Pub Date : 2020-01-22DOI: 10.26683/2304-9359-2019-3(29)-63-70
D. Shchehlov, O. Svyrydiuk, О.I. Kravchik
Objective – to study the efficacy and safety of stent grafts in the treatment of diseases of the cerebral arteries.Materials and methods. It was analysed results of treatment of 6 patients (3 men and 3 women) with disease of the main arteries of the brain, where stent graft was used. The youngest patient was 35 years old, the oldest was 60. Results were evaluated by data of somatic and neurological examination, selective cerebral angiography, computer and magnetic resonance imaging. Surgery performed within 1 to 3 months from the onset of the disease. On a modified Rankin scale four patients have 0 point, two have 1 point. All patients received double disaggregant therapy, clopidogrel 75 mg, and aspirin 100 mg per day before the intervention. Sensitivity to clopidogrel was determined by the method of light transmission aggregate. All interventions were performed under general anesthesia; the duration of the intervention ranged from 25 to 90 minutes, average mean was 45 minutes. Used for stent surgery Atrium Advanta V12 and Graftmaster.Results. In four cases, stent implantation had no technical difficulties. In two cases, technical difficulties arose due to the structural features of the stent system, in particular, the rigid system distal to the stent itself, which limits the stent navigation in curved areas. In one case, due to the use of rigid delivery system and implantation of the stent by the method of retrograde opening from the guide catheter was able to implant at the level of the aneurysm. In one case, the stent was implanted without covering the distal part of the artery, after stent implantation a stasis of contrast fluid in the aneurysm cavity was noted. Control angiography after 6 months to demonstrate total exclusion of an aneurysm from the bloodstream. Using the features of the stent, it was possible to separate the arteriovenous complicity between the vertebral artery and the paravertebral venous plexus with complete reconstruction of the artery. There were no intraoperative and postoperative complications. Duration of stay of patients in hospital 3–5 days. In all cases, reconstruction of the artery was achieved with the exception of an aneurysm from the bloodstream or disconnection of the arteriovenous shunt.Conclusions. The preliminary accumulated results of the use of stent grafts in the aneurysms of the extracranial carotid section indicate that this technique has advantages over “conservative surgical treatment” by reducing surgical trauma, no risk of damage to the cranial nerves, shorter stay time. In case of erosive bleeding and arteriovenous joints, the use of stent graft should be considered as a method of choice.
{"title":"Our experience with graft stents in the treatment of diseases of the main arteries of the brain","authors":"D. Shchehlov, O. Svyrydiuk, О.I. Kravchik","doi":"10.26683/2304-9359-2019-3(29)-63-70","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-3(29)-63-70","url":null,"abstract":"Objective – to study the efficacy and safety of stent grafts in the treatment of diseases of the cerebral arteries.Materials and methods. It was analysed results of treatment of 6 patients (3 men and 3 women) with disease of the main arteries of the brain, where stent graft was used. The youngest patient was 35 years old, the oldest was 60. Results were evaluated by data of somatic and neurological examination, selective cerebral angiography, computer and magnetic resonance imaging. Surgery performed within 1 to 3 months from the onset of the disease. On a modified Rankin scale four patients have 0 point, two have 1 point. All patients received double disaggregant therapy, clopidogrel 75 mg, and aspirin 100 mg per day before the intervention. Sensitivity to clopidogrel was determined by the method of light transmission aggregate. All interventions were performed under general anesthesia; the duration of the intervention ranged from 25 to 90 minutes, average mean was 45 minutes. Used for stent surgery Atrium Advanta V12 and Graftmaster.Results. In four cases, stent implantation had no technical difficulties. In two cases, technical difficulties arose due to the structural features of the stent system, in particular, the rigid system distal to the stent itself, which limits the stent navigation in curved areas. In one case, due to the use of rigid delivery system and implantation of the stent by the method of retrograde opening from the guide catheter was able to implant at the level of the aneurysm. In one case, the stent was implanted without covering the distal part of the artery, after stent implantation a stasis of contrast fluid in the aneurysm cavity was noted. Control angiography after 6 months to demonstrate total exclusion of an aneurysm from the bloodstream. Using the features of the stent, it was possible to separate the arteriovenous complicity between the vertebral artery and the paravertebral venous plexus with complete reconstruction of the artery. There were no intraoperative and postoperative complications. Duration of stay of patients in hospital 3–5 days. In all cases, reconstruction of the artery was achieved with the exception of an aneurysm from the bloodstream or disconnection of the arteriovenous shunt.Conclusions. The preliminary accumulated results of the use of stent grafts in the aneurysms of the extracranial carotid section indicate that this technique has advantages over “conservative surgical treatment” by reducing surgical trauma, no risk of damage to the cranial nerves, shorter stay time. In case of erosive bleeding and arteriovenous joints, the use of stent graft should be considered as a method of choice.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47927918","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-81-90
S. Litvak, M. Yeleynik, L. M. Yakovenko, S. Minov
Objective – according to the separate clinical observation to evaluate the strategy and tactics of an individualized treatment planning after the rupture of posterior inferior cerebellar artery (PICA) aneurysm in acute period of hemorrhagic stroke. Materials and methods. A retrospective analysis of the case of microsurgical treatment of PICA aneurysm in the acute period after hemorrhage was performed. The patient’s diagnosis and treatment was held at the State Institution «Romodanov Neurosurgery Institute, NAMS of Ukraine» in 2019. The patients age at the time of diagnosis was 50 years. The complex of diagnostic workout included clinical neurological examination, instrumental (neuroimaging and functional tests) and laboratory investigation. Results. According to the results of comprehensive clinical and instrumental examination, patient underwent emergency combined one-stage surgical procedure that include aneurysms clipping with external ventriculostomy of the posterior horn of the right lateral ventricle for surgical correction of the consequences after aneurysms rupture (expansion of the blood into the ventricular system, with hemotamponade of III and IV ventricle, internal obstructive hydrocephalus), which caused the emergency of surgical procedure. The intervention (external drainage of the posterior horn of the right lateral ventricle, clipping of left PICA aneurysm) was performed on the 5th day after rapture. Operation and postoperative period have passed without complications with positive neurological and neuroimaging follow-up. Conclusions. The applied diagnostic and therapeutic options can be utilized as a method of choice for individualized surgical planning after rapture of PICA aneurysm.
