Fragmental or Massive Embolization in Cardiogenic Stroke Caused by Nonvalvular Atrial Fibrillation

Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion

BACKGROUND

Acute extracranial internal carotid artery (ICA) occlusion by a huge cardiogenic embolus is rare, but can be catastrophic.

METHODS

Seven patients with acute ischemic stroke due to embolic occlusion of extracranial ICA who underwent emergent cervical surgical embolectomy were retrospectively reviewed. Diagnosis was made in six patients with magnetic resonance imaging (MRI) with optional digital subtraction angiography (DSA), while computed tomography (CT) and DSA were used in one patient with an implanted pacemaker. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month were evaluated.

RESULTS

Complete recanalization was obtained in seven patients (100 %). Median recanalization time from symptom onset and from start of surgery was 402 and 40 min, respectively. All seven patients showed severe left ventricular hypertrophy (LVH) according to an increased cardiothoracic ratio (CTR) ≥50 %. Complications included recurrence of cardioembolic stroke with the right middle cerebral artery occlusion, minimal expansion of infarction, and aggravation of heart failure, each in one patient, respectively. Four (57.1 %) patients had a history or postoperative recurrence of cardioembolic stroke. Median NIHSS at 1 month was 2 (range, 0-30). Median mRS at 3 months was 2 (range, 0-5). Five patients (71.4 %) had a favorable outcome (mRS2).

CONCLUSIONS

Cervical surgical embolectomy for acute extracranial ICA occlusion resulted in a high complete recanalization rate with an acceptable safety profile. A possible association between severe cardiac illness and huge embolus occluding proximal large artery was suggested.

Sudden coma from acute bilateral m1 occlusion: successful treatment with mechanical thrombectomy

We report a case with acute small infarct of the left middle cerebral artery in a 72-year-old man with atrial fibrillation documented by MRI and MR angiography. One hour later, he lost consciousness and CT with CT angiography revealed bilateral hyperdense middle cerebral arteries due to occlusion of the M1 segments. Mechanical thrombectomy of the right middle cerebral artery was successfully performed. During that time, thrombosis on the left side had progressed to carotid T occlusion, which was recanalized as well. The patient had a good outcome with slight aphasia and mild paresis of the left hand and could be transferred to rehabilitation 2 weeks later.