Surgical embolectomy for large vessel occlusion of anterior circulation

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.

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.

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.

Stroke Microsurgical Thrombectomy Human Placenta Simulator

BACKGROUND

Stroke microsurgical cerebrovascular thrombectomy reports are limited, although this technique could be used in many centers as a primary treatment or a salvage intervention option. It requires great ability, so our aim is to describe and validate a stroke microsurgical thrombectomy ex vivo simulator with operative nuances analysis.

METHODS

Human placenta (HP) models simulated middle cerebral artery vessels with intraluminal thrombus to be microsurgically excised. Six neurosurgeons performed 1-mm and 2-mm longitudinal and transverse arteriotomy in different arteries to remove a 1.5-cm length thrombus. Validation through construct validity compared time to complete the task, complete vessel cleaning, vessel manipulation, vessel stenosis, and leakage in both techniques.

RESULTS

All 6 HP models reproduced with fidelity stroke microsurgical thrombectomy, so participants completed 24 sessions, 4 for each neurosurgeon on the same model in different arteries. Construct validity highlighted microsurgical technical difficulties with positive results obtained by parameters variation during performance. Transverse arteriotomy with 1-mm length had best results (P < 0.05) allowing complete thrombus removal, less stenosis, and minor leakage in abbreviated time.

CONCLUSIONS

A HP simulator can reproduce with high fidelity all stroke microsurgical thrombectomy part tasks. Transverse 1-mm arteriotomy followed by thrombectomy and 2 simple sutures can fulfill all quality assurance aspects in such intervention accordingly to training model, due to easier vessel opening, complete thrombus removal, no stenosis, and faster microsuture.

Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery

Background:

Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past.

Case Description:

A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit.

Conclusion:

Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.

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

BACKGROUND

Open microsurgical thrombectomy for acute intracranial large vessel occlusion (LVO) has been the subject of dozens of case reports and series. However, no clear indications exist to define its role in the management of acute ischemic stroke. Our aim was to review all the available data on open microsurgical thrombectomy, for both spontaneous as well as iatrogenic intracranial vessel occlusion, in terms of indication and results.

METHODS

Of the 390 articles screened, 33 were included after full text screening.

RESULTS

A total of 232 patients were reported, of whom 208 received microsurgical thrombectomy and 24 received bypass for large vessel occlusion. Patients were divided into a historic cohort (before 2002) and a recent cohort (articles published after 2002). Patients from the historic cohort were younger: median age, 55 years (interquartile range, 34-57 years) versus 69 years (interquartile range, 63-75 years) in the recent cohort (P < 0.01). The procedure was successful more often in the recent cohort (65% of patients in the historic cohort vs. 98% of patients in the recent cohort) and more patients experienced neurologic improvement (56% of patients in the historic cohort vs. 69% in the recent cohort).

CONCLUSIONS

In the era of endovascular thrombectomy, open microsurgical techniques might still play a role in highly selected patients. The reported patients show that microsurgical thrombectomy seems efficient and effective in improving patient outcome. Ideally, a multidisciplinary approach with vascular neurosurgeons trained and skilled in microvascular techniques is recommended.

Microsurgical embolectomy with superficial temporal artery-middle cerebral artery bypass for acute internal carotid artery dissection: A technical case report

Background:

Dissection of the internal carotid artery (ICA) is an important cause of stroke. Intravenous alteplase administration and mechanical thrombectomy have been strongly recommended for selected patients with acute ischemic stroke. However, the efficacy and safety of these treatments for ischemic stroke due to ICA dissection remain unclear. Here, we report a case of acute ICA dissection successfully treated by microsurgical embolectomy.

Case Description:

A 40-year-old man presented with sudden left hemiparesis and in an unconscious state, with a National Institutes of Health Stroke Scale score of 14. Preoperative radiologic findings revealed an ICA dissection from the extracranial ICA to the intracranial ICA and occlusion at the superior-most aspect of the ICA. A dissection at the superior-most aspect of the ICA occlusion could not be confirmed; therefore, a surgical embolectomy with bypass was initiated. It became apparent that the superior ICA occlusion was not due to dissection but rather to an embolic occlusion; therefore, we undertook a surgical embolectomy and cervical ICA ligation with a double superficial temporal artery-middle cerebral artery bypass. The postoperative course was uneventful and, at the 6-month follow-up, the Modified Rankin Scale score for this patient was 1.