{"title":"Microsurgical treatment of ruptured fusiform posterior inferior cerebellar artery aneurysm: case report","authors":"S. Litvak, M. Yeleynik, L. M. Yakovenko, S. Minov","doi":"10.26683/2304-9359-2019-1(27)-81-90","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-81-90","url":null,"abstract":"Objective – according to the separate clinical observation to evaluate the strategy and tactics of an individualized treatment planning after the rupture of posterior inferior cerebellar artery (PICA) aneurysm in acute period of hemorrhagic stroke. Materials and methods. A retrospective analysis of the case of microsurgical treatment of PICA aneurysm in the acute period after hemorrhage was performed. The patient’s diagnosis and treatment was held at the State Institution «Romodanov Neurosurgery Institute, NAMS of Ukraine» in 2019. The patients age at the time of diagnosis was 50 years. The complex of diagnostic workout included clinical neurological examination, instrumental (neuroimaging and functional tests) and laboratory investigation. Results. According to the results of comprehensive clinical and instrumental examination, patient underwent emergency combined one-stage surgical procedure that include aneurysms clipping with external ventriculostomy of the posterior horn of the right lateral ventricle for surgical correction of the consequences after aneurysms rupture (expansion of the blood into the ventricular system, with hemotamponade of III and IV ventricle, internal obstructive hydrocephalus), which caused the emergency of surgical procedure. The intervention (external drainage of the posterior horn of the right lateral ventricle, clipping of left PICA aneurysm) was performed on the 5th day after rapture. Operation and postoperative period have passed without complications with positive neurological and neuroimaging follow-up. Conclusions. The applied diagnostic and therapeutic options can be utilized as a method of choice for individualized surgical planning after rapture of PICA aneurysm.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49312039","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-58-66
O. Pastushyn, D. Shchehlov, S. Konotopchyk, O. E. Sviridyuk
Objective — to evaluate the effectiveness of endovascular mechanical recanalization methods in ischemic stroke and the analysis of problem cases.Materials and methods. A retrospective analysis of the results of treatment of 33 patients with acute ischemic stroke due to occlusion of a large vessel was performed. There were 18 (54.5 %) men and 15 (45.5 %) women. Endovascular interventions were performed in all patients to restore cerebral arteries patency using various methods and techniques of mechanical thrombectomy. All patients underwent neuroimaging (CT of the brain and selective cerebral subtraction angiography). A topographical assessment of early CT-changes in ischemic stroke was performed using the ASPECTS scale. The severity of neurological symptoms in the acute period of ischemic stroke was assessed according to the NIHSS score. The severity of the condition – on the NIHSS score. The mTICI scale was used to assess the success of recanalization (reperfusion) after mechanical thrombectomy.Results. Successful recanalization (mTICI 2b-3) with the use of stent retrievers and distal aspiration catheters was achieved in 22 (66.7 %) cases. The total number of intraoperative complications was 12.0 %. Mortality rate – 12.0 %.Conclusions. Endovascular reperfusion methods using stent retrievers and distal aspiration catheters for acute ischemic stroke are effective. Endovascular reperfusion advisable to start with a mechanical thrombus aspiration. When performing endovascular recanalization, the use of stent retrievers in combination with guide balloon catheters only without distal aspiration catheters increases the risk of distal reembolism and embolism of other arterial basins.
