Cerebral Hyperperfusion Syndrome Research Articles

Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies.

Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.

Reduction of Uncertainty in Bolus Transit Time Measurement in Quantitative Fluorescence Angiography

Abstract During cerebral revascularization surgeries, blood flow values help surgeons to monitor the quality of the procedure, e.g., to avoid cerebral hyperperfusion syndrome due to excessively enhanced perfusion. The state-of-the-art technique is the ultrasonic flow probe that has to be placed around the blood vessel. This causes contact between probe and vessel, which, in the worst case, leads to rupture. The recently developed intraoperative indocyanine green (ICG) Quantitative Fluorescence Angiography (QFA) is an alternative technique that overcomes this risk. However, it has been shown by the developer that the calculated flow has deviations. After determining the bolus transit time as the most sensitive parameter in flow calculation, we propose a new two-step uncertainty reduction method for flow calculation. The first step is to generate more data in each measurement that results in functions of the parameters. Noise can then be reduced in a second step. Two methods for this step are compared. The first method fits the model for each parameter function separately and calculates flow from models, while the second one fits multiple parameter functions together. The latter method is proven to perform best by in silico tests. Besides, this method reduces the deviation of flow comparing to original QFA as expected. Our approach can be generally used in all QFA applications using two-point theory. Further development is possible if number of dimensions of the achieved parameter data are broadened that results in even more data for processing in the second step.

Impact of Portable Normothermic Machine Perfusion for Liver Transplantation From Adult Deceased Donors.

To assess how liver allografts preserved using portable normothermic machine perfusion (NMP) compare against those that underwent ischemic cold storage (ICS) in the setting of donation after brain death (DBD) and donation after circulatory death (DCD) liver transplantation (LT). Compared with conventional ICS, NMP may offer more homeostatic preservation, permit physiological assessment of organ function, and provide opportunities for graft improvement/modification. We report a single-center US experience of liver NMP. A single-center, retrospective analysis of collected data on 541 adult whole LTs from 469 DBD donors [NMP (n = 58) vs ICS (n = 411)] and 72 DCD donors [NMP (n = 52) vs ICS (n = 20)] between January 2016 and December 2022. In DBD LT, male sex [odds ratio (95% CI): 1.83 (1.08-3.09)] and >10% macrosteatosis of the donor liver [1.85 (1.10-3.10)] were statistically significant independent risk factors of early allograft dysfunction (EAD). Donor age >40 years and cold ischemia time >7 hours were independent risk factors of reperfusion syndrome (RPS). One-year, 3-year, and 5-year incidences of ischemic cholangiopathy (IC) did not differ significantly in DBD cases between the NMP and ICS cohorts. In DCD LT, NMP was an independent protective factor against EAD [0.11 (0.03-0.46)] and RPS [0.04 (0.01-0.25)]. The incidence of IC in the DCD cases at 1-year and 3-year time points was significantly lower in the NMP cohort (1.9% compared with 20% in the ICS group). Compared with conventional ICS, NMP can significantly reduce the incidence of EAD, RPS, and IC after DCD LT.

Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature.

In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.

The utility of transcranial color Doppler in cerebral hyperperfusion syndrome.

The utility of transcranial color Doppler in cerebral hyperperfusion syndrome.

Risk Factors for Cerebral Hyperperfusion Syndrome following Carotid Revascularization

