vessels to application of microanastomosis, application of vessel suture, layer-by-layer sewing of operation wound. Frontal branch of STA is used for creation of microanastomosis with cortical branch of anterior cerebral artery or with distal branch of medial cerebral artery (MCA), and parietal branch of STA is used for anastomosis with MCA. Isolated for application of microanastomoses STA branches are transected and ligated after isolation of recipient vessels. During creation of microanastomosis into vessel-recipient introduced is monofilament thread, which is removed before finishing sewing of vessels through unsewn opening.

EFFECT: method allows to accelerate rehabilitation process after stroke and prevent recurring stroke, which is used due to increase of blood supply basin.

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Description

The present invention relates to medicine, namely to neurosurgery and neurology, can be used in the surgical treatment of cerebral ischemia in patients for primary or secondary prevention of stroke, as well as for the treatment of ischemic stroke.

The national registry in Russia shows that 450,000 stroke patients are observed annually, and mortality from cerebrovascular diseases in Russia has reached 156 per 100,000 of the population. In most cases, it is possible to prevent the development of ischemic stroke using surgical revascularization (A.V. Pokrovsky. The current state of vascular surgery in Russia. 2007. - P.32-35).

A known method of conservative treatment of cerebral ischemia, which consists in the use of vascular, neurometabolic and antiplatelet drugs (Spiridonov A.A., Lavrentiev A.V. et al. Microsurgical revascularization of the carotid pool. - Moscow, 2000. - P.289). The disadvantages of standard conservative therapy include low efficiency (up to 20%), unstable remission (2-3 months) and the presence of complications (10-25%).

It should also be noted that the existing conservative treatment of cerebral ischemia in some cases cannot prevent the formation of a vascular catastrophe leading to ischemic stroke (Suslina Z.A. Stroke - a multidisciplinary problem - Ischemic stroke., - 2007. - P.36-41).

The closest in technical essence to the proposed is a method of surgical treatment of cerebral ischemia, in which the parietal branch of the superficial temporal artery is used to create extra-intracranial microvascular anastomosis with branches of the middle cerebral artery. The operation contains the following successive stages: the formation of a skin-aponeurotic flap; craniotomy for access to cortical vessels; the allocation of a donor vessel from the resulting skin-aponeurotic flap; cortical artery discharge; preparation of blood vessels for the application of anastomosis; imposition of a vascular suture, layer-by-layer suturing of the surgical wound. An aponeurosis skin incision was made in the parietal-temporal region so that the donor vessel: the frontal or parietal branch of the superficial temporal artery was located closer to the middle of the skin-aponeurotic flap. In this case, the selected section of the cortical artery of 1-1.5 cm in size was considered sufficient for the vascular suture, then microclips were applied to the selected section of the cortical vessel and the outer wall of the vessel was opened between the clips. The donor vessel was connected to the recipient vessel according to the end-to-side type, first two fillet welds were applied, then alternating interrupted welds on one side and the other. Temporary clamps were removed from the cortical and donor branches. After hemostasis and washing of the subarachnoid space, the surgical wound is sutured in layers, leaving drainage in the posterior lower corner of the wound (Spiridonov A.A. Lavrentiev A.V. et al. Microsurgical revascularization of the carotid pool. - Moscow, 2000. - P.289).

The disadvantages of surgical treatment using known technologies include damage to the donor vessel or the recipient vessel during excretion, since only one of the branches of the superficial temporal artery (PVA) is released. It is technically more difficult and time-consuming to apply a microsurgical anastomosis, since after the arteriotomy, the walls of the recipient vessel collapse, which complicates their separate capture and application of the microsurgical suture, and subsequently leads to the failure of the anastomosis. It is also possible the failure of vascular microanastomosis in the postoperative period in the form of thrombosis, which is accompanied by the resumption of cerebral ischemia. The lack of a persistent effect in these cases is due to the lack of additional extra-intracranial vascular collateral and a small area of revascularization, which does not allow to stop the initial ischemia.

Based on the current level of technologies for the treatment of cerebral ischemia, as well as elimination of known deficiencies, the task was set: to restore adequate cerebral blood flow during ischemia and to accelerate the rehabilitation process after a stroke, to prevent a re-stroke due to an increase in the blood supply pool, to simplify the application of a microsurgical suture.