Conclusion:

Surgical embolectomy with or without bypass can safely treat acute ischemic stroke due to an ICA dissection that cannot be distinguished between a dissecting occlusion and an embolic occlusion. Thus, it may be considered as an alternative option for patients in whom mechanical thrombectomy has failed or for those who are ineligible for mechanical thrombectomy.

Embolectomy Through Aneurysm Wall for Iatrogenic Occlusion of M1 Portion During Coil Embolization: Technical Note for Transaneurysmal Embolectomy

OBJECTIVE

We describe the technique for surgical "transaneurysmal" embolectomy in a patient with subarachnoid hemorrhage and multiple cerebral aneurysms who manifested large-vessel occlusion during coil embolization.

METHODS

An 84-year-old woman with subarachnoid hemorrhage and bilateral internal carotid artery (ICA)-posterior communicating artery and bilateral middle cerebral artery aneurysms (MCAs) was admitted to our institution. We performed clipping to the left ICA and MCAs; however, we could not find the rupture point of both aneurysms. We chose to treat 2 aneurysms on the other side by coil embolization. After complete coil embolization of a right ICA aneurysm, angiograms showed occlusion of the right MCA just proximal to an MCA aneurysm. Considering the risk of bleeding of an untreated MCA distal to the occlusion by endovascular thrombectomy, we performed open transaneurysmal embolectomy at the occlusion site and surgical clipping of the MCA. After cutting the aneurysmal wall, we inserted a suction tube into the cut surface of the aneurysm. The clot was gradually and completely pulled through the cut surface of the aneurysm. Finally, the aneurysm was completely clipped with titanium clips to preserve the M1 and M2 branches.

DISCUSSION

Different from usual surgical thrombectomy, suturing the vessel wall is not required for transaneurysmal embolectomy and the area of brain ischemia is confined. Aneurysms with the fragile wall may rupture during clearance of tissue on the aneurysmal surface, and suction may increase vessel damage.

CONCLUSION

Transaneurysmal thrombectomy may be useful and safe for large-vessel occlusion just distal to cerebral aneurysms.

Microsurgical Clipping of a Giant Middle Cerebral Artery Aneurysm with Successful Postoperative Endovascular Mechanical Thrombectomy for Emergent Treatment of Large Vessel Occlusion

BACKGROUND

Giant intracranial aneurysms (>25 mm) are uncommon. These lesions typically manifest clinically due to mass effect, acute hemorrhage, or thromboembolic events. To minimize the risk of poor clinical outcome, detailed operative planning and a consideration of all neurosurgical and endovascular techniques are essential before proceeding with microsurgical clipping of ruptured giant aneurysms.

CASE DESCRIPTION

We describe a case involving a 15-year-old male with a ruptured giant middle cerebral artery aneurysm treated with microsurgical clipping. After clip application, poor distal flow was demonstrated intraoperatively, and emergent angiography demonstrated an M1 occlusion with thrombus. A salvage procedure using endovascular mechanical thrombectomy reestablished distal flow resulting in a good neurologic outcome.

CONCLUSIONS

To our knowledge, this is the first case report to describe microsurgical clipping of an aneurysm followed by successful postoperative endovascular mechanical thrombectomy.

Emergent surgical embolectomy in conjunction with cervical internal carotid ligation and superficial temporal artery-middle cerebral artery bypass to treat acute tandem internal carotid and middle cerebral artery occlusion due to cervical internal carotid artery dissection

Background:

Acute tandem cervical dissecting internal carotid artery (ICA) occlusion and intracranial embolic middle cerebral artery (MCA) occlusion can be devastating, and the optimal treatment strategy for this condition has not been established yet.

Case Description:

A 45-year-old male presented with aphasia and right hemiparesis preceded by neck pain. Computed tomography showed a high-density signal along the left MCA, suggesting extensive emboli. Magnetic resonance angiography demonstrated tandem occlusion of the left cervical ICA and intracranial MCA with minimal diffusion-weighted imaging lesion. Emergent surgical embolectomy was performed, and long intracranial MCA emboli were retrieved with collateral cross-flow restoration. The cervical ICA was exposed, and dissection was confirmed. The cervical ICA was ligated, and superficial temporal artery (STA)-MCA anastomosis was added. Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia. At the 6^th postoperative month, follow-up studies demonstrated a robustly patent STA-MCA bypass and no additional ischemic lesion on T2-weighted imaging.

Conclusions:

Surgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.

Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery

BACKGROUND

Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy.

METHODS

We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes.

RESULTS

Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively.