Cerebral hyperperfusion syndrome (CHS) is a rare but known complication of carotid revascularization that can result in severe postoperative disability and death. CHS is a well-described sequela of carotid endarterectomy (CEA) and, more recently, of transfemoral carotid artery stenting (TFCAS), but its incidence after transcarotid artery revascularization (TCAR) has not been delineated. The aims of this study were to determine the impact of procedure type (CEA versus TCAR versus TFCAS) on the development of CHS as well as to identify perioperative risk factors associated with CHS. The Society for Vascular Surgery Vascular Quality Initiative was queried for patients aged ≥18years who underwent CEA, TCAR, or TFCAS from 2015-2021. Emergent procedures were excluded. The primary outcome was postoperative development of CHS, defined as the presence of postoperative seizures, intracerebral hemorrhage due to hyperperfusion, or both. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with CHS. 156,003 procedures were included (72.7% CEA, 12.4% TCAR, and 14.9% TFCAS). The incidence of CHS after CEA, TCAR, and TFCAS were 0.15%, 0.18%, and 0.53%, respectively. There was no significant difference in risk of CHS after TFCAS compared to CEA (odds ratio [OR]: 1.21; 95% confidence interval [CI] 0.76-1.92; P=0.416), nor was there a difference between TCAR and CEA (OR: 0.91; 95% CI 0.57-1.45; P=0.691). Perioperative risk factors associated with an increased risk of CHS included previous history of transient ischemic attack or stroke (OR: 2.50; 95% CI 1.69-3.68; P<0.0001), necessity for urgent intervention within 48hr (OR: 2.03; 95% CI 1.43-2.89; P<0.0001), treatment of a total occlusion (OR: 3.80; 95% CI 1.16-12.47; P=0.028), and need for postoperative intravenous blood pressure medication (OR: 5.45; 95% CI 3.97-7.48; P<0.0001). Age, preoperative hypertension, degree of ipsilateral stenosis less than or equal to 99%, and history of prior carotid procedures were not statistically associated with an increased risk of CHS. Discharging patients on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker was associated with a decreased risk of developing CHS (OR: 0.47; 95% CI 0.34-0.65; P<0.0001). Compared with CEA, TCAR and TFCAS were not statistically associated with an increased risk of postoperative CHS. Patients with a previous history of transient ischemic attack or stroke, who require urgent intervention or postoperative intravenous blood pressure medication, or who are treated for a total occlusion are at a higher risk of developing CHS. Using an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker on discharge appears to be protective against CHS and should be considered for the highest risk patients.

Can Hypothermic Oxygenated Perfusion Mitigate Ischemia-Reperfusion Injury in Ex-Situ Split Grafts? – A Comparative Study with Living Donation in Pediatric Liver Transplantation

Abstract Background The gold standard in pediatric split liver transplantation (SLT) is living donation (LD) providing high-quality grafts with short static cold storage (SCS). Aims This study investigates the protective effect of hypothermic oxygenated perfusion (HOPE) on ex-situ partial grafts from deceased donors in comparison to standard ex-situ Static-Split and LD SLT. Methods We included all consecutive HOPE-Split, Static-Split and LD SLT performed from 2018-2022 at a single center. The primary endpoint was early ischemia-reperfusion injury (IRI) based on reperfusion biopsy (graded from none/0 to severe/4), the occurrence of post reperfusion syndrome (PRS, drop≥30% of systolic arterial pressure) and post-LT transaminase release. Results A total of 46 SLT (14 HOPE-Split, 17 Static-Split, and 15 LD) were included. With a median perfusion duration of 100min, HOPE-Split had a significant decrease of SCS compared to Static-Split (473 min vs 538 min; p=0.02) with similar total preservation time (p=0.13). This translated into lower rates of mild to severe IRI (grade≥2; p=0.03) and significantly reduced neutrophilic infiltrate than Static-Split (p=0.04; Fig.1). The PRS was also reduced in HOPE-Split (0% vs 35%, p=0.02) with less transaminase release. Despite prolonged SCS (473 vs 117min, p&amp;lt;0.001), HOPE-Split was comparable to LD regarding grade≥2 IRI (64 vs 40%; p=0.17) and PRS (0 vs 6.7% p=0.34), with however higher transaminase release (571 vs 244 UI/L/100g; p=0.004). Overall, 3-months surgical complications, graft and recipient survival did not differ among groups. Conclusions HOPE allowed improved preservation of ex-situ split grafts compared to static cold storage, resulting in similar early IRI profiles then LD grafts. Preservation with HOPE may offer a promising strategy to improve outcomes and expand selection criteria in split LT for pediatric recipients.

