Results of the Treatment and Evaluation of Quality of Life in Patients with High-Grade Cerebral Arteriovenous Malformations after Endovascular Embolization

Treatment options for cerebral arteriovenous malformations (cAVMs) may include radiosurgery, endovascular embolization, microsurgical removal, or a combination thereof. However, treatment of high-grade (Spetzler–Martin grades IV and V) cAVMs remains extremely challenging when aiming complete occlusion. The aim. To study the safety of the endovascular embolization in patients with high-grade cAVMs and its impact on the quality of life (QoL). Materials and methods. Between 2012 and 2022, 174 patients with cAVMs were endovascularly treated at Research and Practical Center for Endovascular Neuroradiology of the National Academy of Medical Sciences of Ukraine with an average follow-up of more than 9 months. Of these patients, 11 (6.3%) and 6 (3.4%) had Spetzler–Martin grade IV and grade V cAVM, respectively. Outcomes after surgical procedures were assessed and QoL was evaluated using standardized EQ-5D-3L questionnaire. Results. Five (29.4%) patients had intracerebral hemorrhage, 6 (35.3%) had seizures, 5 (29.4%) had other non-hemorrhagic manifestations and 1 (5.9%) patient had a neurological deficit as a result of cerebral steal. In 17 patients, 28 embolization sessions were performed, and in nearly all of them (96%) N-butyl cyanoacrylate was used as the preferred embolic agent. There were no procedural complications. After embolization, three (17.6%) patients had neurologic deterioration (temporary in 2 patients and persistent in 1 patient). All the patients were alive at the nearest follow-up. After embolization, 2 (11.7%) patients had recurrent hemorrhage, but without additional morbidity. Two of the five patients after cAVM rupture had some degree of disability. With regard to non-hemorrhagic debut, 8 (72%) patients reported symptom reduction. QoL assessment with EQ-5D-3L questionnaire revealed that severe problems were present in 2 (33.3%) of 6 patients after intracerebral hemorrhage and 2 (18.2%) of 11 patients with non-hemorrhagic manifestation. The mean Visual Analogue Scale score for the hemorrhagic group was 76.4 ± 15 points, while the non-hemorrhagic group’s score was 85.2 ± 14 points. Conclusions. Endovascular embolization, which aims to occlude the bleeding site or improve cerebral steal with a manageable consequence profile, can be used safely in carefully selected patients with high-grade cAVMs. Our experience shows that QoL can be satisfactory in 3/4 of patients after high-grade cAVM embolization, and more data from real-world practice are highly needed to determine the best method and time for improving patient outcomes

О СОСТОЯНИИ ЗДРАВООХРАНЕНИЯ В РЕГИОНАХ СИБИРИ И ВЫПОЛНЕНИИ ПОСЛАНИЯ ПРЕЗИДЕНТА РОССИЙСКОЙ ФЕДЕРАЦИИ ФЕДЕРАЛЬНОМУ СОБРАНИЮ РОССИЙСКОЙ ФЕДЕРАЦИИ ОТ 12 ДЕКАБРЯ 2013 ГОДА

The aim of the study was to identify the key problems of regional health services in the Siberian Federal district and justification of the priority directions of their decision. For the first time using the method of expert estimations conducted a study of health problems in the Federal district, identified key issues, as well as justifies the priority directions of their decisions. The study was conducted on the basis of statistical materials of the health authorities of the regions of Siberian Federal district, as well as expert assessments. Identified key health issues and priorities of their decision. Based on the systematic work of the expert community and across government levels defined key for the regions of Siberia health problems and justify the priority directions of their solutions tailored to focus efforts in the social sphere, which will allow to coordinate policies in the health sector on the territory of the Siberian Federal district, which in turn, will increase its effectiveness.Целью исследования было определение ключевых проблем регионального здравоохранения в Сибирском федеральном округе (СФО) и обоснование приоритетных направлений их решения. Впервые с использованием метода экспертных оценок проведено изучение проблем здравоохранения в федеральном округе, выявлены ключевые проблемы, а также обоснованы приоритетные направления их решения. Исследование проведено на основе статистических материалов органов управления здравоохранением регионов СФО, а также экспертных оценок. Определены ключевые проблемы здравоохранения и приоритетные направления их решения. На основе системной работы экспертного сообщества и органов государственного управления разных уровней определены ключевые для регионов Сибири проблемы здравоохранения и обоснованы приоритетные направления их решения с учетом фокусных усилий в социальной сфере, что позволит скоординировать политику в сфере здравоохранения на территории СФО, что, в свою очередь, позволит повысить ее эффективность

The modern options of chronic hepatitis C antiviral therapy with daclatasvir: results of named patient program

Introduction. The options of antiviral therapy (AVT) in the stages of severe liver fibrosis and cirrhosis (LC) as well as in the patients with comorbidities for the long time were limited to the standard therapy by pegilated interferon (peg-IFN) in combination to ribavirin (RBV). Before official registration of interferon-free treatment modes in 2015 experience of the application was limited to clinical trials or treatment within early approach programs. Aim of investigation. To analyze the efficacy of PTV for chronic hepatitis C within the named patient program of expanded access to daclatasvir. Material and methods. Approval of Ministry of Healthcare of the Russian Federation to import of drugs was received for the treatment of 101 HCV-infected patients with compensated LC, who, been untreated had an urgent need for effective therapy, with estimated life expectancy less than 12 months, in 12 centers of the Russian Federation. The patients with 1b HCV genotype received treatment by combination of daclatasvir and asunaprevir 100 mg, patients with 2 and 3 HCV genotypes, and those with 1b HCV genotype after the liver transplantation received daclatasvir to sofosbuvir combination. Results. Sustained virologic response for 24 wks (SVR24) in early approach program was 89% (83 of 93) of patients with severe liver disease who urgently needed effective treatment with estimated life expectancy of less than 12 months if been untreated. In group of the patients receiving treatment mode of daclatasvir + asunaprevir the frequency of SVR24 achievement was 90%. Of 93 patients who underwent complete treatment course no severe adverse effects were registered. During treatment infrequent nonspecific adverse events, such as a headache and fatigue were observed. No significant elevation of alanine transaminase and aspartate aminotransferase activity, or bilirubin level were detected. Conclusions. Daclatasvir combination to asunaprevir or sofosbuvir demonstrated high efficacy, including that at treatment of patients with poor prognostic signs

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial

BACKGROUND: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. METHODS: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. FINDINGS: A primary outcome occurred in 84 (4.8%) patients assigned to surgery under general anaesthesia and 80 (4.5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0.94 [95% CI 0.70 to 1.27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. INTERPRETATION: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. FUNDING: The Health Foundation (UK) and European Society of Vascular Surgery

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial

Background: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. Methods: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. Findings: A primary outcome occurred in 84 (4·8%) patients assigned to surgery under general anaesthesia and 80 (4·5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0·94 [95% CI 0·70 to 1·27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. Interpretation: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. Funding: The Health Foundation (UK) and European Society of Vascular Surgery. © 2008 Elsevier Ltd. All rights reserved