CONCLUSIONS

Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.

Surgical embolectomy for internal carotid artery terminus occlusion

The aim of this study was to assess the efficacy and safety of surgical embolectomy for internal carotid artery terminus (ICA-T) occlusion. Twenty-five consecutive patients with acute ischemic stroke attributed to embolic ICA-T occlusion who underwent surgical embolectomy were retrospectively reviewed. Twenty-four patients were examined based on magnetic resonance imaging, with one patient included based on a computed tomography scan. Recanalization rate, recanalization time, complications, National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month, and modified Rankin Scale (mRS) at 3 months were evaluated. Final recanalization status was Thrombolysis in Myocardial Infarction (TIMI) 3 in 24 patients (96 %). Median recanalization time from symptom onset and from start of surgery was 281 and 79 min, respectively. Two patients (8 %) had major hemorrhagic complications related to surgery. Seventeen patients (68 %) demonstrated NIHSS score improvement of more than 10 points at 1 month. At 3 months, eight patients (32 %) were mRS 0-2, five patients (20 %) were mRS 3, and three patients (12 %) had died. Surgical embolectomy for ICA-T occlusion demonstrated a high complete recanalization rate and should be reconsidered as an additional therapeutic strategy to overcome this devastating situation.

Complex interventional treatment in a patient with atrial fibrillation and stroke caused by large carotid artery thrombus: a case report

Background

The treatment option for acute ischaemic stroke depends on the duration of symptoms, the dynamics of neurological condition changes, the aetiology, type of stroke, as well as the results of angiographic and neuroimaging tests.

Case presentation

A 60-year-old male patient presented with progressive left hemisphere stroke caused by extensive cardiogenic embolism of the common carotid artery and a thrombus closing the internal carotid artery from its ostium to the level of its intracranial division. The complex revascularisation therapy involving surgical embolectomy of the common carotid artery, thrombectomy of the internal carotid artery and intra-arterial thrombolysis has led to the improvement of arterial patency and has countered the progression of acute cerebral ischaemia.

Conclusion

Emergency carotid embolectomy together with thrombectomy and local thrombolytic rt-PA treatment may be a reasonable rescue therapy for carefully selected patients with large-vessel acute stroke. Further research is needed to establish the advantages and safety of surgical thrombectomy in patients with acute embolic occlusion of the carotid artery and ineffectiveness of or contraindications for systemic thrombolytic treatment.

Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture

Acute internal carotid artery (ICA) terminus occlusion is associated with extremely poor functional outcomes or mortality, especially when it is caused by plaque rupture of the cervical ICA with engrafted thrombus that elongates and extends into the ICA terminus. The goal of this study was to evaluate the efficacy and safety of surgical embolectomy in conjunction with carotid endarterectomy (CEA) for acute ICA terminus occlusion associated with cervical plaque rupture resulting in tandem occlusion. A retrospective review of medical records was performed. Clinical and radiographic characteristics were evaluated, including details of surgical technique, recanalization grade, recanalization time, complications, modified Rankin Scale (mRS) score at 3 months, and National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month. Three patients (mean age 77.3 years; median presenting NIHSS Score 22, range 19–26) presented with abrupt tandem occlusion of the cervical ICA and ICA terminus and were selected for surgery after confirmation of embolic high-density signal at the ICA terminus on CT and diffusion-weighted imaging (DWI)/magnetic resonance angiography (MRA) mismatch. All patients underwent craniotomy for surgical embolectomy of the ICA terminus embolus followed by cervical exposure, aspiration of long residual proximal embolus ranging from the cervical to cavernous ICA, and removal of ruptured unstable plaque by CEA. Postoperative MRA demonstrated Thrombolysis In Myocardial Infarction (TIMI) 3 recanalization in all patients (100%) without evidence of additional infarction according to DWI. Mean recanalization time from hospital arrival was 234 minutes and from start of surgery, 151 minutes. Serial postoperative CT and MRI studies showed no symptomatic hemorrhage, brain edema, or progression of infarction. The patients' mRS scores at 3 months were 3, 3, and 1. All 3 patients demonstrated marked improvements in NIHSS scores (median 17 points; range 13–23 points) at 1 month. Considering the dismal prognosis associated with ICA terminus occlusion, especially when accompanied by cervical plaque rupture, emergent surgical embolectomy in conjunction with CEA might be an effective and decisive treatment option with a high complete recanalization rate and acceptable safety profile.

