BACKGROUND: Neurological complications are common in the management of venoarterial extracorporeal membrane oxygenation (VA-ECMO), with most patients requiring sedation and intubation, limiting the assessment of neurological function. There-fore, we must rely on advanced neuroimaging techniques, such as computed tomography angiography (CTA) and computed tomography perfusion (CTP). Because ECMO changes the normal blood flow pattern, it may interfere with the contrast medium in some special cases, leading to artifacts and ultimately mis-leading clinical decisions.
METHODS: A 61-year-old man presented to a local hospital with chest tightness and pain 1 d prior to presentation. The patient was treated with VA-ECMO after sudden car-diac and respiratory arrest at a local hospital. For further treatment, the patient was transferred to our hospital. The initial consciousness assessment was not clear, and routine CTP was performed to understand the intracranial changes, which suggested a large area of cerebral infarction on the right side; however, the cerebral oxygen was not consistent with the CTP results, and the reexamination of CTA still suggested a right cerebral infarction. To identify this difference, bedside transcranial Doppler was performed, and the blood flow on both sides was different. By reducing the ECMO flow, CTP reexamination showed that the results were normal and consistent with the clinical results. On day 3, the patient was alert and showed good limb movements.
CONCLUSIONS: In patients with peripheral VA-ECMO, cerebral perfusion confirmed by CTP and CTA may lead to false cerebral infarction.

(1) Background: Conventional open surgery is still the gold standard for aortic arch disease, and despite recent developments in optimizing strategies for neuroprotection, distal organ perfusion, and myocardial protection, aortic arch replacement is still associated with high morbidity and mortality rates. (2) Methods: We present our case series of 12 patients undergoing surgical management of multiple cardiac diseases involving the aortic arch. In this single-center study, we report our initial experience over a five-year period (from December 2018 to October 2023) with the use of a \"debranching first\" technique for the supra-aortic vessels of a beating heart, followed by the cardiac step addressing proximal diseases, and a final distal step treating the aortic arch. This strategy aims to minimize cardiac, cerebral, and peripheral ischemia. (3) Results: Six patients underwent aortic root replacement with either Bentall (n = 4) or valve-sparing aortic root (David procedure) (n = 2). The mean nasopharyngeal temperature was 34 °C and the mean cardiocirculatory arrest was 14.3 min. The early mortality was 8.3% (1 patient); no patient experienced a permanent neurologic event. (4) Conclusions: In patients with complex aortic disease and concomitant cardiac disease, this approach reduces the need for hypothermia and decreases cardiopulmonary bypass time and myocardial arrest time and therefore could represent a valid surgical option, even in high-risk patients.

BACKGROUND: Hereditary spastic paraplegia (HSP) include various sporadic and hereditary neurodegenerative disorders, characterized by progressive spasticity and weakness of lower limbs, possibly associated to additional features.
METHODS: We report a male HPS patient in his 40 s, showing mental retardation associated with language impairment, dysarthria, and increased urinary frequency. Three months after treatment with electric chronic high-frequency cervical spinal cord stimulation (HF-SCS), he showed an amelioration of motor symptoms (lower limbs spasticity and gait), dysarthria, cognitive functioning (language and constructive praxic abilities), and urinary symptoms (decreased urinary frequency). Single-photon emission computed tomography (SPECT) showed a postoperative increase of cerebral perfusion in right frontal cortex and temporal cortex bilaterally.
CONCLUSIONS: In our patient, HF-SCS might have induced an activation of ascending neural pathways, resulting in changes in activity in various cortical areas (including sensory-motor cortical areas), which may give rise to a modulation of activity in spared descending motor pathways and in neural networks involved in cognitive functions, including language. Although further studies in patients with HPS are needed to clarify whether HF-SCS can be a suitable treatment option in HSP, our observation suggests that HF-SCS, a minimally invasive neurosurgical procedure, might induce beneficial effects of on various symptoms of such orphan disease.

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.

