BACKGROUND AND IMPORTANCE: Extracranial-intracranial bypass remains an enduring procedure for a select group of patients suffering from steno-occlusive cerebrovascular disease. Although the superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is most familiar among neurosurgeons, particular circumstances preclude the use of an STA donor. In such cases, alternative revascularization strategies must be pursued. CLINICAL PRESENTATION: A 63-year-old female presented with symptoms of hemodynamic insufficiency and was found to have left common carotid artery occlusion at the origin. She experienced progressive watershed ischemia and pressure-dependent fluctuations in her neurological examination despite maximum medical therapy. The ipsilateral STA was unsuitable for use as a donor vessel. We performed an extracranial vertebral artery (VA) to MCA bypass with a radial artery interposition graft. CONCLUSION: This technical case description and accompanying surgical video review the relevant anatomy and surgical technique for a VA-MCA bypass. The patient was ultimately discharged home at her preoperative neurological baseline with patency of the bypass. The VA can serve as a useful donor vessel for cerebral revascularization procedures in pathologies ranging from malignancies of the head and neck to cerebral aneurysms and cerebrovascular steno-occlusive disease.

• MeSH
• arteria carotis interna chirurgie   MeSH
• arteria cerebri media diagnostické zobrazování   chirurgie   MeSH
• arteria vertebralis diagnostické zobrazování   chirurgie   MeSH
• cerebrovaskulární poruchy * chirurgie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• revaskularizace mozku * metody   MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH

A 58-year-old patient presented with a severe neurological deficit due to a stroke caused by an occlusion of the left internal carotid artery siphon. Standard treatment failed and neurosurgical consult was delayed. Because of a favorable perfusion imaging finding, microsurgical revascularization via an extra-intracranial bypass (left superficial temporal artery - left middle cerebral artery) was performed 36 hours after the onset of the symptoms. The outcome of the patient was favorable. The authors want to emphasize the need to actively seek patients with a severe neurological deficit and still viable brain tissue. The time window and treatment alternatives are discussed.

• Klíčová slova
• 4D CT angiography, CT perfusion, Carotid artery dissection, Extra-intracranial bypass, Intracranial atherosclerosis, Large vessel occlusion,
• MeSH
• arteria carotis interna chirurgie   MeSH
• cévní mozková příhoda * diagnostické zobrazování   etiologie   chirurgie   MeSH
• ischemická cévní mozková příhoda * komplikace   MeSH
• lidé středního věku MeSH
• lidé MeSH
• perfuze škodlivé účinky   MeSH
• revaskularizace mozku * metody   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH
• práce podpořená grantem MeSH

BACKGROUND: Despite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue for whom persistent emergent large vessel occlusion portends a catastrophic outcome. OBJECTIVE: To test the safety and efficacy of emergent microsurgical intervention in patients with acute ischemic stroke and symptomatic middle cerebral artery occlusion after failure of mechanical thrombectomy. METHODS: A prospective two-center cohort study was conducted. Patients with acute ischemic stroke and middle cerebral artery occlusion for whom recanalization failed at center 1 were randomly allocated to the microsurgical intervention group (MSIG) or control group 1 (CG1). All similar patients at center 2 were included in the control group 2 (CG2) with no surgical intervention. Microsurgical embolectomy and/or extracranial-intracranial bypass was performed in all MSIG patients at center 1. RESULTS: A total of 47 patients were enrolled in the study: 22 at center 1 (12 allocated to the MSIG and 10 to the CG1) and 25 patients at center 2 (CG2). MSIG group patients showed a better clinical outcome on day 90 after the stroke, where a modified Rankin Scale score of 0-2 was reached in 7 (58.3%) of 12 patients compared with 1/10 (10.0%) patients in the CG1 and 3/12 (12.0%) in the CG2. CONCLUSIONS: This study demonstrated the potential for existing microsurgical techniques to provide good outcomes in 58% of microsurgically treated patients as a third-tier option.

