Vascular injury from projectiles can lead to the migration of missile fragments, resulting in arterial or venous missile embolism. In the context of penetrating craniocerebral trauma, this complication is exceedingly rare. This can only occur when a missile breaches a dural venous sinus or the jugular vein, leading to subsequent embolization into the right cardiac chambers or the pulmonary arteries. We present 2 cases of right ventricular missile embolism and 1 case of pulmonary artery missile embolism via dural sinuses and provide a comprehensive review of 7 additional cases from the literature. A 25-year-old male was admitted on day 7 after a penetrating missile head injury. Initial head CT showed a complex wound channel but no intracranial fragment; however, a chest X-ray revealed the metal fragment in the right ventricle. After multidisciplinary consultation, he was managed conservatively with close monitoring for 21 days without complications before transfer for rehabilitation. A 30-year-old male presented on post-injury day 1 with a diametrical penetrating brain injury and a wound track terminating at the right transverse sinus. No fragment was found intracranially, but imaging confirmed its location in the right ventricle. The patient underwent emergency neurosurgical intervention and was subsequently lost to follow-up after transfer. A 26-year-old male presented on day 7 after a transorbital penetrating craniocerebral injury with a right carotid-cavernous fistula and missile embolism to the right pulmonary artery. Endovascular treatment achieved complete fistula occlusion, and the patient received prophylactic anticoagulation. Follow-up imaging demonstrated regression of the fistula with stable positioning of the pulmonary artery fragment, and the patient was transferred to rehabilitation after 14 days. This report highlights venous missile embolism as a rare but critical complication of penetrating craniocerebral trauma. Our analysis, including 3 new cases and a review of the literature, demonstrates that conservative management is a viable and often preferred strategy for stable patients with intracardiac or pulmonary missiles. The decision-making process should be multidisciplinary, individualized, and guided by patient-specific factors.

Acute epidural hematoma (AEDH) is recognized as one of the most urgent neurosurgical conditions. Traditionally, the primary treatment for AEDH has involved craniotomy with surgical evacuation of the hematoma. However, with the widespread adoption of neurointerventional techniques, interest in their application to various forms of traumatic brain injuries has increased. Among these, embolization of the middle meningeal artery (MMA) has emerged as a minimally invasive treatment option for AEDH. This study evaluates the effectiveness of MMA embolization as a primary treatment for AEDH.We conducted a retrospective review of patients treated for AEDH with embolization of the MMA at our institution from January 2019 to July 2024. Patient demographics, clinical presentation, procedural details, and outcomes were analyzed.MMA embolization was successfully performed in 20 patients with AEDH, with only 2 cases requiring subsequent burr-hole evacuation. The thickness of the AEDH was 10 mm or more in 47.8% of cases, and a midline shift was observed in 65.2% of cases. The most common angiographic findings included arteriovenous fistulas (AVFs) and contrast extravasation. N-butyl cyanoacrylate was used as the embolic material in all cases. In one case, Squid 12 was added to enhance penetration at sites of extravasation. No patients experienced recurrent AEDH postintervention.MMA embolization is a promising minimally invasive treatment for AEDH, showing effectiveness as both a primary and adjuvant therapy. Future prospective multicenter studies are needed to validate preliminary findings and optimize treatment protocols for this high-risk patient population.

Background. Currently, the “gold standard” of differential diagnosis of Cushing’s disease is inferior petrosal sinus sampling and measurement of the adenocorticotropic hormone (ACTH) level. The studied literature data indicate a wide variability in the sensitivity and specificity of inferior petrosal sinus sampling in the range of 85–100 and 67–100 %, respectively, which can lead to an erroneous diagnosis of the source of ACTH hyperproduction and, as a consequence, to incorrect and untimely treatment.Aim.To improve the results of differential diagnosis of Cushing»s disease by using bilateral simultaneous sampling of the cavernous and inferior petrosal sinuses.Materials and methods. Cohort single-center retro/prospective study of 70 patients with confirmed ACTH-dependent Cushing’s syndrome. For the purpose of differential diagnosis, a number of indicators were calculated: central-peripheral ratio, prolactin-normalized ACTH ratio, successful catheterization. Sampling results were evaluated in comparison with contrast-enhanced pituitary magnetic resonance imaging data and intraoperative data.Results. The study of the central-peripheral ratio showed the need to assess it simultaneously at the level of the cavernous and inferior petrosal sinuses. This approach makes it possible to significantly increase the sensitivity and specificity of the applied gradient to 93.1 and 85.7 %, respectively. Prolactin-normalized ACTH ratio is a second line predictor in the differential diagnosis of Cushing’s disease with sensitivity and specificity reaching 94.7 and 28.6 %, respectively. The gradient of successful catheterization is a reflection of possible hemodynamic features of a particular sinus, does not serve as an indicator of the correct positioning of microcatheters in the vascular bed.Conclusion. Bilateral simultaneous sampling of the cavernous and inferior petrosal sinuses is an effective method of differential diagnosis of Cushing’s disease and ectopic ACTH-dependent syndrome.