{"title":"Mechanical thrombeсtomy and trombaspiration in stroke. Problem claims","authors":"O. Pastushyn, D. Shchehlov, S. Konotopchyk, O. E. Sviridyuk","doi":"10.26683/2304-9359-2019-1(27)-58-66","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-58-66","url":null,"abstract":"Objective — to evaluate the effectiveness of endovascular mechanical recanalization methods in ischemic stroke and the analysis of problem cases.Materials and methods. A retrospective analysis of the results of treatment of 33 patients with acute ischemic stroke due to occlusion of a large vessel was performed. There were 18 (54.5 %) men and 15 (45.5 %) women. Endovascular interventions were performed in all patients to restore cerebral arteries patency using various methods and techniques of mechanical thrombectomy. All patients underwent neuroimaging (CT of the brain and selective cerebral subtraction angiography). A topographical assessment of early CT-changes in ischemic stroke was performed using the ASPECTS scale. The severity of neurological symptoms in the acute period of ischemic stroke was assessed according to the NIHSS score. The severity of the condition – on the NIHSS score. The mTICI scale was used to assess the success of recanalization (reperfusion) after mechanical thrombectomy.Results. Successful recanalization (mTICI 2b-3) with the use of stent retrievers and distal aspiration catheters was achieved in 22 (66.7 %) cases. The total number of intraoperative complications was 12.0 %. Mortality rate – 12.0 %.Conclusions. Endovascular reperfusion methods using stent retrievers and distal aspiration catheters for acute ischemic stroke are effective. Endovascular reperfusion advisable to start with a mechanical thrombus aspiration. When performing endovascular recanalization, the use of stent retrievers in combination with guide balloon catheters only without distal aspiration catheters increases the risk of distal reembolism and embolism of other arterial basins.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46856657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-32-40
Yu.M. Samonenko, D. Shchehlov, O. E. Sviridyuk, A. V. Naida, O. Slobodian
Objective – to improve the treatment quality for patients with spinal arteriovenous malformations (AVM).Materials and methods. A retrospective analysis of endovascular and surgical treatment of patients was made. In SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» since 2005 till 2018 were operated 55 patients (34 (61.8 %) men and 21 (38.2 %) women). The age of patients ranged from 11 to 62 years (middle age is 45.3 years). The classification proposed by Anson and Spetzler in 1992 was used in order to divide patients into experimental groups: type I, arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile AVM; and type IV, perimedullary AVF. Patients with type I were 36 (65.5 %), with ІІ type – 10 (18.2 %), with ІIІ type – 5 (9.0 %), with IV type – 4 (7.3 %). For diagnostics were used MRI and spinal angiography. The Aminoff–Logue scale was used for assessment of the neurological deficiency severity. Early postoperative complications (CSF) leakage, wound infection, early postoperative worsening) were counted.Results. 12 (21.8 %) patients were treated using the microsurgical method and 43 (78.2 %) were treated endovascular. We used endovascular and microsurgical methods to treat patients with I type spinal AVM. Microsurgical intervention for 9 (33 %) patients was performed. Complete disconnection of fistula was achieved in 9 patients. Early postoperative complication (CSF leakage) was observed in 1 (11 %) case. Endovascular treatment was performed for 27 (67 %) patients. Total disconnection was achieved in 16 (59 %) cases, 17 patients (63 %) had early transient neurological worsening. Embolization is the first-line treatment for patients with type II AVM – 8 (80 %) patients. Complete obliteration of AVM was attained in 5 patients (62.5 %), 6 (75 %) patients suffered from early worsening of postoperative neurological symptoms. The microsurgical method was used in case of low risk of spinal cord injury in 2 patients (20 %), AVMs were excluded totally in 2 patients and in 1 patient neurological deterioration was stabilized. All patients with III type AVM were treated endovascular. AVM was obliterated complete in 1 patient (20 %). Three (60 %) patients had transient neurological deterioration. Endovascular method was used to treat 3 (75 %) patients with type IV AVM. Totally disconnection of AVM was achieved in 1 (33 %) patient. Super-selective catheterization of all conductive arteries was not possible. Neurological worsening was observed in 1 (33 %) patient.Conclusions. Angiography is the first-line diagnostic method which permits to find the most effective and safe way (endovascular or/and microsurgical treatment) to disconnect AVM from spinal cord bloodstream. Microsurgical intervention helps to achieve eye-controlled total arteriovenous disconnection. Microsurgical technique usage leads to good neurological results – neurological improvement the following day after surgery in all cases of A
{"title":"Endovascular and microsurgical treatment for spinal arteriovenous malformations. Our experience","authors":"Yu.M. Samonenko, D. Shchehlov, O. E. Sviridyuk, A. V. Naida, O. Slobodian","doi":"10.26683/2304-9359-2019-1(27)-32-40","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-32-40","url":null,"abstract":"Objective – to improve the treatment quality for patients with spinal arteriovenous malformations (AVM).Materials and methods. A retrospective analysis of endovascular and surgical treatment of patients was made. In SO «Scientific-practical Center of endovascular neuroradiology NAMS of Ukraine» since 2005 till 2018 were operated 55 patients (34 (61.8 %) men and 21 (38.2 %) women). The age of patients ranged from 11 to 62 years (middle age is 45.3 years). The classification proposed by Anson and Spetzler in 1992 was used in order to divide patients into experimental groups: type I, arteriovenous fistula (AVF); type II, glomus intramedullary AVM; type III, juvenile AVM; and type IV, perimedullary AVF. Patients with type I were 36 (65.5 %), with ІІ type – 10 (18.2 %), with ІIІ type – 5 (9.0 %), with IV type – 4 (7.3 %). For diagnostics were used MRI and spinal angiography. The Aminoff–Logue scale was used for assessment of the neurological deficiency severity. Early postoperative complications (CSF) leakage, wound infection, early postoperative worsening) were counted.Results. 