• Klíčová slova
• Stroke, Thrombectomy, Thrombolysis,
• MeSH
• arteria carotis interna chirurgie   MeSH
• cévní mozková příhoda * diagnostické zobrazování   chirurgie   MeSH
• endovaskulární výkony * metody   MeSH
• infarkt arteria cerebri media MeSH
• ischemická cévní mozková příhoda * MeSH
• ischemie mozku * diagnostické zobrazování   chirurgie   MeSH
• kohortové studie MeSH
• lidé MeSH
• prospektivní studie MeSH
• retrospektivní studie MeSH
• trombektomie škodlivé účinky   metody   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• randomizované kontrolované studie MeSH

Aim of the study: To present our rescue approach of carotid artery occlusion as well as to discuss other possible techniques that can be applied in similar situations.Materials and methods: Two cases from our institution with acute complications during carotid micro-endarterectomy (CEA).Results: Two cases from our institution with acute postoperative complications during CEA that were successfully addressed are presented with imaging and detailed description of the surgical techniques used.Conclusion: CEA are common surgical procedures pursued to achieve revascularization of carotid arteries when occluded partially or fully by an atherosclerotic plaque. As with any surgical procedure, associated complications exist in small percentage of the cases. These can include blood flow limitation due to an insufficient artery wall after atherosclerotic plaque extraction as well as distal kinking of the internal carotid artery. A direct end-to-end ACE-ACI bypass with occlusion of the proximal ACI and distal ACE stump preserves distal flow to the ACI, however the original arteriotomy of ACC must be completely sutured up to the arterial stumps.

• Klíčová slova
• Carotid endarterectomy, carotid artery kinking, vascular surgery,
• MeSH
• anastomóza chirurgická MeSH
• arteria carotis interna diagnostické zobrazování   chirurgie   MeSH
• aterosklerotický plát * MeSH
• karotická endarterektomie * metody   MeSH
• lidé MeSH
• stenóza arteria carotis * diagnostické zobrazování   chirurgie   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND AND PURPOSE: DSA (digital subtraction angiography) is the gold standard for measuring carotid artery stenosis (CS). Yet, the correlation between DSA and stenosis is not well documented. MATERIAL AND METHODS: We compared CS as measured by DSA to carotid artery specimens obtained from carotid endarterectomy surgery. Patients were divided into three groups according to NASCET criteria (North American Symptomatic Carotid Endarterectomy Trial): stenosis of 30-49% (mild), stenosis of 50-69% (moderate), and stenosis of 70-99% (severe). RESULTS: This prospective cohort study involved 644 patients. The mean stenosis in the mild stenosis group (n = 128 patients) was 54% ECST (European Carotid Surgery Trial), 40% NASCET, and 72% ESs (endarterectomy specimens). The mean absolute difference between ECST and NASCET was 14%. The mean stenosis in the moderate stenosis group (n = 347 patients) was 66% ECST, 60% NASCET, and 77% ES. The mean absolute difference between ECST and NASCET was 6%. The mean stenosis in the severe group (n = 169 patients) was 80% ECST, 76% NASCET, and 79% ES. No significant correlation coefficients were found between DSA and ES methods. In the mild group, the CC was 0.16 (ESCT) and 0.13 (NASCET); in the moderate group, the CC was 0.05 (ESCT) and 0.01 (NASCET); and in the severe group, the CC was 0.23 (ESCT) and 0.10 (NASCET). For all groups combined, CC was 0.22 for the ECST and 0.20 for the NASCET method. CONCLUSION: The relationship between DSA and ES methods to measure CS is almost random. This lack of a relationship between the DSA and ES techniques questions the validity of current DSA-based guidelines.

• Klíčová slova
• Angiography, Atherosclerosis, Carotid artery, Digital subtraction, Endarterectomy, Stroke,
• MeSH
• arteria carotis interna chirurgie   MeSH
• digitální subtrakční angiografie MeSH
• karotická endarterektomie * MeSH
• lidé MeSH
• prospektivní studie MeSH
• stenóza arteria carotis * diagnostické zobrazování   chirurgie   MeSH
• stenóza MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• srovnávací studie MeSH

BACKGROUND: Clipping of ophthalmic artery (OA) aneurysms present one of the treatment strategies for long-term disease management. Existing surgical techniques primarily require extra/intradural removal of the anterior clinoid process, carrying a higher risk of infection, damage to surrounding structures or technical complications. METHODS: We present the technique of minimally invasive partial medial clinoidectomy with the unroofing of the optic canal for surgical clipping of OA aneurysms, and besides its pros and cons, we also discuss proper technical indications. CONCLUSION: The partial medial clinoidectomy improves manoeuvrability around the paraclinoid region, provides better protection for adjacent structures and renders excellent treatment outcome.

