Cryptogenic stroke. Part 2: paradoxical embolism

Cryptogenic stroke (CS) is defined as a subtype of stroke associated with a heterogeneous group of pathogenetic mechanisms that remained undetermined in the course of advanced diagnostic research. One third or fourth of the ischemic strokes is cryptogenic. Paradoxical embolism is considered the important cause of cryptogenic stroke and transient ischaemic attack (TIA) in young patients. It may occur via the following: patent foramen ovale (PFO), atrial septal defect (ASD), and pulmonary arteriovenous malformation (PAVM). When interviewing patients with suspected paradoxical embolism to obtain their health history, a practitioner should consider factors associated with Valsalva maneuvers, deep vein thrombosis/PE or predisposing conditions or situations, as well as symptoms of hereditary hemorrhagic telangiectasia (telangiectasia of the skin and mucous membranes, hemorrhagic syndrome) and pulmonary arteriovenous malformations (PAVMs) (shortness of breath, hemoptysis). If paradoxical embolism is suspected, it is necessary to conduct a stepwise diagnostic search, including transcranial Doppler ultrasound with bubble test, contrast-enhanced transesophageal echocardiography, and CT angiopulmonography. Diagnosis of relevant clinical conditions involves a search of atrial tachyarrhythmias, deep vein thrombosis, and thrombophilia. As the pathogenetic role of ASD and PAVMs in the development of embolic cryptogenic stroke is beyond doubt, the clinical significance of PFO should be determined taking into account several factors, including the presence of deep vein thrombosis/PE, the severity of the right-left shunt, the presence of ASD, the RoPE score, and detection of thrombophilia. The secondary prevention techniques of ischemic stroke or TIA with underlying PFO should be selected on a case-by-case basis, depending on the clinical significance of the anomaly, comorbid pathology, life expectancy of the patient: endovascular occlusion, anticoagulant or antiplatelet therapy. The secondary prevention with underlying ASD and LAVM includes surgical techniques such as endovascular occlusion or open surgery followed by monitoring of their effectiveness.

Choice of X-ray surgical tactics for the treatment of venogenic erectile dysfunction in patients with pelvic varicose veins

The aim of the study was to develop an interventional approach for X-ray endovascular occlusion of the periprostatic plexus veins in patients with venogenic erectile dysfunction by systematizing X-ray phlebographic images obtained by standard dynamic pharmacocavernosography and dynamic multispiral computed cavernosography.Materials and methods. A comprehensive examination was carried out in 192 patients with venous erectile dysfunction. The age of the patients ranged from 19 to 66 (36.5 ± 0.73) years. The indication for occlusion of the veins of the periprostatic plexus was a combination of erectile dysfunctions on the IIEF-5 scale from 5 to 20 points and pathological venous drainage from the proximal cavernous bodies of the penis.Results. According to the Doppler ultrasound of the scrotum organs, TRUS of the prostate and the veins of the periprostatic plexus, all patients were diagnosed with pelvic varicose disease as a simultaneous combination of varicose veins of the gonadal veins and veins of the pelvic organs. Standard dynamic pharmacocavernosography was performed in 96 patients with erectile dysfunction. Pathological venous drainage was detected in 79 patients: proximal type - in 68 (86.0 %) of cases, distal type - in 4 (5.1 %) of cases and mixed type - in 7 (8.9 %) of cases. Periprostatic plexus vein occlusion was performed in 20 patients with venogenic erectile dysfunction with proximal pathological venous drainage. Complete disappearance of complaints of erectile dysfunction 6 months after X-ray surgical occlusion of the periprostatic plexus veins was noted in 81.0 % of cases (an increase in the index on the IIEF-5 scale from 12.7 ± 0.9 to 19.8 ± 0.9 points). The discrepancy between the data on the presence of venous leakage according to the results of standard pharmaco-Doppler sonography and the data on its absence according to the results of dynamic pharmacocavernosography in 19 patients determined the indications for dynamic multispiral computed pharmacocavernosography. The implementation of dynamic multispiral computed pharmacocavernosography made it possible to improve the visualization of variants of pathological venous outflow into the periprostatic venous plexus and the veins of the small pelvis from the cavernous bodies of the penis and to offer our own X-ray anatomical classification.Conclusion. The most common type of pathological venous drainage is its proximal type (86.0 % of cases). X-ray surgical occlusion of the veins of the periprostatic plexus is an effective method for the treatment of venogenic erectile dysfunction. Visualization of X-ray phlebographic images of the small pelvis during dynamic multispiral computed cavernosography with 3D reconstruction surpasses the results of standard dynamic pharmacocavernosography in the diagnosis of proximal, distal and mixed types of pathological venous drainage from the corpora cavernosa of the penis. Dynamic multispiral computed pharmacocavernosography with 3D reconstruction allows to determine the shape of the pathological venous drainage of the proximal type and determines the choice of antegrade or retrograde method of X-ray endovascular occlusion of the peripheryprostatic plexus veins in patients with venogenic erectile dysfunction.

Endosurgical treatment of traumatic inferior gluteal artery pseudoaneurysm in adolescent

Inferior gluteal artery pseudoaneurysms are rare, and most of the cases are due to blunt (pelvic fractures, femur’s dislocations) or penetrating trauma. Herein, we present a case of traumatic blunt rupture of an inferior gluteal artery pseudoaneurysm in adolescent 15th years old. Patient went through the complex examination and endosurgical treatment: endovascular occlusion of inferior gluteal artery and endoscopic evacuation of the large hematoma. Patient in short time came back to his ordinary live and sport.