12 (21.8 %) patients were treated using the microsurgical method and 43 (78.2 %) were treated endovascular. We used endovascular and microsurgical methods to treat patients with I type spinal AVM. Microsurgical intervention for 9 (33 %) patients was performed. Complete disconnection of fistula was achieved in 9 patients. Early postoperative complication (CSF leakage) was observed in 1 (11 %) case. Endovascular treatment was performed for 27 (67 %) patients. Total disconnection was achieved in 16 (59 %) cases, 17 patients (63 %) had early transient neurological worsening. Embolization is the first-line treatment for patients with type II AVM – 8 (80 %) patients. Complete obliteration of AVM was attained in 5 patients (62.5 %), 6 (75 %) patients suffered from early worsening of postoperative neurological symptoms. The microsurgical method was used in case of low risk of spinal cord injury in 2 patients (20 %), AVMs were excluded totally in 2 patients and in 1 patient neurological deterioration was stabilized. All patients with III type AVM were treated endovascular. AVM was obliterated complete in 1 patient (20 %). Three (60 %) patients had transient neurological deterioration. Endovascular method was used to treat 3 (75 %) patients with type IV AVM. Totally disconnection of AVM was achieved in 1 (33 %) patient. Super-selective catheterization of all conductive arteries was not possible. Neurological worsening was observed in 1 (33 %) patient.Conclusions. Angiography is the first-line diagnostic method which permits to find the most effective and safe way (endovascular or/and microsurgical treatment) to disconnect AVM from spinal cord bloodstream. Microsurgical intervention helps to achieve eye-controlled total arteriovenous disconnection. Microsurgical technique usage leads to good neurological results – neurological improvement the following day after surgery in all cases of A","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48660093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-91-98
V. Molotkovets
Objective – to study morphological features regenerative nerve neuroma after a complete intersection and restorative surgery with the use of electric welding technology.Materials and methods. The experimental model of operative intervention on injured peripheral nerve by immediate nerve stump’s epineurium welding and partial hindlimb immobilization was developed. The study was performed on 66 white, non-breeding male rats aged 5–7 months with a body weight of 350–450 g of vivarium breeding in Institute of Neurosurgery named after acad. A.P. Romodanov NAMS of Ukraine. Animals were divided into four experimental groups: 1 – surgical animals that included access to the sciatic nerve and its full intersection (n = 21), 2 – animals that were surgically intervened, which included access to the sciatic nerve, its intersection and the restoration of anatomical integrity by the application of an epineural suture (n = 18), 3 – animals that were operated surgically, which included access to the sciatic nerve, its intersection and the restoration of anatomical integrity by electric welding of the epineurium of the ends (n = 21), 4 – sham group, who were given access to the transverse nerve without its intersection (n = 6). In the experimental group of electric welding, the operation was performed using the apparatus EKWZ-300, «Patonmed» in the automatic mode dA2, with variable high-frequency (440 kHz) modulated current up to 0,3 A, the voltage at the 34 V pincer shield, the duration of the rectangular exposure pulse 0.8 s. Formated 5–6 electric weld point connections along the perimeter of the intersection with a complete alignment of the ends. The neurohistological method of study was used to study the morphological picture of the peripheral nerve in the region of the regenerative neurology and the distal segment in 1 and 3 months after surgical intervention. Results. It was established that simultaneous use of the technique of welded epineural joint of parts and partial immobilization of the limb in the postoperative period leads to uniform maturation of the neuro-connective tissue and its more complete neuroticisation.Conclusions. Recovery processes in the injured peripheral nerve occur better with the simultaneous formation of an immediate welded epineural joint of the ends and partial immobilization of the limb.
{"title":"Morphological changes of the nerve after restorative treatment using electric welding technology (experimental study)","authors":"V. Molotkovets","doi":"10.26683/2304-9359-2019-1(27)-91-98","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-91-98","url":null,"abstract":"Objective – to study morphological features regenerative nerve neuroma after a complete intersection and restorative surgery with the use of electric welding technology.Materials and methods. The experimental model of operative intervention on injured peripheral nerve by immediate nerve stump’s epineurium welding and partial hindlimb immobilization was developed. The study was performed on 66 white, non-breeding male rats aged 5–7 months with a body weight of 350–450 g of vivarium breeding in Institute of Neurosurgery named after acad. A.P. Romodanov NAMS of Ukraine. Animals were divided into four experimental groups: 1 – surgical animals that included access to the sciatic nerve and its full intersection (n = 21), 2 – animals that were surgically intervened, which included access to the sciatic nerve, its intersection and the restoration of anatomical integrity by the application of an epineural suture (n = 18), 3 – animals that were operated surgically, which included access to the sciatic nerve, its intersection and the restoration of anatomical integrity by electric welding of the epineurium of the ends (n = 21), 4 – sham group, who were given access to the transverse nerve without its intersection (n = 6). In the experimental group of electric welding, the operation was performed using the apparatus EKWZ-300, «Patonmed» in the automatic mode dA2, with variable high-frequency (440 kHz) modulated current up to 0,3 A, the voltage at the 34 V pincer shield, the duration of the rectangular exposure pulse 0.8 s. Formated 5–6 electric weld point connections along the perimeter of the intersection with a complete alignment of the ends. The neurohistological method of study was used to study the morphological picture of the peripheral nerve in the region of the regenerative neurology and the distal segment in 1 and 3 months after surgical intervention. Results. It was established that simultaneous use of the technique of welded epineural joint of parts and partial immobilization of the limb in the postoperative period leads to uniform maturation of the neuro-connective tissue and its more complete neuroticisation.Conclusions. Recovery processes in the injured peripheral nerve occur better with the simultaneous formation of an immediate welded epineural joint of the ends and partial immobilization of the limb.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47448466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-21-31