BACKGROUND: Aortic arch repair for aortic dissection is still associated with a high mortality rate. Providing adequate means of neuromonitoring to guide cerebral hemodynamics is advantageous, especially during selective anterior cerebral perfusion (SACP).
OBJECTIVE: We aimed to investigate an easy multimodal neuromonitoring set-up consisting of processed electroencephalography (EEG), near infrared spectroscopy (NIRS), and transcranial doppler sonography (TCD).
METHODS: We collected intraoperative data from six patients undergoing surgery for aortic dissection. In addition to standard hemodynamic monitoring, patients underwent continuous bilateral NIRS, processed EEG with bispectral index (BIS), and intermittent transcranial doppler sonography of the medial cerebral artery (MCA) with a standard B‑mode ultrasound device. Doppler measurements were taken bilaterally before cardiopulmonary bypass (CPB), during CPB, and during SACP at regular intervals.
RESULTS: Of the patients four survived without neurological deficits while two suffered fatal outcomes. Of the survivors two suffered from transient postoperative delirium. Multimodal monitoring led to a change in CPB flow or cannula repositioning in three patients. Left-sided mean flow velocities of the MCA decreased during SACP, as did BIS values.
CONCLUSIONS: Monitoring consisting of BIS, NIRS, and TCD may have an impact on hemodynamic management in aortic arch operations.
UNASSIGNED: HINTERGRUND: Operationen am Aortenbogen bei Aortendissektion sind immer noch mit einer hohen Sterblichkeit verbunden. Vorteilhaft wäre hierbei ein adäquates Neuromonitoring zur Steuerung der zerebralen Hämodynamik, insbesondere während der Phase der selektiven Hirnperfusion (SACP).
UNASSIGNED: Wir untersuchten ein einfaches multimodales Neuromonitoring-Setup, bestehend aus Elektroenzephalographie (EEG), Nahinfrarotspektroskopie (NIRS) und transkranieller Dopplersonographie (TCD).
UNASSIGNED: Sechs Patienten mit Operationen des Aortenbogens aufgrund einer Aortendissektion wurden eingeschlossen. Zusätzlich zum hämodynamischen Standardmonitoring erhielten diese eine kontinuierliche bilaterale NIRS-Ableitung, eine prozessierte EEG mit bispektralem Index (BIS) und eine intermittierende transkranielle Dopplersonographie der A. cerebri media (MCA) mit einem Standard-B-Mode-Ultraschallgerät. Dopplermessungen wurden beidseits in regelmäßigen Intervallen vor und während des kardiopulmonalen Bypasses (CPB) sowie während SACP durchgeführt.
UNASSIGNED: Vier Patienten überlebten ohne neurologisches Defizit, während zwei verstarben. Zwei der Überlebenden erlitten ein vorübergehendes postoperatives Delir. Multimodales Monitoring resultierte in einer Veränderung des CPB-Flusses oder einer Kanülenrepositionierung bei drei Patienten. Die linksseitige Flussgeschwindigkeiten der MCA wie auch die BIS-Werte waren während SACP geringer.
UNASSIGNED: Ein Monitoring bestehend aus BIS, NIRS und TCD kann das hämodynamische Management während Operationen des Aortenbogens beeinflussen.

Sinking skin flap syndrome (SSFS) is a complication among long-term survivors of stroke or traumatic brain injury treated by decompressive craniectomy. The syndrome encompasses a wide spectrum of neurological symptoms including cognitive decline, seizures, speech and sensorimotor deficits. Early cranioplasty appears to improve cerebral perfusion, but the efficacy of cranioplasty in neurocognitive outcome in long-standing SSFS patient is unclear. We report a 64-year-old patient who suffered from traumatic brain injury and underwent decompressive craniectomy 18 years ago. She had chronic SSFS with pre-cranioplasty assessments demonstrating severe neurocognitive impairments which were static over time. After cranioplasty with custom-made polyetheretherketone flap to restore the 264 cm2 skull defect, magnetic resonance perfusion scan with pseudo-continuous arterial spin labelling technique showed a two-fold augmentation of cerebral blood flow in both frontal lobes, as well as areas distal to the sunken skin flap compared to baseline. This is accompanied by improvement of neurocognitive function as assessed by Montreal Cognitive Assessment, Neurobehavioral Cognitive State Examination, and Rivermead Behavioural Memory Test three and six months after cranioplasty. The patient\'s quality of life and that of her primary carer also showed improvement. This report describes a case of neurocognitive and global cerebral perfusion improvement after cranioplasty in the setting of prolonged SFSS of 18 years, and adds to the growing body of literature supporting the therapeutic role of cranioplasty beyond purely protective or cosmetic indications. The advantages and clinical utility of pCASL MR perfusion in assessing serial CBF before and after cranioplasty is illustrated.

暂无摘要。

High-intensity exercise may pose a risk to patients with postconcussion syndrome (PCS) when symptomatic during exertion. The case of a paralympic athlete with PCS who experienced a succession of convulsion-awakening periods and reported a marked increase in postconcussion symptoms after undergoing a graded symptom-limited aerobic exercise protocol is presented. Potential mechanisms of cerebrovascular function failure are then discussed.