Intraoperative Hemodynamics of Parasylvian Cortical Arteries for Predicting Postoperative Symptomatic Cerebral Hyperperfusion after Direct Revascularization in Patients with Moyamoya Disease: A Preliminary Study.

Objective. The search for methods by which to predict the risks of cerebral hyperperfusion syn-drome (CHS) in adults with moyamoya disease (MMD), including those utilizing new biomarkers, still deserves further research. The objective of this study was to investigate the association between the hemodynamics of parasylvian cortical arteries (PSCAs) and postoperative CHS. Methods. A consecutive number of adults with MMD who had undergone direct bypass between September 2020 and December 2022 were recruited. Intraoperative microvascular doppler ultrasonography (MDU) was performed to evaluate the hemodynamics of PSCAs. The intraoperative flow direction, mean value of velocity (MVV) of recipient artery (RA) and bypass graft were recorded. According to flow direction after bypass, RA was divided into entering sylvian (RA.ES) and leaving sylvian (RA.LS) subtypes. Univariate, multivariate, and ROC analyses of the risk factors for postoperative CHS were performed. Results. A total of 16 (15.09%) cases in 106 consecutive hemispheres (101 patients) sat-isfied the postoperative CHS criteria. According to univariate analysis, advanced Suzuki stage, MVV of RA before bypass, and fold increase of MVV in RA.ES after bypass were significantly associated with postoperative CHS (p < 0.05). Multivariate analysis indicated that left-operated hemisphere (OR (95%CI), 4.58 (1.05-19.97), p = 0.043), advanced Suzuki stage (OR (95%CI), 5.47 (1.99-15.05), p = 0.017), and fold increase of MVV in RA.ES (OR (95%CI), 1.17 (1.06-1.30), p = 0.003) were statistically significantly associated with the occurrence of CHS. The cut-off value of fold increase of MVV in RA.ES was 2.7-fold (p < 0.05). Conclusions. Left-operated hemisphere, advanced Suzuki stage, and postoperative fold increase of MVV in RA.ES were potential risk factors for postoperative CHS. Intraoperative MDU was useful for evaluating hemodynamics and predicting CHS.

Todd's paralysis due to hyperperfusion syndrome after carotid endarterectomy mimicking postoperative stroke.

Todd's paralysis is a neurological deficit that is observed in <10% of patients following epileptic seizures. Cerebral hyperperfusion syndrome (CHS) is a rare complication following carotid endarterectomy (CEA), seen in 0-3% of the patients, characterized by focal neurological deficit, headache, disorientation, and sometimes seizures. In this case report, we present a case of CHS after CEA followed by seizures and Todd's paralysis that mimicked postoperative stroke. A 75-year-old female patient was admitted for CEA of the right internal carotid artery, following a transient ischemic attack two months prior. Four hours after CEA with graft interposition, the patient suffered a temporary weakness of the left arm and leg followed by generalized spasms within a few seconds. CT angiography showed regular patency of the carotid arteries and the graft, and brain CT showed no sign of oedema, ischemia or hemorrhage. However, left-sided hemiplegia occurred following the seizure, and the patient suffered four more seizures over the next 48 hours, with persisting hemiplegia. On the second postoperative day, the motor skills of the left side fully recovered, and the patient was communicative, and of orderly mental status. Brain CT performed on the third postoperative day showed entire right hemisphere oedema. A moderate hemiparesis with seizures as a consequence of CHS after CEA has been described, however in all cases with seizures and hemiplegia, the underlying cause was always a verified stroke or intracerebral hemorrhage. This case highlights the importance of considering Todd's paralysis in patients with seizures after CEA due to CHS and prolonged periods of hemiplegia after the seizures.