Y. Flomin
Objective – to identify factors that are associated with incomplete functional recovery or sustained disability in patients managed at a Comprehensive Stroke Unit (CSU).Materials and methods. We included 764 patients (41.7 % of women) aged from 20 to 95 years (median – 66 years, interquartile interval 57–75 years), who were in period from 2010 to 2018 admitted to our Stroke Center (SC) operating as a CSU. Upon admission all participants were examined by a Neurologist. Work-up and treatment were in line with recommendations of clinical guidelines. Ischemic stroke was diagnosed in 80.5 % of the patients, hemorrhagic stroke – in 19.5 %. Univariate and multivariate analyses were performed. The functional state was assessed using a modified Rankin scale (MRS). We The considered that the desired outcome was achieved if, at the time of discharge from the hospital, the initial MRS score decreased by ≥ 2 or reached ≤ 2.Results. The baseline NIHSS score ranged from 0 to 39 (median – 10, interquartile interval 6–17). 17.5 % of patients were admitted to our SC in the 1st day, 19.0 % – between 2 and 7 days, 7.5 % – between 8 and 14 days, 14.7 % – between 15 and 30 days, 10.3 % – between 31 and 60 days, 13.0 % – between 61 and 180 days, and 18.0 % – later than 180 days after the stroke onset. According to the univariate analysis, the risk of not achieving the desired outcome was associated with many factors: stroke type and subtype, the patient’s age, time delay before SC admission, the initial severity of stroke, cognitive impairment, limitations of mobility and ADLs, the presence and severity of certain types of neurological deficit, in addition to certain vascular risk factors (atrial fibrillation, smo-king) and signs of inflammation (increased erythrocyte sedimentation rate and C-reactive protein) on admission. Multivariate analysis revealed 4 independent predictors that are strongly associated with the lack of the desired functional outcome: patient age (odds ratio (OR) – 1.03, on average, for each additional year), initial stroke severity (after adjustment to the rest of factors, OR – 1.05, on average, for each additional point of the baseline NIHSS score), global disability on admission (OR – 2.3, on average for each point of the initial MRS score) and the time from stroke onset to the SC admission (compared with a shorter delay, OR – 3.3–4.2, if the patient was hospitalized between 15 and 180 days from the onset, OR – 9.2 if admitted later than 6 months after the onset). The area under the curve of operational characteristics – 0.92 (95 % CI 0.89–0.94) proved the excellent quality of the prediction model and the strong link of this set of factors to the risk of incomplete functional recovery at the time of discharge.Conclusions. According to the results of univariate analysis, the risk of incomplete functional recovery and sustained disability after treatment is associated with a wide range of factors, such as stroke type and subtype, severity of neuro
{"title":"The risk of incomplete functional recovery and sustained disability in patients treated in an integrated stroke unit","authors":"Y. Flomin","doi":"10.26683/2304-9359-2019-1(27)-21-31","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-21-31","url":null,"abstract":"Objective – to identify factors that are associated with incomplete functional recovery or sustained disability in patients managed at a Comprehensive Stroke Unit (CSU).Materials and methods. We included 764 patients (41.7 % of women) aged from 20 to 95 years (median – 66 years, interquartile interval 57–75 years), who were in period from 2010 to 2018 admitted to our Stroke Center (SC) operating as a CSU. Upon admission all participants were examined by a Neurologist. Work-up and treatment were in line with recommendations of clinical guidelines. Ischemic stroke was diagnosed in 80.5 % of the patients, hemorrhagic stroke – in 19.5 %. Univariate and multivariate analyses were performed. The functional state was assessed using a modified Rankin scale (MRS). We The considered that the desired outcome was achieved if, at the time of discharge from the hospital, the initial MRS score decreased by ≥ 2 or reached ≤ 2.Results. The baseline NIHSS score ranged from 0 to 39 (median – 10, interquartile interval 6–17). 17.5 % of patients were admitted to our SC in the 1st day, 19.0 % – between 2 and 7 days, 7.5 % – between 8 and 14 days, 14.7 % – between 15 and 30 days, 10.3 % – between 31 and 60 days, 13.0 % – between 61 and 180 days, and 18.0 % – later than 180 days after the stroke onset. According to the univariate analysis, the risk of not achieving the desired outcome was associated with many factors: stroke type and subtype, the patient’s age, time delay before SC admission, the initial severity of stroke, cognitive impairment, limitations of mobility and ADLs, the presence and severity of certain types of neurological deficit, in addition to certain vascular risk factors (atrial fibrillation, smo-king) and signs of inflammation (increased erythrocyte sedimentation rate and C-reactive protein) on admission. Multivariate analysis revealed 4 independent predictors that are strongly associated with the lack of the desired functional outcome: patient age (odds ratio (OR) – 1.03, on average, for each additional year), initial stroke severity (after adjustment to the rest of factors, OR – 1.05, on average, for each additional point