One of the possible measures that can enhance the quality of medical care, reduce the number of adverse outcomes, and also achieve target values for the use of reperfusion methods of treatment for acute ischemic stroke is to improve the system of care for patients with in-hospital ischemic stroke. One type of in-hospital stroke is perioperative stroke that develops during or 30 days after surgery. Since the publication in 2014 of the last fundamental work on the prevention of perioperative stroke, the approaches to primary and secondary prevention, diagnosis, conservative and reperfusion treatment of ischemic stroke have been seriously modified. The numerous changes have created the preconditions for a revision of existing approaches to providing care for patients with perioperative ischemic stroke. In 2021, updated documents from foreign researchers/associations on the perioperative ischemic stroke in non-cardiac and non-neurosurgical patients were published. The second part of our review presents current data on the perioperative antithrombotic prophylaxis, clinical and instrumental diagnosis, treatment and organization of care for perioperative ischemic stroke in this category of patients. The issues of using reperfusion treatment methods in non-cardiac and non-neurosurgical patients with perioperative stroke, such as systemic thrombolytic therapy and endovascular interventions, are discussed in detail, including the world experience of their “offlabel” use.

INTRODUCTION:In absence of hereditary diseases multiple brain arteriovenous malformations are extremely rare. The case series that would include more than 13 patients are unlikely to be found, which causes an obstacle to comprehensively analyzing the peculiarities of epidemiology, symptoms and treatment options for this disorder. We describe patent with two independent arteriovenous malformations in frontal and parietal lobes that have been treated with combination of preoperative embolization, surgical excision and stereotactic radiosurgery. Systematic review of literature was also performed, focusing on epidemiology of sporadic multiple arteriovenous malformations, niduses location, clinical presentation, treatment and outcomes.EVIDENCE ACQUISITION:We systematically analyzed relevant literature using the PubMed database, encompassing studies in English (published between 1956 and 2023) reporting incidence, epidemiological features, symptomatology and treatment of sporadic multiple brain arteriovenous malformations.EVIDENCE SYNTHESIS:Forty-eight studies with a total of 80 sporadic multiple cerebral arteriovenous malformations were extracted from the literature. Twenty-two papers reported incidence of multiple brain arteriovenous malformations. The average incidence (including our data) was 2.4%, varying significantly between children and adults. Hemorrhage from one AVM was the most frequent debut of multiple cerebral arteriovenous malformations. Surgical removal of niduses remains a valuable treatment option even considering the enhancement of embolization techniques and the development of radiosurgery.CONCLUSIONS:Sporadic multiple cerebral arteriovenous malformations represent a difficult problem to solve. The possibility of persistence of multiple brain arteriovenous malformations should be taken into account when diagnosing and following-up.

Clinical guidelines and the order of providing care in acute cerebrovascular accidents (CVA) have been developed for standard clinical situations, primarily for patients admitted to medical institutions in an emergency state. However, there are clinical situations when a generally accepted order of therapeutic and diagnostic measures concerning patients with stroke is unjustified and, on the contrary, its implementation threatens life and health of a patient. These situations include ischemic strokes developing intraoperatively during such endovascular interventions as diagnostic cerebral and coronary angiography and transcutaneous neuro- and cardiovascular surgery. Ischemic cerebral events after diagnostic endovascular procedures are relatively rare complications, but their development can lead to unfavorable consequences. Thus, the rates of transient cerebral circulatory disorders after cerebral angiography, a stroke with a reversible neurological deficit, and an ischemic stroke with a persistent neurological deficit are 2.45 %, 0.3 %, and 1.0 % respectively, while total mortality due to acute cerebrovascular pathology is 0.14 %. The rate of cerebral stroke after coronary angiography and percutaneous coronary interventions is up to 0.4 %. Prevention of neurologic complications in diagnostic and surgical transcutaneous interventions is strongly dependant on their correct technique, rational perioperative antithrombotic therapy, and lesser duration of endovascular operations.