THU-530 - Post reperfusion syndrome in liver transplant after normothermic perfusion: experience of a reference center

THU-530 - Post reperfusion syndrome in liver transplant after normothermic perfusion: experience of a reference center

Prediction, prevention, and treatment of post reperfusion syndrome in adult orthotopic liver transplant patients.

This review explores proposed predictors, preventative measures, and treatment options for post-reperfusion syndrome (PRS) in liver transplantation and provides updated data for clinicians. The review aims to understand the status and progress made regarding PRS during orthotopic liver transplantation. Moreover, the predictors of PRS will be analyzed to highlight risk factors. Mediators of PRS and the modes of action of the currently available preventative and management agents that target particular PRS factors will be investigated. Data is drawn from secondary sources from databases of peer-reviewed journals. The bibliographies of select sources were also used to obtain additional data studies using the 'snowball' method. The initial data search provided 1394 studies analyzed using PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. After applying the eligibility criteria, 18 studies were fit for inclusion. The study identified that in addition to the severity of underlying medical conditions, other significant PRS predictors included patient age, sex, duration of cold ischemia, and the surgical technique. While the use of epinephrine and norepinephrine is well-established, further preventative measures commonly involve specifically targeting known mediators of the syndrome, such as antioxidants, vasodilators, free radical scavengers, and anticoagulants. Current management strategies involve supportive therapy. Machine Perfusion may ultimately decrease the risk of PRS. PRS still holds unknowns, including the underlying pathophysiology, controllable factors, and ideal management practices. There is a need for further study, particularly prospective trials since liver transplantation is the gold standard for treating end-stage liver disease and the incidence of PRS remains high.

Flow diversion jet: A dangerous mechanism in the flow diversion treatment of giant intracranial aneurysms.

Cerebral hyperperfusion syndrome (CHS) occurs after the restoration of blood flow to a previously low-flow, low-pressure region of the cerebral vasculature, which subsequently responds with chronic compensatory vasodilation, leading to a dysregulated state. Sudden restoration of normal blood flow can overwhelm the vasculature leading to intracranial hemorrhage (ICH). Separately, the Windkessel phenomenon describes the capacity for elastic vessels to expand with systolic pressure and decompress with diastole, thereby suppressing distal pulse pressure. We encountered a case involving giant basilar aneurysms in which we believe the Windkessel phenomenon precipitated a catastrophic manifestation of CHS at treatment. We present a 60-year-old female found to have marked dolichoectasia of the right cervical internal carotid, vertebral, and basilar arteries concurrent with two large vertebrobasilar dissecting-type fusiform aneurysms. Managed conservatively for ten years before developing gait ataxia, new imaging revealed dramatic interval growth of the larger aneurysm. Flow diversion with partial coiling of the aneurysms was pursued. The patient suffered intra-procedural catastrophic thalamic and midbrain hemorrhage with intraventricular extension. A meticulous review of the case data was undertaken. Our findings suggest that giant aneurysms can act as a Windkessel reservoir, depressing the distal pulse pressure. Flow diversion bypasses the reservoir, increasing the distal pulse pressure beyond the autoregulatory capacity, resulting in ICH analogous to CHS. CHS and Windkessel phenomenon can contribute to catastrophic sequelae in the treatment of giant intracranial aneurysms with flow diversion. Awareness of this mechanism can protect future patients from harm.

Analysis of Risk Factors for Epilepsy after Combined Re-Vascularization in Adult Patients with Moyamoya Disease.