of the baseline NIHSS score), global disability on admission (OR – 2.3, on average for each point of the initial MRS score) and the time from stroke onset to the SC admission (compared with a shorter delay, OR – 3.3–4.2, if the patient was hospitalized between 15 and 180 days from the onset, OR – 9.2 if admitted later than 6 months after the onset). The area under the curve of operational characteristics – 0.92 (95 % CI 0.89–0.94) proved the excellent quality of the prediction model and the strong link of this set of factors to the risk of incomplete functional recovery at the time of discharge.Conclusions. According to the results of univariate analysis, the risk of incomplete functional recovery and sustained disability after treatment is associated with a wide range of factors, such as stroke type and subtype, severity of neuro","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45262526","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-67-75
Y. Cherednychenko, A.Yu. Miroshnychenko, L. Dzyak, M. Zorin, N. Cherednychenko
A case of treating of 59 years old patient with a multifocal occlusive and stenotic lesion of the main arteries of the head is described. Patients has occlusions of both internal carotid arteries, left external carotid artery, right vertebral artery, severe stenosis in the initial segment of the left subclavian artery and severe stenosis in the ostium of the left vertebral artery, with cognitive impairment and coordination disorders.A single-session stenting of the stenosis in the ostium of left vertebral artery with balloon-expan-dable elution-stent with usage of the modified Szabo anchor technique and stenting of the stenosis in the initial segment of the subclavian artery with a balloon-expandable peripheral stent was performed. Stenoses are eliminated, all cerebral arteries of the vertebrobasilar basin and both carotid basins are supplied by the left vertebral artery.After 50 days, the patient’s neurological status was assessed and a computed tomographic perfusiography of the brain was performed. The cognitive status improved significantly (initially – 23 points on the MoCA scale, after the operation – 27 points), coordination disorders regressed. According to computed tomographic brain perfusion, there are increase in CBF (cerebral blood flow) above normal in all areas except for the area of stroke; an increase in CBV (cerebral blood volume) above normal, which is a reflection of arterioles vasodilation; increase in MTT (mean transit time) in all zones, which is a sign of collateral blood flow. Based on these data, it was concluded that further revascularization operations on the occluded cerebral arterial basins can lead to the hyperperfusion syndrome clinical manifestation. The performed endovascular stage of treatment was effective and sufficient to significantly improve the patient’s neurological and cognitive status and prevent the development of recurrent ischemic stroke.
{"title":"Endovascular treatment of a patient with multifocal occlusal-stenotic lesion of the head main arteries using a modified anchor stenting technique and confirming the efficacy and adequacy of treatment by controlling changes in cerebral hemoperfusion","authors":"Y. Cherednychenko, A.Yu. Miroshnychenko, L. Dzyak, M. Zorin, N. Cherednychenko","doi":"10.26683/2304-9359-2019-1(27)-67-75","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-67-75","url":null,"abstract":"A case of treating of 59 years old patient with a multifocal occlusive and stenotic lesion of the main arteries of the head is described. Patients has occlusions of both internal carotid arteries, left external carotid artery, right vertebral artery, severe stenosis in the initial segment of the left subclavian artery and severe stenosis in the ostium of the left vertebral artery, with cognitive impairment and coordination disorders.A single-session stenting of the stenosis in the ostium of left vertebral artery with balloon-expan-dable elution-stent with usage of the modified Szabo anchor technique and stenting of the stenosis in the initial segment of the subclavian artery with a balloon-expandable peripheral stent was performed. Stenoses are eliminated, all cerebral arteries of the vertebrobasilar basin and both carotid basins are supplied by the left vertebral artery.After 50 days, the patient’s neurological status was assessed and a computed tomographic perfusiography of the brain was performed. The cognitive status improved significantly (initially – 23 points on the MoCA scale, after the operation – 27 points), coordination disorders regressed. According to computed tomographic brain perfusion, there are increase in CBF (cerebral blood flow) above normal in all areas except for the area of stroke; an increase in CBV (cerebral blood volume) above normal, which is a reflection of arterioles vasodilation; increase in MTT (mean transit time) in all zones, which is a sign of collateral blood flow. Based on these data, it was concluded that further revascularization operations on the occluded cerebral arterial basins can lead to the hyperperfusion syndrome clinical manifestation. The performed endovascular stage of treatment was effective and sufficient to significantly improve the patient’s neurological and cognitive status and prevent the development of recurrent ischemic stroke.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46145588","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-76-80
P. Antosik, M. Filus, M. Błaszyk, R. Juszkat
Accidental carotid cannulation using a large-bore catheter is one of the complications of central venous catheter insertion, reported in 1 % of performed procedures. Management of arterial catheterization contains direct manual compression, endovascular treatment, and open surgical repair. Inadvertent arterial cannulation can lead to hemorrhage, pseudoaneurysm, arteriovenous fistula, stroke or death. Mechanical removal of thrombotic material is presently the most effective method of stroke treatment. Rapid and early restoration of blood flow is crucial for the improvement of the neurological condition. This report describes a case of a patient with signs of severe stroke after management of accidental carotid catheterization using balloon tamponade. Aspiration thrombectomy was successfully performed to manage acute ischaemia of the brain.