The problem is solved as follows:

Treatment of cerebral ischemia includes the formation of a skin aponeurotic flap, craniotomy, isolation of the donor vessel of the frontal and parietal branches of the superficial temporal artery (PVA), isolation of the recipient vessel, preparation of vessels for the application of microanastomosis, application of a vascular suture, layered suturing of the surgical wound. New in solving this problem is that the frontal PVA branch is used to create a microanastomosis with the cortical branch of the anterior cerebral artery or with the distal branch of the middle cerebral artery (SMA), and the parietal branch of PVA is used for an anastomosis with SMA. Moreover, the PVA branches selected for the application of microanastomoses intersect and ligate after the isolation of the recipient vessels. When creating a microanastomosis, a monofilament thread is placed in the recipient vessel, which is removed before the end of the stitching of the vessels through an un sewn hole.

We explain the essential distinguishing features of the proposed "Method for the treatment of cerebral ischemia":

The use of both branches of the superficial temporal artery (PVA) as a donor vessel for direct anastomosis provides an increase in the area of brain revascularization and restoration of adequate cerebral blood flow, accelerates the rehabilitation process after a stroke, and also prevents the development of repeated ischemic stroke.

It is important that the ligation of donor vessels is carried out only after isolation of the recipient vessels (after craniotomy). In this case, the blood flow through the donor vessels remains until the stage of application of the microanastomosis, which allows you to maintain adequate blood flow through the formed anastomosis in the future.

The placement of a monofilament filament in the recipient vessel during microanastomosis, which is removed before the vessels are sutured through an un sewn opening, allows an adequate and complete microvascular suture to be performed, to reduce the time of the most difficult stage of microsurgery and to prevent anastomatic vasoconstriction.

Patent studies on subclasses A 61 B 17/00, 17/12 and analysis of scientific and medical information reflecting the current level of surgical treatment of cerebral ischemia did not reveal identical technologies. Thus, the proposed method is new.

The interconnection and interaction of the essential distinguishing features of the proposed method ensures the achievement of a new technological medical result: they increase the effectiveness of treatment by restoring adequate cerebral blood flow during ischemia, speeding up the rehabilitation process after a stroke, easier and faster to perform a microvascular suture, and also prevent the development of repeated ischemic stroke. This allows us to conclude that the technical solution meets the criterion of "inventive step".

The method comprising the claimed invention is intended for use in healthcare. The possibility of its implementation is confirmed by the methods and means described in the application. The inventive method ensures the achievement of the technical result perceived by the applicant, namely, increasing the efficiency of surgical treatment of cerebral ischemia and providing preventive revascularization of patients with manifestations of chronic cerebrovascular circulatory failure. From the above it follows that the claimed invention meets the patentability criterion of "industrial applicability".

The essence of the proposed method is illustrated by drawings, which show:

figure 1 is a diagram of a separate allocation of branches of the superficial temporal artery (PVA) after controlling their pulsation;

figure 2 - diagram of the selected branches of the PVA and dissected temporal muscle, allotted to the periorbital region;

figure 3 - intraoperative scheme selected both branches of the PVA (frontal and parietal: donor vessels) with preserved blood flow through them after a craniotomy;

figa is a diagram showing the placed monofilament thread in the donor vessel after arteriotomy;

figb is a diagram of the extraction of monofilament yarn after the end of the application of microanastomosis;

5 is a diagram of suturing wounds after performing both vascular anastomoses;

6 and 7 - magnetic resonance imaging, showing an increase in the diameter of the donor vessel 12 months after performing a vascular anastomosis.

The proposed "Method for the treatment of cerebral ischemia" is as follows:

For revascularization of ischemic areas of the brain in the basins of the anterior cerebral and middle cerebral arteries, the branches of the external carotid artery are used separately. The selection of the branches of the superficial temporal artery is performed by dissecting the skin after controlling the pulsation of its distal branches so that both branches are in the center of the surgical wound (see the appendix to the description of figure 1). Then the branches of the superficial temporal artery are isolated from the aponeurotic tissue and the underlying temporal muscle within the surgical wound. A semicircular dissection of the temporal muscle and its displacement anteriorly to the periorbital region are performed (see the appendix to the description of FIG. 2). A craniotomy is performed from 4-5 milling openings under the selected branches of the superficial temporal artery. The median membranous artery is damaged when performing a craniotomy, but usually this does not cause a deterioration in cerebral perfusion after surgery. The dura mater is opened crosswise with the formation of four sheets (see the appendix to the description of figure 3). To compensate for blood flow, the frontal branch of the superficial temporal artery is used to create a direct anastomosis end to the side with the cortical branch of the anterior cerebral artery or with the distal branch of the middle cerebral artery, which supplies the frontal region. In this case, a vascular collateral network with distal branches of the superficial temporal artery is formed in order to increase blood flow in the paramedian region of blood supply to the anterior cerebral artery. The parietal branch of the superficial temporal artery is usually used to create an anastomosis with the middle cerebral artery. The recipient's midbrain artery is selected from the cortical cortical arteries near the Silvian fissure.

The donor artery is crossed immediately after the selection and preparation of the recipient artery. Until this time, blood flow along the branches of the superficial temporal artery is maintained, which further avoids the failure of microanastamosis. After proximal clipping, distal ligation, and intersection, the donor artery is washed with a heparin solution. The recipient vessel is isolated and the microvascular suture is performed (see FIG. 5). A feature of the microvascular suture stage is the placement of a monofilament filament 5-10 mm long through an arteriotomy opening in the recipient vessel. Before the end of vascular stitching, the monofilament yarn is removed through an un sewn hole (see FIGS. 4A and 4B). Then the bone flap is returned to the place and placed under the muscle flap.

The authors took into account standard contraindications for extra-intracranial microanastamosis in patients with cerebral ischemia: severe neurological deficiency, age over 70 years and the absence of hemodynamic deficiency, confirmed by instrumental methods of research and diagnostic tests.

The proposed "Method for the treatment of cerebral ischemia" is illustrated by the following clinical example.

Patient Grechka S.I., born in 1955, was admitted to the neurosurgical department on 05/10/2006 with complaints of recurrent headaches in the right half of the head, weakness and numbness in the left limbs, pain in the cervical spine.

Considers herself a patient since October 27, 2005, when an ischemic stroke first developed in the right carotid pool with the development of transient left-sided hemiparesis. An ischemic stroke repeated on September 9, 2006, for which he was treated in the neurological department of the Clinical Hospital in Irkutsk.

At admission: the patient's condition is moderate. In the lungs, vesicular breathing, no wheezing. Heart sounds are clear, rhythmic, pulse - 76 beats / min. HELL on the upper extremities is symmetrical, 130/80 mm Hg The abdomen is soft, painless in all departments. There is no dysuria. The symptom of Pasternatsky is negative on both sides.

Ripple of the carotid and subclavian arteries is absent in the ICA projection on the right, over the bifurcations of both carotid arteries - systolic murmur. The pulsation of the arteries of the lower extremities is distinct at all levels. There is no noise.

Clinical and biochemical parameters within normal limits, chest x-ray and ECG - without features.

The conclusion of the neurologist: a condition after an ischemic stroke in the basin of the middle cerebral artery on the right 12/27/2005, repeated 09/09/2006. Arterial hypertension. Stage 3, risk 4. Cerebral atherosclerosis. Left-side hemiparesis to the degree of plegia in the arm. Moderate atenoneurotic syndrome with alarming layers. Cognitive impairment.

MRI of the brain: mixed infarction of the right parietal lobe on the background of cerebrovascular ischemia. External and moderately pronounced internal hydrocephalus.

MSCT AG: Occlusion of the ICA on the right. ICA stenosis on the left is less than 50%. Hypoplasia of the vertebral artery on the left.

Doppler ultrasound of extracranial arteries: signs of stenosing atherosclerosis in the system of the internal carotid artery, stenosis of the left internal carotid artery 50%. ICA occlusion on the right. Hypoplasia of the left vertebral artery.

Clinical diagnosis: Atherosclerosis and pathological loop formation of extracranial vessels. ICA occlusion on the right, ICA stenosis on the left 45% by Nascet. Hypoplasia of the left vertebral artery. The third (decompensated) stage of chronic cerebrovascular insufficiency: focal form, completed stroke in the pool of the right middle cerebral artery, moderate neurological deficit (90 points).