Re-vascularization is an effective treatment for moyamoya disease (MMD) patients, including direct re-vascularization, indirect re-vascularization and combined re-vascularization, in which combined re-vascularization is particularly widely used. At present, there are few reports on the analysis of epilepsy after combined re-vascularization surgery. To analysis the risk factors of epilepsy in adult MMD patients after combined re-vascularization. Patients with MMD who underwent combined re-vascularization in the Department of Neurosurgery of the First People's Hospital of Yunnan Province from January 2015 to June 2020 were included. Their pre-operative and post-operative complication-related indicators were collected. Finally, logistic regression was used to analyze the clinical risk factors of epilepsy in MMD patients after operation. The incidence of epilepsy after combined re-vascularization was 15.5%. Univariate analysis showed that pre-operative ischemic or hemorrhagic stroke, pre-operative epilepsy, pre-operative history of diabetes, the location of the bypass recipient artery (frontal or temporal lobe), post-operative new cerebral infarction, hyper-perfusion syndrome, and post-operative intra-cranial hemorrhage were the clinical risk factors of epilepsy in MMD patients (all P < 0.05). Multi-variate logistic regression analysis showed that pre-operative epilepsy, the location of the bypass recipient artery, new cerebral infarction, hyper-perfusion syndrome, and post-operative intra-cranial hemorrhage (all P < 0.05) were independent risk factors for post-operative epilepsy in MMD patients. Pre-operative epilepsy, the location of the bypass recipient artery, new cerebral infarction, hyper-perfusion syndrome, and intra-cranial hemorrhage may have a causal relationship with epilepsy in adult MMD patients. It is suggested that some risk factors could be intervened to reduce the incidence of post-operative epilepsy in MMD patients.

PECULIARITIES OF CONNECTIVE TISSUE METABOLISM IN PATIENTS WITH POST-INFARCTION REMODELING AND REPERFUSION SYNDROME

Early restoration of coronary blood flow in acute myocardial infarction with elevation helps reduce the area of myocardial necrosis, prevent dilatation of the ventricular cavity, and reduce the development of arrhythmias and mortality. However, despite modern technologies in STEMI treatment, the development of reperfusion syndrome, in particular, arrhythmias, is possible after the restoration of blood flow in the infarct-related artery, which is a consequence of acute cellular, metabolic and local electrophysiological changes in the myocardium.&#x0D; The aim: is to investigate the long-term effects of reperfusion syndrome on the catabolic/anabolic activity of connective tissue and the processes of connective tissue framework formation in the post-infarction period in patients with myocardial infarction.&#x0D; Materials and methods. The study involved 156 patients with acute myocardial infarction with ST segment elevation (STEMI), and 15 apparently healthy individuals (control of laboratory parameters). The average age of the patients was (57.8±1.2) years. The percent of male patients prevailed (76 %).&#x0D; All MI patients were divided into two groups: Group I (98 people) – MI patients without clinical signs of reperfusion syndrome during revascularization, Group II (58 people) – MI patients with the signs of reperfusion syndrome in the form of rhythm and conductivity disturbances during revascularization of coronary arteries by percutaneous coronarography intervention (PCI) with prolonged stenting of the infarct-dependent coronary artery.&#x0D; Peculiarities of connective tissue metabolism were studied by the content of free and bound oxyproline, glycosaminoglycans, and antibodies to atypical collagens (Ig M and Ig G) in blood serum.&#x0D; Results. The recovery period after myocardial infarction showed an increase in collagen catabolism over collagen synthesizing processes in patients with MI who had reperfusion syndrome. The described patterns were also established by changes in glycosaminoglycans. The study showed an increase in the level of antibodies to atypical collagens. Particularly, the level of Ig M, which was within the norm (0.43±0.18) ng/ml, in patients with MI without reperfusion manifestations was three times higher (p&lt;0.001), and in cases of combination of MI and reperfusion syndrome – the highest (p&lt;0.001).&#x0D; Conclusions:&#x0D; &#x0D; Changes in collagen-synthesizing processes are observed in patients with MI, with a tendency to increase the processes of catabolism of the connective tissue matrix.&#x0D; The presence of reperfusion syndrome manifestations in MI patients after revascularization aggravates the processes of catabolism, even in the recovery period after MI.&#x0D; Increase in the activity of catabolic processes stimulates fibrosis and formation of rigid matrix and atypical collagen, to which antibodies are synthesized, thus blocking the pathological circuit of restructuring of the heart connective tissue framework, and accordingly its pathological remodeling.&#x0D; The obtained study results contribute to the identification of more sophisticated approaches to revascularization techniques to avoid negative effects of reperfusion syndrome, as well as new effective medications for collagen synthesis correction, which can increase the effectiveness of rehabilitative management of such&#x0D;