The coexistence of Moyamoya Syndrome with Arteriovenous Malformation is exceedingly rare. Here, we present the case of a 37-year-old female patient diagnosed with AVM in the right parietal lobe, accompanied by severe stenosis of the right middle cerebral artery and right anterior cerebral artery, along with moyamoya collateral induction. Our objective was to investigate the frequency and mutual influence of these conditions, and to determine a preferable treatment strategy by conducting a comprehensive review of previous case reports. We conducted a thorough search of PubMed, Scopus, and Web of Science databases, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our review encompassed 36 publications, reporting a total of 64 cases of AVM coexisting with Moyamoya Syndrome. Notably, bilateral stenosis was observed in half of the cases. Among patients with unilateral stenosis, AVM was localized in the opposite hemisphere only in 2 cases. Treatment approaches varied, with 18 cases undergoing active treatment for both stenosis and AVM, 11 cases treating stenosis prior to AVM, 5 cases addressing AVM first, and 3 cases treating both AVM and stenosis simultaneously. Embolization, either standalone or supplemented by stereotactic radiosurgery, was employed in six cases. Stereotactic radiosurgery alone was utilized in 12 cases, while 15 patients underwent surgical removal of the AVM. Our findings provide valuable insights for neurosurgeons managing patients with concurrent AVM and Moyamoya Syndrome. The variety of treatment approaches observed in the literature underscores the complexity of these cases, emphasizing the need for individualized strategies. This information may guide future systematic reviews and meta-analyses, contributing to a better understanding of the optimal management of these rare coexisting vascular pathologies.

Introduction. The etiology and pathogenesis of cerebral aneurysms are diverse. The rare cause of cerebral aneurysms occurrence is cardioembolism in cases of heart tumors, in particular in myxoma. Cardiac myxoma (from Latin muxa, mucus) is the most common (about 50 %) benign tumor of heart. With untimely diagnosis and absence of the disease treatment, embolisms in cerebral vessels may occur with typical symptoms of ischemic stroke as well as in some cases the myxomal aneurysms may develop. There are several theories of their origin. The myxomal aneurysms of cerebral vessels are more common in women and in the vast majority of cases they develop in carotid basins. In a quarter of cases, the disease onsets as intracranial hemorrhage caused by rupture of an oncotic (myxomal) aneurysm, that significantly exceeds the frequency of ruptures (1–3 % per year) in cases of “normal” bifurcation‑hemodynamic intracranial aneurysms. The mortality rate is 3.4 %. The majority (80 %) of ruptures were observed within 2 years after the diagnosis of cardiac myxoma, and in half (48.6 %) of cases clinically significant episodes of embolism were noted. Timely treatment can prevent the hemor rhagic type of course of these aneurysms. Various methods of treatment are described in the literature: different options for surgical eradication as well as the possibilities of chemotherapy and radiation exposure. Aim. To present a case of successful radical reconstructive endovascular treatment of patient with distal cerebral aneurysm associated with cardiac myxoma, combined with presence of multiple cavernous malformations and also to highlight issues of diagnosis, differential diagnosis and existing treatment options for these diseases. Clinical observation. The article presents a clinical observation of multiple aneurysms associated with myxoma of the heart in combination with multiple cavernous angiomas of the brain. The possibility of reconstructive eradication of distal aneurysm after its transformation from fusiform to saccular is demonstrated. The etiology and pathogenesis of occurrence, the nuances of differential diagnosis, possible methods and the algorithm for choosing a method for treating brain aneurysms associated with myxomas are reflected. The patient underwent reconstructive aneurysm shutdown by embolization with microspirals, which became possible due to the anatomical shape that favored this type of treatment. Conversion to destructive intervention was not required. Due to the natural course of the disease, the patient remains at risk of progression of a distal aneurysm in the basin of the same artery, and therefore it will be observed in dynamics. Conclusion. All patients with cardiac myxomas, both before and in dynamics after their removal, are recommended to perform noninvasive visualization of brain vessels for verification of such complication as metastatic (myxomal) aneurysms. The prognosis in most patients with multiple intracranial aneurysms associated with myxoma is favorable and most aneurysms associated with myxoma are stable. However, in cases with progressive or ruptured aneurysms, surgical treatment options should be considered including microsurgical or endovascular eradication. Radiation and chemotherapy methods may have a certain therapeutic value.