Stroke in patients with occlusion of the internal carotid artery: options for treatment

Ischemic stroke may occur in patients in whom vascular imaging shows the ipsilateral internal carotid artery (ICA) to be occluded. In younger patients this is often due to carotid artery dissection, while in older people this most likely results from cardiac embolism or thrombosis secondary to high-grade stenosis at the carotid bifurcation. Interventional techniques aim at recanalization of the carotid artery for early restoration of cerebral blood flow and secondary prevention of future strokes. In chronic ICA occlusion the ischemic infarct may be related to hemodynamic compromise. In this situation, extracranial-intracranial bypass surgery was introduced, but its role remains still unclear. Ischemic stroke may also occur in patients with a chronic occlusion of the contralateral ICA. This situation demands the usual stroke treatment, but surgical and neuroradiological interventions face a higher risk than unilateral vascular pathology. Medical treatment supports stroke prevention in carotid artery occlusion.

Emergent surgical embolectomy for middle cerebral artery occlusion due to carotid plaque rupture followed by elective carotid endarterectomy

Embolic intracranial large artery occlusion with severe neurological deficit is associated with an extremely poor prognosis. The safest and most effective treatment strategy has not yet been determined when such emboli are associated with unstable proximal carotid plaque. The authors performed emergent surgical embolectomy for left middle cerebral artery (MCA) occlusion, and the patient experienced marked neurological recovery without focal deficit and regained premorbid activity. Postoperative investigation revealed “vulnerable plaque” of the left internal carotid artery without apparent evidence of cardiac embolism, such as would be seen with atrial fibrillation. Specimens from subsequent elective carotid endarterectomy (CEA) showed ruptured vulnerable plaque that was histologically consistent as a source of the intracranial embolic specimen. Surgical embolectomy for MCA occlusion due to carotid plaque rupture followed by CEA could be a safer and more effective alternative to endovascular treatment from the standpoint of obviating the risk of secondary embolism that could otherwise occur as a result of the manipulation of devices through an extremely unstable portion of plaque. Further, this strategy is associated with a high probability of complete recanalization with direct removal of hard and large, though fragile, emboli.

Surgical embolectomy for middle cerebral artery occlusion after thrombolytic therapy: A report of two cases

Background:

Occlusion of the intracranial main trunk results in a poor functional outcome and a high mortality rate. Accordingly, some revascularization procedures such as intravenous administration of recombinant tissue plasminogen activator (rt-PA), endovascular surgery, or surgical embolectomy in the very acute stage have been attempted.

Case Description:

We describe two patients with middle cerebral artery occlusion due to cardiogenic embolism. One patient was subjected to surgical embolectomy shortly after intravenous rt-PA and the other was subjected to same after intra-arterial urokinase. Complete recanalization without new cerebral infarction territory was achieved in both patients.

Conclusion:

Based on our experience, we think that surgical embolectomy is an effective and safe procedure and should be attempted when no response to early thrombolytic therapy is obtained.

The Anterior Temporal Approach for Microsurgical Thromboembolectomy of an Acute Proximal Posterior Cerebral Artery Occlusion

BACKGROUND:

In a short window of time, intravenous and intra-arterial thrombolysis is the first treatment option for patients with an acute ischemic stroke caused by the occlusion of one of the major brain vessels. Endovascular treatment techniques provide additional treatment options. In selected cases, high revascularization rates following microsurgical thromboembolectomy in the anterior circulation were reported. A technical note on successful thromboembolectomy of the proximal posterior cerebral artery has not yet been published.

OBJECTIVE:

To describe the technique of microsurgical thromboembolectomy of an acute proximal posterior cerebral artery occlusion and the brainstem perforators via the anterior temporal approach.

METHODS:

The authors present a technical report of a successful thromboembolectomy in the proximal posterior cerebral artery. The 64-year-old male patient had an acute partial P1 thromboembolic occlusion, with contraindications for intravenous recombinant tissue plasminogen activator. The patient underwent an urgent microsurgical thromboembolectomy after a frontotemporal craniotomy.

RESULTS:

The postoperative computerized tomography angiography showed complete recanalization of the P1 segment and its perforators, which were previously occluded. The early outcome after 1 month and 1 year follow-ups showed improvement from modified Rankin scale 4 to modified Rankin scale 1.

CONCLUSION:

Microsurgical thromboembolectomy can be an effective treatment option for proximal occlusion of the posterior cerebral artery in selected cases and experienced hands. Compared with endovascular treatment, direct visual control of brainstem perforators is possible.