BACKGROUND: Cerebral small vessel disease (CSVD) causes between 25% and 30% of all ischaemic strokes. In acute lacunar ischaemic stroke, despite often mild initial symptoms, early neurological deterioration (END) occurs in approximately 15-20% of patients and is associated with poor functional outcome, yet its mechanisms are not well understood.
OBJECTIVE: In this review we systematically evaluated data on: (1) definitions and incidence of END; (2) mechanisms of small vessel occlusion; (3) predictors and mechanisms of END; and (4) prospects for the prevention or treatment of patients with END.
RESULTS: We identified 67 reports (including 13407 participants) describing the incidence of END in acute lacunar ischaemic stroke. The specified timescale for END varied from <24h to 3 weeks. The rate of END ranged between 2.3% and 47.5 with a pooled incidence of 23.54% (95% CI 21.02-26.05%) but heterogeneity was high (I2=90.29%). The rates of END defined by NIHSS decreases of ≥1, ≥2, ≥3, and 4 points were: 24.17 (21.19-27.16)%; 22.98 (20.48-25.30)%; 23.33 (16.23-30.42)%; and 10.79 (2.09-23.13)%, respectively, with lowest heterogeneity and greatest precision for a cut-off of ≥2 points. Of the 20/67 studies (30%) reporting associations of END with clinical outcome, 19/20 (95%) reported worse outcomes (usually measured using the modified Rankin score at 90 days or at hospital discharge) in patients with END. In a meta-regression analysis female sex, hypertension, diabetes, and smoking, were associated with END.
CONCLUSIONS: Early neurological deterioration occurs in over 20% of patients with acute lacunar ischaemic stroke and might provide a novel target for clinical trials. A definition of an NIHSS ≥2 decrease is most used and provides the best between-study homogeneity. END is consistently associated with poor functional outcome. Further research is needed to better identify patients at risk of END, to understand the underlying mechanisms and to carry out new trials to test potential interventions.

Brain injury resulting from adverse events during pregnancy and delivery is the leading cause of neonatal morbidity and disability. Surviving neonates often suffer long-term motor, sensory, and cognitive impairments. Birth asphyxia is among the most common causes of neonatal encephalopathy. The integration of ultrasound, including Doppler ultrasound, and near-infrared spectroscopy (NIRS) offers a promising approach to understanding the pathology and diagnosis of encephalopathy in this special patient population. Ultrasound diagnosis can be very helpful for the assessment of structural abnormalities associated with neonatal encephalopathy such as alterations in brain structures (intraventricular hemorrhage, infarcts, hydrocephalus, white matter injury) and evaluation of morphologic changes. Doppler sonography is the most valuable method as it provides information about blood flow patterns and outcome prediction. NIRS provides valuable insight into the functional aspects of brain activity by measuring tissue oxygenation and blood flow. The combination of ultrasonography and NIRS may produce complementary information on structural and functional aspects of the brain. This review summarizes the current state of research, discusses advantages and limitations, and explores future directions to improve applicability and efficacy.

This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain\'s susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.

Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.

A single bout of cardiovascular exercise can have a cascade of physiological effects, including increased blood flow to the brain. This effect has been documented across multiple modalities, yet studies have reported mixed findings. Here, we systematically review evidence for the acute effect of cardiovascular exercise on cerebral blood flow across a range of neuroimaging techniques and exercise characteristics. Based on 52 studies and a combined sample size of 1,174 individuals, our results indicate that the acute effect of cardiovascular exercise on cerebral blood flow generally follows an inverted U-shaped relationship, whereby blood flow increases early on but eventually decreases as exercise continues. However, we also find that this effect is not uniform across studies, instead varying across a number of key variables including exercise characteristics, brain regions, and neuroimaging modalities. As the most comprehensive synthesis on the topic to date, this systematic review sheds light on the determinants of exercise-induced change in cerebral blood flow, a necessary step toward personalized interventions targeting brain health across a range of populations.

Hemodynamic management in pediatric neurosurgical patients is essential for maintaining cerebral perfusion pressure (CPP), avoiding hemorrhage, and preventing secondary neurological injury. Antihypertensive infusions approved for pediatrics are not widely studied in the pediatric neurosurgical population and may have adverse effects on intracranial pressure (ICP), contributing to reduced CPP. Clevidipine is an ultra-rapid-acting intravenous antihypertensive agent used for hemodynamic control in adult surgical patients. In pediatric patients, clevidipine is safe and effective in controlling blood pressure in the perioperative period, although studies evaluating its effect on ICP in neurosurgical patients are lacking. The objective of this research was to evaluate the effect of clevidipine on ICP in pediatric neurosurgical patients.
This single-center retrospective study involved patients admitted to the pediatric ICU between January 1, 2017, and December 31, 2020. Patients eligible for inclusion had ICP monitoring devices and received clevidipine infusion for a minimum of 6 hours postoperatively, with at least one ICP measurement pre- and postinfusion. Excluded patients had an elevated preinfusion ICP > 20 mm Hg. The primary outcome was the average change in ICP from preinfusion baseline to hours 6 to < 12, 12 to < 24, and 24 to < 48 of clevidipine infusion. Secondary outcomes included frequency of ICP measurements > 20 mm Hg, CPP measurements < 50 mm Hg, treatment failure defined by a need for concurrent antihypertensive infusion, and frequency of elevated serum triglycerides > 200 mg/dL. Descriptive data were expressed as frequency with percentage or median with interquartile range as appropriate. Analysis of continuous outcome variable data involved Mann-Whitney U-tests with an alpha significance of 0.05.
Data from 47 patients were included in the analysis. The average change in ICP from preinfusion baseline to 48 hours was < 1 mm Hg. Of 3025 total postinfusion ICP measurements in 47 patients, 67 measurements (2.2%) in 13 patients (28%) were > 20 mm Hg. CPP measurements < 50 mm Hg occurred in 16 of 45 patients (36%). Three patients (6.4%) required use of a secondary antihypertensive medication infusion, and 5 of 14 patients (36%) had serum triglycerides > 200 mg/dL.
Use of clevidipine had minimal effect on ICP. The results of this study suggest that clevidipine is effective at safely maintaining ICP and CPP measurements without detrimental adverse effects in pediatric neurosurgical patients.

Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.

Intraoperative study of blood flow in the brain vessels is among the most critical topics of modern neurosurgery. One of the promising methods for intraoperative monitoring of blood flow is laser speckle contrast imaging (LSCI). This systematic review aims to analyze the experience of using intraoperative LSCI in neurosurgical interventions.
The literature search was carried out in the PubMed and Web of Science databases using the keywords \"Laser-Speckle,\" \"Laser Speckle,\" \"Laser speckle contrast imaging,\" and \"LSCI.\" We allowed the search to include the following criteria: 1) publication in the English language, 2) full access to the article, 3) information about the method of treatment, and 4) the results presented for at least one patient.
The initial search resulted in the detection of 508 publications, of which 476 were eliminated during the initial assessment of titles and abstracts. Two more articles were excluded due to the lack of data in the English language. Twenty articles were found to be focused on nonhuman studies and therefore were excluded. In three more studies treatment of non-neurosurgical patients was reported. The final analysis included 8 articles with 102 patients overall.
LSCI is a promising intraoperative method for intraoperative cerebral blood flow assessing. This method offers several advantages over other modalities. The experience of use is limited to a small number of case series. Further investigation of the method and its implementation in clinical practice is needed.

OBJECTIVE: New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis.
METHODS: The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI).
RESULTS: A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, p value = .0029 and OR, 1.74, 95% CI, 1.09-2.77, p value = .019).
CONCLUSIONS: In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.

To present the technique of extra-intracranial bypass surgery using the orifice of maxillary artery bypass, to evaluate the advantages and disadvantages of this and alternative revascularization options.
Radial artery graft harvesting was performed at the 1st stage. Simultaneously, the second team of surgeons performed a combined (submandibular and anterior) access to the donor artery (mandibular segment of maxillary artery behind the ramus of the mandible). Craniotomy and mobilization of potential recipient arteries (M2-M3 segments of the middle cerebral artery) were performed at the 2nd stage. Distal anastomosis in end-to-side fashion was formed with M3 segment of the middle cerebral artery. At the 3rd stage, radial artery was passed through a subcutaneous tunnel in zygomatic region. The orifice of maxillary artery was resected together with distal external carotid artery (ECA) and orifice of superficial temporal artery. After transposition of ECA and orifice of maxillary artery, proximal end-to-end anastomosis was performed with radial artery. After that, the main surgical stage was performed, i.e. exclusion of M3 segment of the middle cerebral artery together with aneurysm.
Harvesting of mandibular segment of the maxillary artery as a donor vessel reduces the length of bypass graft to 12-14 cm since this branch is localized close to the skull base. You can also form optimal proximal end-to-end anastomosis for intracranial redirecting blood flow maxillary artery.
The described method makes it possible to form anastomosis with a short bypass graft and reduce the risk of thrombosis. This procedure is effective for cerebral bypass in patients with skull base tumors, complex aneurysms, and occlusive-stenotic lesions of carotid arteries.
Представить методику обходного шунтирования сосудов головного мозга с использованием устья верхнечелюстной артерии, оценить достоинства и недостатки данной методики и альтернативных вариантов реваскуляризации.
На 1-м этапе произведено выделение графта из лучевой артерии. Одновременно второй бригадой хирургов выполнен комбинированный (поднижнечелюстной и предушный) доступ к артерии-донору — нижнечелюстному сегменту верхнечелюстной артерии (ВЧА) за ветвью нижней челюсти. На 2-м этапе произведены краниотомия и выделение потенциальных артерий реципиентов (сегменты М2—М3 средней мозговой артерии — СМА). Осуществлен дистальный анастомоз по классической методике с сегментом М3 СМА по типу «конец в бок». На 3-м этапе лучевая артерия проведена в подкожном тоннеле в скуловой области. Устье ВЧА резецировано вместе с дистальным отделом наружной сонной артерии (НСА) и устьем поверхностной височной артерии. После транспозиции НСА и устья ВЧА выполнен проксимальный анастомоз с лучевой артерией по типу «конец в конец». После этого выполнен основной этап операции — выключение сегмента М3 средней мозговой артерии вместе с аневризмой.
Представленная методика выделения и использования в качестве донора наиболее крупной из конечных ветвей НСА — нижнечелюстного сегмента ВЧА, расположенного близко к основанию черепа, позволяет сократить длину обходного шунта до 12—14 см и выполнить проксимальный анастомоз по оптимальной методике «конец в конец» с целью перенаправления всего потока крови из ВЧА интракраниально.
Применение разработанного авторами статьи способа позволяет в более комфортных условиях для хирурга сформировать анастомоз с относительно короткой рабочей частью шунта и, соответственно, с меньшим риском его тромбоза. Метод обеспечивает эффективное заместительное шунтирование головного мозга у пациентов с опухолями основания черепа, сложными аневризмами и окклюзионно-стенотическим поражением сонных артерий.