• Klíčová slova
• Case series, Microsurgery, Ophthalmic aneurysm, Partial medial clinoidectomy,
• MeSH
• arteria carotis interna chirurgie   MeSH
• arteria ophthalmica * diagnostické zobrazování   chirurgie   MeSH
• intrakraniální aneurysma * diagnostické zobrazování   chirurgie   MeSH
• klínová kost chirurgie   MeSH
• lidé MeSH
• neurochirurgické výkony metody   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

INTRODUCTION: Acute symptomatic occlusion of the internal carotid artery (ICA) is associated with unfavorable prognosis. However, no clear definition of its optimal treatment exists. The aim of this study was to evaluate the efficacy and risks of urgent carotid endarterectomy (CEA) in patients with ischemic stroke due to acute extracranial ICA occlusion. METHODS: A retrospective analysis was performed of all consecutive patients undergoing urgent CEA for acute extracranial ICA occlusion during the period from July 2014 to June 2021. The primary outcome was functional independence at three months defined as modified Rankin Scale (mRS) score 2. Secondary outcomes included the severity of the neurological deficit at the time of discharge and its comparison with the preoperative condition as assessed using the National Institutes of Health Stroke Scale (NIHSS), the incidence of symptomatic intracerebral hemorrhage (ICH), and 30-day periprocedural mortality. RESULTS: During the study period, a total of 42 urgent CEAs were performed for acute extracranial ICA occlusions. The median preoperative NIHSS score was 7 (interquartile range [IQR] 5-13). The median time interval between the onset of symptoms and surgery was 290 minutes (IQR 235-340). Technical success rate of urgent CEA was 97.6% (41 patients). The median NIHSS at the time of hospital discharge was 2 (IQR 3-7; p.

• Klíčová slova
• carotid endarterectomy, emergent, internal carotid artery, occlusion, stroke, urgent,
• MeSH
• arteria carotis interna chirurgie   MeSH
• časové faktory MeSH
• cévní mozková příhoda * etiologie   MeSH
• ischemická cévní mozková příhoda * MeSH
• karotická endarterektomie * škodlivé účinky   MeSH
• lidé MeSH
• retrospektivní studie MeSH
• stenóza arteria carotis * komplikace   chirurgie   MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

OBJECTIVE: The clinical outcome of surgical extracranial internal carotid artery (eICA) recanalization may be adversely affected by intraoperative ischemia. Median nerve somatosensory evoked potential (SEP) amplitude correlates well with cerebral blood flow. Our study presents the value of intraoperative SEP and selective shunting in the prevention of intraoperative ischemia development during urgent eICA recanalization. METHODS: Prospective recruitment of patients with acute unilateral eICA occlusion. All underwent surgical recanalization with intraoperative monitoring of scalp median SEPs. Preoperative clinical findings, cerebral collaterals, and 3 month functional outcome were evaluated. RESULTS: The cohort consisted of 33 patients. Intraoperative SEP amplitude decreased significantly in 6 (18.2%). An intraluminal shunt was inserted twice (6.1%), surgical complications occurred in 6 (18.2%), intracerebral hemorrhage was not found. Favorable outcome 3 months after surgery according to the modified Rankin scale (mRS 0-2) was achieved in 28 (84.8%), 3 patients died (9.1%). CONCLUSIONS: Intraoperative SEP during urgent eICA recanalization seems to be beneficial. Thanks to the effective measure based on the intraoperative SEP changes, the clinical outcome in four(12.1%) could be positively affected. SIGNIFICANCE: The results suggest that selective shunting based on intraoperative median SEPs may prevent intraoperative ischemia and may improve overall outcome of urgent eICA recanalization.

• Klíčová slova
• Intraoperative monitoring, Ischemic stroke, Selective shunting, Somatosensory evoked potentials, Urgent recanalization,
• MeSH
• arteria carotis interna chirurgie   MeSH
• intraoperační neurofyziologická monitorace * MeSH
• ischemie mozku * prevence a kontrola   MeSH
• lidé MeSH
• nemoci arterie carotis * chirurgie   MeSH
• prospektivní studie MeSH
• somatosenzorické evokované potenciály fyziologie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