Risk factors of postoperative cerebral hyperperfusion syndrome and its relationship with clinical prognosis in adult patients with moyamoya disease

BackgroundTo investigate the incidence, risk factors, and clinical prognosis of cerebral hyperperfusion syndrome (CHS) after superficial temporal artery-middle cerebral artery anastomosis combined with encephalo-duro-arterio-synangiosis (STA-MCA/EDAS) in adult patients with moyamoya disease (MMD).MethodsThe clinical data of 160 adult patients with MMD treated by STA-MCA/EDAS from January 2016 to January 2017 were retrospectively analyzed. According to CHS diagnosis, MMD patients were divided into CHS and non-CHS group. Univariate and multivariate analysis of risk factors and Kaplan-Meier curve of stroke-free survival for CHS were performed.ResultsA total of 12 patients (7.5%) developed postoperative CHS, of which 4 patients (2.5%) presented with cerebral hemorrhage. Univariate and multivariate analysis showed moyamoya vessel on the surgical hemisphere (OR = 3.04, 95% CI = 1.02–9.03, P = 0.046) and left operated hemisphere (OR = 5.16, 95% CI = 1.09–21.34, P = 0.041) were independent risk factors for CHS. The other variables, such as age, gender, presentation, hypertension, diabetes, smoking, mean mRS score on admission, modified Suzuki stage and pre-infarction stage on surgical hemisphere, and bypass patency, had no association with postoperative CHS (P > 0.05). At final follow-up with average 38 months, there were 18 out of 133 patients (13.5%, 4.91% per person year) presented with newly developed complications. There was no significant difference between newly developed complications, mean mRS scores, and Kaplan-Meier curve of stroke-free survival in patients with and without CHS (P > 0.05).ConclusionThe concentration of moyamoya vessels and left operated hemisphere was independent risk factors for CHS, which could not affect the clinical prognosis if treated timely and properly. The current study offers a new perspective of moyamoya vessels and supporting data for choosing MMD candidates on cerebral revascularization.

Cerebral hyperperfusion syndrome after stenting for revascularization of intracranial internal carotid artery dissection

Cerebral hyperperfusion syndrome (CHS) is one of the complications of cerebral revascularization. The main pathophysiology of CHS was considered to be cerebral autoregulation impairment due to long-standing cerebral hypoperfusion. Herein, we describe the case of a 40-year-old man with symptomatic intracranial arterial dissection (IAD) related to internal carotid artery stenosis. The patient underwent intracranial stenting 11 days after onset due to severe cerebral hypoperfusion presenting with neurological symptoms, and CHS presenting with intracerebral hemorrhage, post-operatively. The present case indicated not only the potential risk of CHS after intracranial stenting in IAD-related stenosis but also that cerebral hypoperfusion-even in a short period-might lead to CHS.

