Open Microvascular Thrombectomy for Acute Intracranial Large Vessel Occlusion: Microsurgery in the Endovascular Thrombectomy Era

Correspondence: Microsurgical thrombectomy: Where the ancient art meets the new era

Surgical thrombectomy remains a feasible technique in an accurately selected patient population with large vessel occlusion, even though endovascular mechanical thrombectomy is the gold standard. It especially warrants consideration in cases where the endovascular approach is unfeasible or fails. The current extension in the therapeutic window of time in mechanical thrombectomy also provides opportunities to open thrombectomy. To support our view, we present a case of a patient who suffered an ischemic stroke. Intravenous thrombolysis proved ineffective and mechanical thrombectomy was impossible due to extreme tortuosity of the internal carotid artery. Therefore, surgical thrombectomy was performed. The patient underwent successful recovery and states a great satisfaction. To improve efficiency and outcomes, a properly organised and trained surgical team with plentiful neurovascular experience is necessary. Finally, open thrombectomy is the most effective approach to completely restore luminal patency compared to the endovascular approaches yet risks due to the operation should be taken into account.

Delayed microsurgical revascularization in an acute ischemic stroke based on perfusion study

A 58-year-old patient presented with a severe neurological deficit due to a stroke caused by an occlusion of the left internal carotid artery siphon. Standard treatment failed and neurosurgical consult was delayed. Because of a favorable perfusion imaging finding, microsurgical revascularization via an extra-intracranial bypass (left superficial temporal artery - left middle cerebral artery) was performed 36 hours after the onset of the symptoms. The outcome of the patient was favorable. The authors want to emphasize the need to actively seek patients with a severe neurological deficit and still viable brain tissue. The time window and treatment alternatives are discussed.

2-1-2 Stroke microsurgical thrombectomy technique as a tertiary/salvage treatment option

BACKGROUND

Microsurgical thrombectomy (MST) has been used for many years in few stroke cases without any prospective randomized study, nor detailed systemized technique description. As many centers worldwide are recruited for stroke thrombectomy availability, MST might increase in the near future either as a tertiary or salvage treatment option. A straightforward surgical plan is mandatory empowering a safe, efficient, and rapid neurosurgical operation, so our aim is to describe the 2-1-2 microsurgical technique.

METHODS

Three patients presented at emergency department with large stroke not suitable to venous thrombolysis and/or mechanical thrombectomy due to late arrival time and endovascular suite technical problems. They were referred to 2-1-2 MST after imaging showed brain collaterals on head angio-CT scan and ASPECTS greater than 6 points. The procedure comprised 2 insulin needle punctures in the target artery, 1mm micro-scissor transverse arteriotomy, milk thrombus removal and 2 simple sutures micro stitches. Sixty days clinical follow-up and brain imaging control provided data results.

RESULTS

All patients treated with 2-1-2 MST technique had complete thrombus removal by precise surgical maneuvers avoiding surgeons unplanned and insecure movements to reduced operation time. Head angio-CT scan evidenced complete cerebrovascular circulation re-flow with clinical improvements in 60 days follow-up without complications or hospital readmissions.

CONCLUSIONS

2-1-2 MST technique can be rapidly and efficaciously performed in a systemized manner offering a tertiary or salvage technique for acute stroke treatment. Specific microsurgical training is mandatory to accomplish this treatment and larger studies are necessary to confirm our hypothesis.