{"title":"Management of acute ischaemic stroke due to Sheldon catheter insertion into the right common carotid artery using the aspiration thrombectomy: a case report","authors":"P. Antosik, M. Filus, M. Błaszyk, R. Juszkat","doi":"10.26683/2304-9359-2019-1(27)-76-80","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-76-80","url":null,"abstract":"Accidental carotid cannulation using a large-bore catheter is one of the complications of central venous catheter insertion, reported in 1 % of performed procedures. Management of arterial catheterization contains direct manual compression, endovascular treatment, and open surgical repair. Inadvertent arterial cannulation can lead to hemorrhage, pseudoaneurysm, arteriovenous fistula, stroke or death. Mechanical removal of thrombotic material is presently the most effective method of stroke treatment. Rapid and early restoration of blood flow is crucial for the improvement of the neurological condition. This report describes a case of a patient with signs of severe stroke after management of accidental carotid catheterization using balloon tamponade. Aspiration thrombectomy was successfully performed to manage acute ischaemia of the brain.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42661449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-41-57
S. Litvak, L. Yakovenko
Objective – to establish the features of clinical presentation and to optimize surgical treatment of arterial aneurysms (AA) of the anterior cerebral artery–anterior connecting artery (ACA–AComA) complex.Materials and methods. The results of surgical treatment of 267 (100 %) patients with AA of the ACA–AComA complex during the period from 01.01.2011 till 31.12.2017 were analyzed. There were 143 (53.6 %) women and 124 (46.4 %) men. Microsurgical clipping was performed in 165 (61.8 %) cases, endovascular coiling in 122 (38.2 %) cases. The organization of the medical care, clinical and instrumental examinations, medical and surgical treatment was done according to the current protocols (the Decree of the Ministry of Health of Ukraine dated April 17, 2014, N 275, EBM Guidelines, 28.8.2017, Juha E. Jääskeläinen).Results. The AA rupture was diagnosed in 238 (89.2 %) patients. 181 (67.9 %) patients were hospitalized till the 28th day since AA rapture. The severity of the patients state according to the level of conscious during hospitalization: in conscious – 92 (34.4 %), obtunded – in 127 (47.6 %), stuporous – in 28 (10.5 %), comatose – 20 (7.5 %). The severity of subarachnoid hemorrhage (SAH) according to WFNS (World Federation of Neurological Surgeons) Grading Scale: grade I – in 63 (23.6 %) patients, grade II – in 43 (16.1 %) patients, grade III – in 78 (29.2 %) patients, grade IV – in 36 (13.5 %) patients, grade V – in 18 (6.8 %) patients. Altered mental status was found in 87 (32.6 %) patients, among them in 29 (10.8 %) patients with non-hemorrhagic presentation. Motor deficiency was diagnosed in 116 (43.4 %) patients, cranial nerve palsy – in 42 (15.7 %) patients, particular visual disturbances – in 28 (10.5 %) cases, oculomotor palsy – in 5 (1, 9 %) cases, visual and oculomotor disturbances – in 9 (3.3 %) cases.Subarachnoid hemorrhage with intracerebral hematoma was detected in 184 (77.3 %) patients. Localization of hematomas: frontal lobes – 161 (87.5 %) cases, corpus callosum – 15 (8.1 %) and/or septum pellucidum – 8 (4.4 %). The intraventricular hemorrhage was diagnosed in 81 (34 %) patients: 1–4 points according to Graeb score – in 32 (39.5 %) patients, 5–8 points – in 27 (33.3 %) patients, 9–12 points – in 22 (27.2 %) patients. Lateral or axial dislocation was found in 28 (11.8 %) cases. Cerebral vasospasm in acute period was observed in 59.7 % of patients, and in 19.3 % of patients in «cold» period.The localization of the AA of ACA–AComA complex (according to M.G. Yasargil): anterior – in 50 (18.7 %) cases, posterior – in 42 (15.7 %), superior – in 98 (36.7 %), inferior – in 35 (13.2 %), mixed projection – 42 (15.7 %) cases. Saccular aneurysms were found in 192 (71.9 %) patients, «complex» AA – in 75 (28.1 %). The size of AA in the most observations (252 (94.3 %)) was less than 15 mm. Hypoplasia or aplasia of one A1 segments of ACA we revealed in 45 (18.9 %) cases.Comorbid conditions: hypertension (HTN) – in 175 (65.5 %) patients, the comb
{"title":"Results of the surgical treatment of the aneurysms of anterior cerebral artery – anterior communicating artery complex","authors":"S. Litvak, L. Yakovenko","doi":"10.26683/2304-9359-2019-1(27)-41-57","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-41-57","url":null,"abstract":"Objective – to establish the features of clinical presentation and to optimize surgical treatment of arterial aneurysms (AA) of the anterior cerebral artery–anterior connecting artery (ACA–AComA) complex.Materials and methods. The results of surgical treatment of 267 (100 %) patients with AA of the ACA–AComA complex during the period from 01.01.2011 till 31.12.2017 were analyzed. There were 143 (53.6 %) women and 124 (46.4 %) men. Microsurgical clipping was performed in 165 (61.8 %) cases, endovascular coiling in 122 (38.2 %) cases. The organization of the medical care, clinical and instrumental examinations, medical and surgical treatment was done according to the current protocols (the Decree of the Ministry of Health of Ukraine dated April 17, 2014, N 275, EBM Guidelines, 28.8.2017, Juha E. Jääskeläinen).Results. The AA rupture was diagnosed in 238 (89.2 %) patients. 