РЕПЕРФУЗИОННЫЙ СИНДРОМ ПРИ ЭНДОВАСКУЛЯРНОЙ РЕВАСКУЛЯРИЗАЦИИ МИОКАРДА: КЛИНИЧЕСКОЕ НАБЛЮДЕНИЕ

CHD retains a leading position worldwide due to high rates of mortality and disability. The best and proven strategy aimed at saving the damaged myocardium in ST-segment elevation myocardial infarction (STEMI) is rapid and effective reperfusion of the ischemic heart muscle through primary percutaneous coronary intervention (PCI) or pharmacoinvasive therapy. However, the restoration of blood flow by itself can lead to reperfusion damage to the affected myocardium. In acute coronary catastrophe caused by acute occlusion of the coronary artery, myocardial stun and hibernation develop locally. With STEMI, hibernation can be observed both near the infarction zone and in more distant areas of the myocardium. In patients with STEMI, the appearance of life-threatening arrhythmias (ventricular tachycardia and ventricular fibrillation) occurs in 4.3 % of cases and is primarily associated with reperfusion after PCI. In most cases, arrhythmias that occur during the procedure are stopped spontaneously; however, when accompanied by ventricular tachyarrhythmia, hemodynamic instability, the use of electric pulse therapy (EIT) is provided. The article presents a clinical case of a patient C., 52, whose reperfusion syndrome manifested itself by the development of life-threatening ventricular tachyarrhythmias: unstable ventricular tachycardia «torsade de points» with transformation into VF, which were stopped by EIT: defibrillation. No recurrence of ventricular tachyarrhythmia was observed in this patient. At this stage, we explain the resulting episode of unstable ventricular tachycardia with short-term myocardial stunning due to short-term ischemia and myocardial damage.

Expression of hypoxia-inducing factor-1α and matrix metalloproteinase-9 in the recipient parasylvian cortical arteries with different hemodynamic sources in adult moyamoya disease.

In our latest research, we have demonstrated that the recipient parasylvian cortical arteries (PSCAs) with hemodynamic sources from the middle cerebral artery (M-PSCAs) has a higher risk of postoperative cerebral hyperperfusion (CHP) syndrome than those from non-M-PSCAs in adult moyamoya disease (MMD) patient. However, whether there are differences between M-PSCAs and non-M-PSCAs in vascular specimens characteristics has not been studied. In this study, we further investigate the vascular specimen of recipient PSCAs by histological and immunohistochemical methods. 50 vascular specimens of recipient PSCAs were obtained from 50 adult MMD patients during the combined bypass surgeries in our departments of Zhongnan hospital. 4 recipient PSCAs samples were also obtained in the same way from the middle cerebral artery occlusion patients. The samples were received the pathological sectioning, hematoxylin and eosin staining, and immunohistochemistry, then the vascular wall thickness, matrix metalloproteinase-9 (MMP-9) and hypoxia-inducing factor-1α (HIF-1α) were analyzed. M-PSCAs adult MMD patients had a thinner intima than non-M-PSCAs in the recipient PSCAs specimens. In recipient non-M-PSCAs vascular specimens, the immunoreactivity indicating HIF-1α and matrix metalloproteinase-9 (MMP-9) was significantly higher than M-PSCAs groups. The logistic regression analyses showed that the M-PSCAs was an independent risk factor of postoperative cerebral hyperperfusion (CHP) syndrome (OR 6.235, 95% CI1.018-38.170, P = 0.048) in MMD. Our results indicate that M-PSCAs adult MMD patients had thinner intima than non-MCAs adult MMD patients in the PSCAs. More importantly, HIF-1α and MMP-9 were overexpressed in non-M-PSCAs vascular specimens.

Prediction of hemorrhagic cerebral hyperperfusion syndrome after direct bypass surgery in adult nonhemorrhagic moyamoya disease: combining quantitative parameters on RAPID perfusion CT with clinically related factors.