Given the above, namely: the presence of a completed stroke in the MCA pool on the right, ICA stenosis on the left up to 45% according to Nascet, hypoplasia of the left vertebral artery, the viability of collateral blood flow in the carotid system, the absence of gross somatic pathology, the patient is shown the first stage of treatment with EICMA on the right (direct microvascular anastomosis between the cortical branches of the SMA on the right and the frontal or parietal branches of the PVA on the right end to the side). In the absence of the possibility of allocating an adequate cortical vessel, the recipient, the patient will be performed indirect myo-, fool-angiosynastosis.

For the purpose of preoperative access planning according to duplex scanning, the branches of the superficial temporal artery were marked on the skin of the right temporal-parietal region.

Operation: Direct anastomoses: double extra-intracranial microsurgical vascular anastomosis on the right (EIKMA) between the parietal branch of PVA and SMA on the right, frontal branch and PVA on the right. Patient position: on the back with a head turn to the left.

Anesthesia: ETN. Magnification: Olympus 5000 Microscope.

After preliminary mapping using dopplerography and processing of the surgical field, a skin incision was made above the superficial temporal artery on the right. Using microsurgical technique, the parietal and frontal branches of the superficial temporal artery on the right, about 7 mm long, were not ligated, with preservation of blood flow along them. Performed skeletonization of the temporal muscle and its division into two portions above the donor vessels. A milling hole was applied and an automatic craniotomy was performed with sizes up to 6 cm in diameter. TMT is fixed to the bone edge by 10 interrupted sutures, pulsates, and is opened crosswise from the center. During the audit, the brain is somewhat atrophic, the arterial network is weakly expressed. The arachnoid membrane was opened, the cortical portion of the angular branch of the middle cerebral artery was highlighted on the right for 1.5 cm, the proximal and distal sections of the artery were taken into 2 removable clips, arteriotomy was performed linearly between the clips. A proline No. 3 thread is introduced into the formed hole. Then the PVA parietal branch is ligated and crossed. Under a magnification (microscope), a 20-fold microanastomosis was applied between the parietal branch of the superficial temporal artery and the cortical branch of the angular artery with an end-to-side type of thread 10/0 (12 sutures). Before the last two sutures are applied, the proline thread is removed from the recipient vessel. After removing the clips, the function of the anastomosis is satisfactory. In the same way, a direct anastomosis of the frontal PVA branch with the cortical frontal branch of the SMA was performed. Both anastomoses are wealthy, pulsation and blood flow are complete. Hemostasis using sergisella. The lower half of the TMT is removed and the temporal muscle is tightly stitched with the remains of the TMT with the formation of indirect duromyosinangeosis. The bone flap is fixed with 5 separate sutures. Layer wound closure. Aseptic dressing.

Condition after surgery with positive dynamics in the form of regression of left-side hemiparesis, cephalgic syndrome and restoration of motor aphasia.

With ultrasound scan, MSCT, MRI and diagnostic tests performed after 3 and 12 months, anastomoses from both arteries are viable (see the appendix to the description of Fig.6, 7).

In the period from 2005 to 2007, using the above method, 26 patients with cerebral ischemia were operated on. During the follow-up examination in all patients, the performed anastomoses are consistent. None of the patients after the revascularization operation in the postoperative period had ischemic strokes, both large and small.

Thus, the proposed "Method for the treatment of cerebral ischemia" allows you to restore adequate cerebral blood flow during ischemia, accelerate the rehabilitation process after a stroke, easier and faster to perform a microvascular suture, and also prevent the development of repeated ischemic stroke.

Claims (1)

A method for the treatment of cerebral ischemia, including the formation of a skin aponeurotic flap, craniotomy, isolation of the donor vessel of the frontal and parietal branches of the superficial temporal artery (PVA), isolation of the recipient vessel, preparation of vessels for the application of microanastomosis, application of a vascular suture, layered suturing of the surgical wound, different that the frontal branch of PVA is used to create a microanastomosis with the cortical branch of the anterior cerebral artery or with the distal branch of the middle cerebral artery (SMA), and the parietal branch s PVA - for anastomosis with SMA; at the same time, the PVA branches selected for the application of microanastomoses intersect and ligate after isolating the vessels of the recipients, and when creating the microanastomosis, a monofilament thread is placed in the recipient vessel, which is removed before the end of the stitching of the vessels through an un sewn hole.

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