Abstract:

Introduction: more than 10 million ischemic strokes are recorded in the world every year - a disease, the mechanism of development of which is associated with impaired blood flow to the brain tissues, mainly due to embolism in intracranial arteries. One of treatment methods of ischemic stroke within the «therapeutic window», in the absence of contraindications, is systemic thrombolytic therapy. Thrombolytic therapy has a number of limitations and contraindications, including ongoing or occurring bleeding of various localization within a period of up to 6 months.

Aim: was to evaluate the possibility of performing and the effectiveness of «off-label» simultaneous selective thrombolytic therapy and uterine arteries embolization in a patient with acute ischemic stroke with multiple distal lesions of middle cerebral artery branches against the background of ongoing uterine bleeding.

Case report: patient S., 42 years old, was hospitalized to the pulmonary department for bronchial asthma treatment with the aim of preoperative preparation before extirpation of the uterus, against the background of menometrorrhagia. At one of days of hospitalization, patient suffered from acute dysarthria, right-sided hemiparesis. When performing multislice computed tomography and angiography, multiple occlusions were revealed in the distal segments (M3-M4) of the left middle cerebral artery. The patient underwent simultaneous selective thrombolytic therapy of the left middle cerebral artery and uterine artery embolization.

Results: in the next few hours of the postoperative period, the patient experienced regression of neurological deficit: symptoms of dysarthria were arrested, almost complete restoration of motor activity in the right extremities, residual slight asymmetry of the face; bleeding from uterine stopped.

The patient was discharged on the 16th day with a slight neurological deficit. The follow-up period is 18 months. Neurological status with minor deficits: slight asymmetry of facial muscles; the strength of muscles of right limbs is reduced to 4-4,5 points. Ultrasound: a significant decrease in the size of the uterus and myomatous nodes. Menstrual cycle is restored.

Conclusions: a wide range of angiographic instruments and skills of endovascular surgeons made it possible to perform «off-label» simultaneous intervention in a patient with ischemic stroke and multiple distal lesions of branches of the middle cerebral artery against the background of ongoing uterine bleeding and giant myoma. The use of methods of endovascular hemostasis makes it possible to stop bleeding by overcoming contraindications to thrombolytic therapy. The use of thrombolytic therapy within the «therapeutic window» allows regression of neurological deficits in patients with multiple distal cerebral artery lesions.

References 

1.     GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019; 18(5): 439-458.

https://doi.org/10.1016/S1474-4422(19)30034-1

2.     Клинические рекомендации по ведению больных с ишемическим инсультом и транзиторными ишемическими атаками. Москва; 2017: 92.

Clinical guidelines for the management of patients with ischemic stroke and transient ischemic attacks. Moscow; 2017: 92 [In Russ].

3.     Клинические рекомендации по проведению тромболитической терапии при ишемическом инсульте. Москва; 2015: 34.

Clinical guidelines for thrombolytic therapy in ischemic stroke. Moscow; 2015: 34 [In Russ].

4.     Chiasakul T, Bauer KA. Thrombolytic therapy in acute venous thromboembolism. Hematology Am Soc Hematol Educ Program. 2020; 1: 612-618.

5.     Yuan K, Zhang JL, Yan JY, et al. Uterine Artery Embolization with Small-Sized Particles for the Treatment of Symptomatic Adenomyosis: A 42-Month Clinical Follow-Up. Int J Gen Med. 2021; 14: 3575-3581.

6.     Клинические рекомендации: миома матки. Москва; 2020: 48.

Clinical guidelines: uterine fibroids. Moscow; 2020: 48 [In Russ].

Abstract:

Department of Obstetrics and Gynaecology of the Therapeutic and Moscow Faculties of Scientific Research Practical Laboratory of intracardiac and contrast methods of roentgenological studies under the Federal Facility Russian State Medical University of the Russian Ministry of Public Health, Moscow.

This article opens a new series of publications dedicated to a currently important issue of endovascular treatment of uterine myoma - uterine artery embolization (UAE). The authors presently possessing the most abundant hands-on experience in UAE in Russia, based on own experience and literature data discuss herein the most urgent problems related to UAE in treatment for uterine myoma and other obstetrical and gynaecological pathology. Amongst them are the problems of determining the indications for and contraindications to an intervention, outcomes of UAE (including that combined with other therapeutic methods), problems of optimization of the technique and development of technical procedures allowing for UAE to be performed virtually in any situation, as well as the problems related to selection of embolizing substances. The authors also give a detailed consideration to the so-called "myths" about UAE - currently existing negative views on certain aspects of intervention, which are based on outdated and inexact evidence. The authors draw a conclusion that endovascular methods are highly promising in obstetrical and gynaecological pathology.

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Abstract:

Comparative analysis of transradial and transfemoral approach for uterine artery embolization is presented.

Materials and methods: for the period from september 2013 to december 2014, 58 women underwent uterine artery embolization (UAE). Age varied from 25 to 49. Transradial approach (TRA) was used in 26 patients (44,8%), transfemoral approach (TFA) - in 32 patients (55,2%).

Results: uterine artery embolization was successful in all patients in both groups. Operation duration was 20,7 minutes in TRA group and 26,3 in TFA group (p>0,05). Mean number of used catheters was lower in TRA group (1,2 and 2,3 respectively p>0,02). In early post-operative period there was no complication in access place in TRA group, in 2 cases (7,7%) small subcutaneous hematomas were noted. They didn't require any special treatment. In TFA group, in 1 case (3.1%) it was noted the presence of hematoma, 5 cm in diameter, and in 4 cases (12,5%) - there were small subcutaneous hematomas that didn't require any special treatment. The usage of TRA is associated with a statistically significant reduction in the incidence of all parameters of discomfort, associated with UAE and improving the quality of life of patients in the early post-operative period compared with TFA. Significantly more often in patients with TRA group compared to the group TFA completely absent from the discomfort associated with the procedure (61.5% and 6.25%, respectively, p <0,001).

Conclusions: the use of TRA allowed to decrease an average of 29.6% of total duration of the intervention, decrease up to 51.5% of time spent on the uterine artery catheterization and 40.8% patient radiation dose. In addition, TRA allowed early mobilization of patients and reduced by 59% the incidence of discomfort associated with the UAE.  

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