181 (67.9 %) patients were hospitalized till the 28th day since AA rapture. The severity of the patients state according to the level of conscious during hospitalization: in conscious – 92 (34.4 %), obtunded – in 127 (47.6 %), stuporous – in 28 (10.5 %), comatose – 20 (7.5 %). The severity of subarachnoid hemorrhage (SAH) according to WFNS (World Federation of Neurological Surgeons) Grading Scale: grade I – in 63 (23.6 %) patients, grade II – in 43 (16.1 %) patients, grade III – in 78 (29.2 %) patients, grade IV – in 36 (13.5 %) patients, grade V – in 18 (6.8 %) patients. Altered mental status was found in 87 (32.6 %) patients, among them in 29 (10.8 %) patients with non-hemorrhagic presentation. Motor deficiency was diagnosed in 116 (43.4 %) patients, cranial nerve palsy – in 42 (15.7 %) patients, particular visual disturbances – in 28 (10.5 %) cases, oculomotor palsy – in 5 (1, 9 %) cases, visual and oculomotor disturbances – in 9 (3.3 %) cases.Subarachnoid hemorrhage with intracerebral hematoma was detected in 184 (77.3 %) patients. Localization of hematomas: frontal lobes – 161 (87.5 %) cases, corpus callosum – 15 (8.1 %) and/or septum pellucidum – 8 (4.4 %). The intraventricular hemorrhage was diagnosed in 81 (34 %) patients: 1–4 points according to Graeb score – in 32 (39.5 %) patients, 5–8 points – in 27 (33.3 %) patients, 9–12 points – in 22 (27.2 %) patients. Lateral or axial dislocation was found in 28 (11.8 %) cases. Cerebral vasospasm in acute period was observed in 59.7 % of patients, and in 19.3 % of patients in «cold» period.The localization of the AA of ACA–AComA complex (according to M.G. Yasargil): anterior – in 50 (18.7 %) cases, posterior – in 42 (15.7 %), superior – in 98 (36.7 %), inferior – in 35 (13.2 %), mixed projection – 42 (15.7 %) cases. Saccular aneurysms were found in 192 (71.9 %) patients, «complex» AA – in 75 (28.1 %). The size of AA in the most observations (252 (94.3 %)) was less than 15 mm. Hypoplasia or aplasia of one A1 segments of ACA we revealed in 45 (18.9 %) cases.Comorbid conditions: hypertension (HTN) – in 175 (65.5 %) patients, the comb","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44181207","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-13DOI: 10.26683/2304-9359-2019-1(27)-12-20
D. Gunia, E. Ekvtimishvili, G. Basiladze
Objective – to improve treatment results of patients with ruptured brain aneurysms using follow-up cerebral digital subtraction angiography to avoid de novo or aneurismal regrow.Materials and methods. Analysis of follow-up cerebral digital subtraction angiography and treatment results of two patient (60 and 64-year-old females) with brain anterior communicated artery de novo aneurysm and regrowed aneurysm of an anterior communicated artery after microsurgical clipping.Results. Two patient underwent endovascular treatment of ruptured brain aneurysms after non follow-up cerebral digital subtraction angiography. In first case de novo aneurysm of anterior communicating artery and in second – regrowed aneurys of anterior communicating artery after surgical clipping. Both patients were discharged from the clinic in I and IV modified Rankin scale. Conclusions. Digital subtraction angiography follow-up of intracranial aneurysms treated by endovascular or microsurgical approach is important for the detection and prediction for the risk of bleeding (aneurysm recurrence and de novo aneurysm). There exist no guidelines on the frequency of monitoring and imaging modality to adopt and the monitoring is adapted on a case-by-case basis. Digital subtraction angiography is the gold standard for the evaluation of aneurysmal occlusion after coiling and microsurgical clipping and remains also necessary for evaluating other devices.
{"title":"Necessity of follow-up cerebral digital subtraction angiography after endovascular coiling or microsurgical cliping of ruptured intracranial aneurysms to exclude de novo or aneurysmal regrow and avoid its rupture: report of 2 cases","authors":"D. Gunia, E. Ekvtimishvili, G. Basiladze","doi":"10.26683/2304-9359-2019-1(27)-12-20","DOIUrl":"https://doi.org/10.26683/2304-9359-2019-1(27)-12-20","url":null,"abstract":"Objective – to improve treatment results of patients with ruptured brain aneurysms using follow-up cerebral digital subtraction angiography to avoid de novo or aneurismal regrow.Materials and methods. Analysis of follow-up cerebral digital subtraction angiography and treatment results of two patient (60 and 64-year-old females) with brain anterior communicated artery de novo aneurysm and regrowed aneurysm of an anterior communicated artery after microsurgical clipping.Results. Two patient underwent endovascular treatment of ruptured brain aneurysms after non follow-up cerebral digital subtraction angiography. In first case de novo aneurysm of anterior communicating artery and in second – regrowed aneurys of anterior communicating artery after surgical clipping. Both patients were discharged from the clinic in I and IV modified Rankin scale. Conclusions. Digital subtraction angiography follow-up of intracranial aneurysms treated by endovascular or microsurgical approach is important for the detection and prediction for the risk of bleeding (aneurysm recurrence and de novo aneurysm). There exist no guidelines on the frequency of monitoring and imaging modality to adopt and the monitoring is adapted on a case-by-case basis. Digital subtraction angiography is the gold standard for the evaluation of aneurysmal occlusion after coiling and microsurgical clipping and remains also necessary for evaluating other devices.","PeriodicalId":33226,"journal":{"name":"Endovaskuliarna neirorentgenokhirurgiia","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-06-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46024727","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：