OBJECTIVE:To develop the principles for the treatment of traumatic intracranial aneurysms after combat damage to skull and brain.MATERIAL AND METHODS:There were 18 patients with traumatic intracranial aneurysms from February 2022 to the present. Of these, 15 ones had gunshot penetrating wounds of the skull and brain. In 3 cases, aneurysms developed after explosive injury. All patients underwent computed tomography (CT) of the brain, CT angiography of brain vessels and selective cerebral angiography. We analyzed nature of brain damage, trajectory of the wounding projectile and aneurysm location to determine predictors of traumatic intracranial aneurysms. Surgical treatment was performed in all cases.RESULTS:Hemorrhagic manifestations were observed in 11 patients. In 4 cases, traumatic intracranial aneurysms were diagnosed before rupture. Blunt head injury was followed by subarachnoid hemorrhage in 2 cases and ischemic stroke in 1 case. Endovascular or microsurgical intervention was performed depending on location of aneurysm, clinical manifestations and severity of brain damage. In case of distal aneurysms, endovascular and microsurgical destructive interventions prevailed. At the same time, proximal aneurysms (within or below the circle of Willis) required reconstructive endovascular treatment.CONCLUSION:Traumatic aneurysms should be suspected in all patients with penetrating craniocerebral injuries. Follow-up is contraindicated for traumatic intracranial aneurysms due to high risk of hemorrhage.

A clinical case of traumatic cerebral artery aneurysm formation after a penetrating diametrical gunshot wound is presented. Based on data of primary primary and delayed cerebral angiography, intraoperative imaging of the arterial appearance, the evolution (emergence and growth) of a traumatic cerebral aneurysm within 14 days after wounding is traced. The clinical observation is of interest due to a combination of factors: the presence of an unrelated wound aneurysm in the same basin, available intraoperative images of the injured artery as the initial stage of traumatic aneurysm formation, and the possibility to trace angiographic stages of aneurysm formation. Two-stage surgical treatment was performed: removal of the wounding projectile and intravascular intervention (implantation of a flow-deflecting stent) at the level of the aneurysm. In the conclusion the clinical picture, radiological signs of penetrating cranial wounds characteristic for traumatic aneurysm formation, and their treatment tactics are discussed.

OBJECTIVE To evaluate safety and feasibility of transradial approach for neuroendovascular procedures and to familiarize neurosurgeons and neuroradiologists with the capabilities and limitations of this approach, as well as technical features influencing its effectiveness. MATERIAL AND METHODS A retrospective analysis was performed in 270 patients who underwent transradial neuroendovascular procedures between January 2015 and December 2019. Diagnostic and surgical interventions were performed in 203 (75.2%) and 67 (24.8%) patients, respectively. The authors comprehensively describe catheterization technique and choosing the instrument for effective and safe transradial access. RESULTS The right vertebral and both common carotid arteries were the most accessible for selective catheterization (100% of cases). The left common carotid artery was catheterized in all cases, the left internal carotid artery - only in 92% of cases. If catheterization of the left vertebral artery was necessary, we used the left-sided radial approach. Conversion to femoral approach was required in 2.6% of cases for the left internal carotid artery disease (n=7). Radial artery occlusion occurred in 3.7% of cases (n=10) and was asymptomatic in all cases. We present a video clip (https://youtu.be/3wZ6O8u-lpk) devoted to various surgical interventions through radial approach. CONCLUSION Radial approach is safe and feasible and may be used for neuroendovascular procedures.