The aim of this study was to identify predictive factors for hemorrhagic cerebral hyperperfusion syndrome (hCHS) after direct bypass surgery in adult nonhemorrhagic moyamoya disease (non-hMMD) using quantitative parameters on rapid processing of perfusion and diffusion (RAPID) perfusion CT software. A total of 277 hemispheres in 223 patients with non-hMMD who underwent combined bypass were retrospectively reviewed. Preoperative volumes of time to maximum (Tmax) > 4 seconds and > 6 seconds were obtained from RAPID analysis of perfusion CT. These quantitative parameters, along with other clinical and angiographic factors, were statistically analyzed to determine the significant predictors for hCHS after bypass surgery. Intra- or postoperative hCHS occurred in 13 hemispheres (4.7%). In 7 hemispheres, subarachnoid hemorrhage occurred intraoperatively, and in 6 hemispheres, intracerebral hemorrhage was detected postoperatively. All hCHS occurred within the 4 days after bypass. Advanced age (OR 1.096, 95% CI 1.039-1.163, p = 0.001) and a large volume of Tmax > 6 seconds (OR 1.011, 95% CI 1.004-1.018, p = 0.002) were statistically significant factors in predicting the risk of hCHS after surgery. The cutoff values of patient age and volume of Tmax > 6 seconds were 43.5 years old (area under the curve [AUC] 0.761) and 80.5 ml (AUC 0.762), respectively. In adult patients with non-hMMD older than 43.5 years or with a large volume of Tmax > 6 seconds over 80.5 ml, more prudence is required in the decision to undergo bypass surgery and in postoperative management.

Endogenous intoxication, oxidative stress and antioxidant system in acute lower limb ischemia

Aim. To study features of endogenous intoxication syndrome (EI), oxidative stress (LPO) and antioxidant defence (AOS) in patients with acute lower limb ischemia (LLI).Materials and methods. Some parameters of EI, LPO and AOS were studied. EI syndrome was studied in 86 patients with LLI who underwent complex examination and treatment in 2020-2021 in the Department of Vascular Surgery of the RNCfCS. POL and AOS parameters were studied in 14 patients out of 86. There were 51 (59.3%) men and 35 (40.7%) women, mean age was 56.0±5.8 years. Acute occlusion of the iliofemoral segments was noted in 33 (38.4%) patients, in 32 (37.2%) - the femoral segment, and in 21 (24.4%) - the popliteal and femoral vessels. In all cases, ischemia had a unilateral localization - on the right in 59 (68.6%) cases and on the left in 27 (31.4%) cases. In 52 (58.1%) cases, there were clinical signs of grade II b ischemia, and in 36 (41.9%) cases - grade III A (according to V.S. Saveliev, 1987). The average duration of ischemia was 77.9±28.3 hours.Results and discussion. In all cases of LLI before revascularization, there were signs of acute inflammatory reaction and EI syndrome in the form of increased ESR (42.3±7.1 mm/h), CRP concentration (16.1±4.2 mg/L), fibrinogen (8.5±0.9 g/L) and leukocytosis (12.7±1.5×109/L). Also, all patients had a slight elevation of blood glucose against the background of EI (7.5±1.8 mmol/L), a significant increase of creatinine concentration (128.9±6.1 µmol/L), urea (9.2±0.6 mmol/L) and aminotransferases as compared to normal indices. Results of LPO and AOS indices study in 14 patients showed that in LLI, malondialdehyde (MDA) increases 2.6-fold (3.9±0.1 μmol/L), diene conjugate increases 3.7-fold (0.77±0.04 units a/mL). However, after the elimination of ischemia, there was no significant decrease for 12.2±2.4 days, which confirms the presence of reperfusion syndrome. AOS indices - superoxide dismutase (20,8±1,0 u/l) and catalase (128,9±11,2 μl/l) increased 1,2 and 1,1 times in the examined patients cohort, respectively. Statistically significant associations were established between the following indices: Ischemia level and urea (r=0.89), Ischemia level and white blood cell count (r=-0.82), Hb and Er (r=0.99), Hb and creatinine (r=0.79), Hb and urea (r=0.79), Er and urea (r=0.79), creatinine and Er (r=0.90), ACTV and creatinine (r=-0.77), creatinine and urea (r=0.90).Conclusion. Acute lower limb ischemia is accompanied by ischemia-reperfusion damage manifested by endogenous intoxication syndrome, impaired glucose metabolism and activation of lipoperoxidation processes and antioxidant system. After the elimination of acute ischemia, there is not always a significant decrease in lipid peroxidation and some inflammation parameters. Therefore, prolonged use of antioxidants in the reperfusion period is recommended.