BACKGROUND: Thrombectomy is an effective treatment for acute ischaemic stroke (AIS). AIMS: The aim of this study was to compare clinical outcomes with intracranial artery occlusion site among AIS patients treated in the setting of a cardiology cath lab. METHODS: This was a single-centre, prospective registry of 214 consecutive patients with AIS enrolled between 2012 and 2018. All thrombectomy procedures were performed in a cardiology cath lab with stent retrievers or aspiration systems. The functional outcome was assessed by the modified Rankin Scale (mRS) after three months. RESULTS: Ninety-three patients (44%) had middle cerebral artery (MCA) occlusion, 28 patients (13%) had proximal internal carotid artery (ICA) occlusion, 27 patients (13%) had tandem (ICA+MCA) occlusion, 39 patients (18%) had terminal ICA (T-type) occlusion, and 26 patients (12%) had vertebrobasilar (VB) stroke. Favourable clinical outcome (mRS ≤2) was reached in 58% of MCA occlusions and in 56% of isolated ICA occlusions, but in only 31% of T-type occlusions and in 27% of VB stroke. Poor clinical outcome in T-type occlusions and VB strokes was influenced by the lower recanalisation success (mTICI 2b-3 flow) rates: 56% (T-type) and 50% (VB) compared to 82% in MCA occlusions, 89% in isolated ICA occlusions and 96% in tandem occlusions. CONCLUSIONS: Catheter-based thrombectomy achieved significantly better clinical results in patients with isolated MCA occlusion, isolated ICA occlusions or tight stenosis and tandem occlusions compared to patients with T-type occlusion and posterior strokes. Visual summary. Endovascular intervention of isolated MCA or ICA occlusions provides greatest clinical benefit, while interventions in posterior circulation have lower chance for clinical success.

• MeSH
• arteria carotis interna diagnostické zobrazování   chirurgie   MeSH
• arterie MeSH
• cévní mozková příhoda * etiologie   chirurgie   MeSH
• endovaskulární výkony * MeSH
• ischemická cévní mozková příhoda * MeSH
• ischemie mozku * chirurgie   MeSH
• lidé MeSH
• retrospektivní studie MeSH
• stenty MeSH
• trombektomie MeSH
• výsledek terapie MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

BACKGROUND: An indication for selective shunting during carotid endarterectomy (CEA) is based on monitoring during a procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) may be a simple technique, but its relevance during CEA, especially with respect to cutoff values indicating shunt implantation, still needs to be elucidated. METHODS: One hundred twenty five patients underwent CEA under local anesthesia (LA) and were monitored clinically throughout the whole procedure. The patients were also monitored using bilateral NIRS probes during surgery. The NIRS values were recorded and evaluated before and after selective cross-clamping, firstly by the external carotid artery (ECA), followed by the internal carotid artery (ICA). The decrease in the ipsilateral CO values, with respect to the indication of shunting, was only analyzed after selective cross-clamping of the ICA. The decision to use an intraluminal shunt was solely based on the neurological status evaluation after ICA cross-clamping. RESULTS: One hundred five patients (85%) were stable throughout the CEA, while 20 patients (15%) clinically deteriorated during surgery. The mean drop in the CO after selective ICA clamping in clinically stable patients was 6%, while in patients with clinical deterioration, the NIRS decreased by 14.5% (p < 0.05). When the cutoff value for selective shunting was set as a 10% decrease of the ipsilateral CO after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83.0%. CONCLUSIONS: Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cutoff value for selective shunting during CEA. Despite the availability of a variety of monitoring tools, the NIRS may be an easy, reliable option, especially in the scenario of acute CEA in general anesthesia.

• Klíčová slova
• Carotid endarterectomy, Cerebral oximetry, Intraluminal shunt, Neuromonitoring, Stroke,
• MeSH
• arteria carotis externa diagnostické zobrazování   chirurgie   MeSH
• arteria carotis interna diagnostické zobrazování   chirurgie   MeSH
• blízká infračervená spektroskopie MeSH
• chirurgické nástroje * MeSH
• difuzní magnetická rezonance MeSH
• karotická endarterektomie * MeSH
• konstrikce MeSH
• lidé středního věku MeSH
• lidé MeSH
• mozek diagnostické zobrazování   patofyziologie   chirurgie   MeSH
• neurochirurgické výkony * MeSH
• oxymetrie * MeSH
• prospektivní studie MeSH
• ROC křivka MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Check Tag
• lidé středního věku MeSH
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• pozorovací studie MeSH
• práce podpořená grantem MeSH