Background. Surgical treatment of complex neurovascular pathology remains an important problem requiring use of a combination of various techniques. Utilization of a hybrid operating room allows to simultaneously or sequentially combine microsurgical and endovascular surgical methods which can improve treatment outcomes. Aim. To improve surgical treatment of patients with cerebrovascular pathology by utilizing the capabilities of a hybrid operating room. Materials and methods. Surgical interventions were performed in a hybrid operating room with a combination of endovascular and microsurgical methods for treating the following cerebrovascular pathologies: complex dural fistulas, complex aneurysms, arteriovenous malformations. The type of surgical intervention – hybrid, combined, staged – was chosen in accordance with the nature of the pathology. Results. In 5 years, 41 patients underwent surgery in the hybrid operating room. Among them, 33 patients had arteriovenous malformations, 6 had complex aneurysms, 2 had complex dural fistulas. Combination interventions were performed in 27 patients, staged – in 12, hybrid – in 2. According to the Modified Rankin Scale (mRS) the following outcomes were observed: no complications in cases of complex aneurysms (6 patients) – mRS 0 (points), as well as in cases of dural fistulas (2 patients) – mRS 0 (points); in arteriovenous malformation, 30 patients did not have any complications – mRS 0; 3 patients had complications (of different types) – mRS 1. Conclusions. The combination of microsurgical and endovascular methods of treatment in a hybrid operating room allows to combine the positive features of the two methods in accordance with surgical needs which improves the outcomes of neurosurgical interventions in complex neurovascular pathology.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Introduction. In most cases, dural arteriovenous fistulas of the brain can be effectively treated endovascularly. However, rare fistulas with an isolated segment of the venous sinus may be difficult to treat surgically. Hybrid surgical interventions (combination of open surgical access to the sinus and puncture embolization in hybrid operating room) can significantly increase the effectiveness of surgical treatment of patients with this pathology.The objective was to improve the results of surgical treatment of patients with cerebral dural arteriovenous fistulas with isolated segment of the venous sinus by using a hybrid surgical intervention.Methods and materials. 2 surgical interventions were performed using microsurgical and endovascular methods. Surgical interventions were made in hybrid operating room.Results. Radical occlusion of dural arteriovenous fistulas was achieved in both cases. The postoperative period was favorable in both cases with positive dynamics in the neurological status.Conclusions. Hybrid interventions combining microsurgical and endovascular methods make it possible to achieve radical occlusion of “complex” cerebral dural arteriovenous fistulas with isolated segments of the venous sinus.

OBJECTIVE:To develop a method for early (24 hrs after intervention) prognosis of functional outcome at discharge in patients after endovascular thrombectomy (EVT) in anterior cerebral circulation based on NIHSS.MATERIAL AND METHODS:A retrospective analysis of endovascular treatment in 362 acute stroke patients (189 men, 173 women, median age 69 years) with anterior circulation large vessel occlusion was performed in the regional vascular centers of St. Petersburg.RESULTS:The original scale (S10-10) developed for prognosis of functional outcome at discharge is based on total scores on 3 patterns: NIHSS 24 hrs after EVT (10 and less - 1, greater than 10 - 2), NIHSS improvement 24 hrs (greater than 10 - 0, 1-10 - 1, 0 and less - 2), older than 78 yr - 1. According to the total score, 5 grades are determined: 1 (good, mRs 0-2 75%, mRs 3-5 25%, mRs 6 0%), 2 (favorable, mRs 0-2 66%, mRs 3-5 26%, mRs 6 8%), 3 (unfavorable, mRs 0-2 14%, mRs 3-5 68%, mRs 6 18%), 4 (unfavorable with high mortality, mRs 0-2 1%, mRs 3-5 52%, mRs 6 47%), 5 (highly negative, mRs 0-2 0%, mRs 3-5 16%, mRs 6 84%). S10-10 greater than 2 indicates unfavorable prognosis. The scale allows accurate prognosis of functional outcome at discharge (AUC 0.89; AUC 0.84 in a validation cohort) and length of in-patient staying and time to death for S10-10 greater than 2.CONCLUSION:Accurate prognosis of functional outcome at discharge can be done 24 hrs after EVT in anterior cerebral circulation based on the widely used neurological scale (NIHSS) taking into account patient age.

Middle meningeal artery embolization as primary method for treatment of chronic subdural hematomas became more popular in past decade. There are few large case series (>150 patients) and literature reviews characterizing advantages and drawbacks of endovascular treatment and technical features of surgeries. In this manuscript, the authors report 11 patients with chronic subdural hematoma scheduled for middle meningeal artery embolization and review the literature data on this issue.