Minimally invasive and rapid surgical embolectomy (MIRSE) as rescue treatment following failed endovascular recanalization for acute ischemic stroke

Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis

Background  Supraorbital eyebrow craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor and vascular pathologies. The purpose of this study was to investigate how patient cosmetic outcomes are affected by technique variations of this approach. Methods  PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to PRISMA guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used, and the primary end points were patient satisfaction and percentage of permanent cosmetic complications. Results  A total of 2,629 manuscripts were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Overall, 93.04 ± 11.93% of patients reported favorable cosmetic outcome following supraorbital craniotomy, and mean number of cases with permanent cosmetic complications was 6.62 ± 12.53%. We found that vascular cases are associated with more favorable cosmetic outcomes than tumor cases ( p  = 0.0001). Addition of orbital osteotomy or use of a drain is associated with adverse cosmetic outcomes ( p  = 0.001 and p  = 0.0001, respectively). The location of incision, size of craniotomy, utilization of an endoscope, method of cranial reconstruction, skin closure, use of antibiotics, and addition of pressure dressing did not significantly impact cosmetic outcomes ( p  > 0.05 for all). Conclusions  Supraorbital craniotomy is a minimally invasive technique associated with generally high favorable cosmetic outcomes. While certain techniques used in supraorbital keyhole approach do not pose significant cosmetic risks, utilization of an orbital osteotomy and the addition of a drain correlate with unfavorable cosmetic outcomes.

Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study

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.

Supraorbital Keyhole Craniotomy via Eyebrow Incision: A Systematic Review and Meta-Analysis

BACKGROUND

Supraorbital eyebrow keyhole craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor resection and aneurysm clipping. The purpose of this study is to provide a contemporary review on the outcomes related to this approach and to determine whether they vary with the type of pathology and the addition of an endoscope.

METHODS

PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used.

RESULTS

A total of 2629 manuscripts were identified. of those, 124 studies (8241 surgical cases) met the inclusion criteria. Mean total complication rate was 26.7 ± 25.7% and the mean approach-related mortality rate was 1.3 ± 2.8%. Technical success, defined as gross total tumor resection or complete aneurysm clipping, was achieved in 83.6 ± 21.5% of the cases. Vascular pathologies were associated with greater technical success, lower total complications, and longer length of hospital stay compared with tumor cases (P < 0.05 for all). For vascular cases, addition of the endoscope yielded lower technical success (P = 0.001) and lower complication rate (P = 0.041). The use of the endoscope for tumor pathologies did not affect technical success, complications, mortality, length of hospital stay, operative time, or reoperation rate (P > 0.05).

CONCLUSIONS

The supraorbital craniotomy via an eyebrow incision is a feasible minimally invasive approach with an overall high technical success rate for both vascular and tumor pathologies.

Microsurgical Embolectomy in the Current Era of Pharmacological and Mechanical (Endovascular) Thrombolysis-A Reappraisal

Introduction

Microsurgical embolectomy though is the oldest known recanalization technique is being dismissed in favor of the latest mechanical endovascular techniques for the management of acute large vessel occlusion.

Aim and Objective

We aim to highlight the role of microsurgical embolectomy in the current era of pharmacological and mechanical (endovascular) thrombolysis.

Methods

An outline of the microsurgical embolectomy technique is described along with its current indications, advantages, and disadvantages.

Results

It carries higher complete (TICI 3) revascularization rates with lower risk of distal embolic events especially in cases with high clot burdens; but is more labor-intensive and has longer reperfusion time in comparison to endovascular methods along with the requirement of highly skilled neurovascular surgeons to perform it quickly.

Conclusion

Microsurgical embolectomy is an important indispensable recanalization technique in the armamentarium of vascular neurosurgeons.

Diminishing returns with successive device passes in mechanical thrombectomy for stroke

BACKGROUND

Multiple device passes are associated with complications and poor functional outcomes following mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO).

OBJECTIVE

To characterize the relationship between number of device passes, complications, angiographic outcomes, and clinical outcomes in MT for ELVO.

METHODS

This is a single-center, retrospective cohort study. Individual device passes for MT were evaluated for any change in Thrombolysis in Cerebral Infarction (TICI) score, successful revascularization (TICI 2b or 3), and complications. Outcomes were compared among groups requiring multiple passes with various cut-off points. Risk factors for unfavorable clinical outcome [90 day modified Rankin Scale > 2] were assessed using multivariate analysis.

RESULTS

Successful revascularization was achieved in 75% of 163 patients and 36% required only one device pass. After the second pass, the likelihood of angiographic improvement significantly decreased (p < 0.001). Using multiple cut-off points, higher post-procedural NIHSS scores, mortality rates, and unfavorable 90-day outcomes were associated with a greater number of passes. Multivariate analysis revealed ICA thrombus (comparison: M2, OR: 25, 95% CI 2-275, p = 0.01) and failed revascularization (OR: 68, 95% CI 3.12-1489, p = 0.01) as the only significant predictors of unfavorable clinical outcome. Nonetheless, the likelihood of favorable clinical outcome was higher in patients with an ICA occlusion who were revascularized in < 2 vs. ≥ 2 (44 vs 4%, p = 0.01) or < 3 vs. ≥ 3 (32 vs. 0%, p = 0.02) passes.

CONCLUSION

The likelihood of angiographic improvement in patients with ELVO significantly decreases after the second pass. A greater number of passes is associated with worsened clinical outcomes.

When the fat hits the brain-salvage STA-MCA bypass for an intracranial ICA occlusion due to a fat embolus

Background

Large fat embolus is a rare but potential reversible cause of ischaemic stroke.

Methods and results

We describe the neurosurgical management of a complete right internal carotid artery occlusion due to a large fat embolus, caused by a mitral valve replacement.

Conclusion

Knowledge of acute cerebral ischaemia due to large fat embolism and its hallmark 'hypodense artery' is mandatory. Extracranial to intracranial bypass is a feasible rescue treatment after failure of endovascular embolectomy.

Supraorbital Keyhole Approach for Intracranial Aneurysms : Transitioning from Concerns to Confidence

For surgical minimalism to reduce iatrogenic traumatization, a supraorbital keyhole approach has already been successfully applied to treat many unruptured anterior circulation aneurysms. However, using this minimal approach also raises several technical concerns due to the small cranial opening and cosmetic impact of a facial incision. Yet, such technical limitations can be overcome by using favorable surgical indications, slender surgical instruments, and optimized surgical techniques, while excellent cosmetic outcomes can be achieved using a short skin incision located <1 cm from the supraorbital margin, reconstruction of any bone defects around the bone flap, and meticulous wound closure. Thus, given such reassuring surgical results, in terms of the clipping status, neurological effects, and cosmetic outcomes, any concerns can be transitioned into confidence.

Intradural Procedural Time to Assess Technical Difficulty of Superciliary Keyhole and Pterional Approaches for Unruptured Middle Cerebral Artery Aneurysms

Objective

This study used the intradural procedural time to assess the overall technical difficulty involved in surgically clipping an unruptured middle cerebral artery (MCA) aneurysm via a pterional or superciliary approach. The clinical and radiological variables affecting the intradural procedural time were investigated, and the intradural procedural time compared between a superciliary keyhole approach and a pterional approach.

Methods

During a 5.5-year period, patients with a single MCA aneurysm were enrolled in this retrospective study. The selection criteria for a superciliary keyhole approach included : 1) maximum diameter of the unruptured MCA aneurysm <15 mm, 2) neck diameter of the MCA aneurysm <10 mm, and 3) aneurysm location involving the sphenoidal or horizontal segment of MCA (M1) segment and MCA bifurcation, excluding aneurysms distal to the MCA genu. Meanwhile, the control comparison group included patients with the same selection criteria as for a superciliary approach, yet who preferred a pterional approach to avoid a postoperative facial wound or due to preoperative skin trouble in the supraorbital area. To determine the variables affecting the intradural procedural time, a multiple regression analysis was performed using such data as the patient age and gender, maximum aneurysm diameter, aneurysm neck diameter, and length of the pre-aneurysm M1 segment. In addition, the intradural procedural times were compared between the superciliary and pterional patient groups, along with the other variables.

Results

A total of 160 patients underwent a superciliary (n=124) or pterional (n=36) approach for an unruptured MCA aneurysm. In the multiple regression analysis, an increase in the diameter of the aneurysm neck (p<0.001) was identified as a statistically significant factor increasing the intradural procedural time. A Pearson correlation analysis also showed a positive correlation (r=0.340) between the neck diameter and the intradural procedural time. When comparing the superciliary and pterional groups, no statistically significant between-group difference was found in terms of the intradural procedural time reflecting the technical difficulty (mean±standard deviation : 29.8±13.0 min versus 27.7±9.6 min).

Conclusion

A superciliary keyhole approach can be a useful alternative to a pterional approach for an unruptured MCA aneurysm with a maximum diameter <15 mm and neck diameter <10 mm, representing no more of a technical challenge. For both surgical approaches, the technical difficulty increases along with the neck diameter of the MCA aneurysm.

Clip-knotting technique for intracranial arterial suturing through deep and narrow surgical corridors-how I do it

BACKGROUND

One of the most difficult procedures through a deep and narrow surgical corridor is tying a knot following microsuturing, even though microvascular suturing is a fundamental technique for neurovascular surgeons.

METHODS

A novel technique replacing the conventional knot-tying method was devised. The proposed clip-knotting technique uses an aneurysm clip to hold both remaining ends of a thread that is sutured in a running manner.

CONCLUSIONS

The proposed clip-knotting technique can facilitate the microsuturing procedure for intracranial arterial repair in a deep and narrow operative field.