J Clin Neurol.  2011 Sep;7(3):159-163. 10.3988/jcn.2011.7.3.159.

Emergency Microsurgical Embolectomy for the Treatment of Acute Intracranial Artery Occlusion: Report of Two Cases

• Kim DW
• Jang SJ
• Kang SD

• KMID: 2287632
• DOI: http://doi.org/10.3988/jcn.2011.7.3.159

Abstract

BACKGROUND
The main treatment for acute arterial ischemic stroke is intravenous or intra-arterial thrombolysis within a particular time window. Endovascular mechanical embolectomy is another treatment option in the case of major artery occlusion. Endovascular mechanical embolectomy is a useful technique for restoring blood flow in patients with large-vessel occlusion, and especially in those who are contraindicated for thrombolytics or in whom thrombolytic therapy has failed.
CASE REPORT
We report herein two cases of emergency microsurgical embolectomy for the treatment of acute middle cerebral artery and internal carotid artery occlusion as an alternative treatment for major artery occlusion.
CONCLUSIONS
Emergency microsurgical mechanical embolectomy may be an alternative treatment option for restoring blood flow in selected patients with large-vessel acute ischemic stroke.

Keyword

acute ischemic stroke; large-vessel occlusion; microsurgical embolectomy; alternative treatment

MeSH Terms

Arteries
Carotid Artery, Internal
Embolectomy
Emergencies
Humans
Middle Cerebral Artery
Stroke
Thrombolytic Therapy

Figure

• 

  Fig. 1 Case 1. A: Cerebral angiography 5 months prior to the most recent admission showing left cervical internal carotid artery (ICA) stenosis with intraluminal atheroma (arrowhead). B and C: Admission brain CT scans demonstrating a high-density spot at the carotid and Sylvian cistern (arrow) and revealing no abnormalities except for an old localized cerebral infarction in the left temporoparietal lobe along the middle cerebral artery (MCA) territory. D and E: Diffusion and perfusion brain MRI showing diffusion-perfusion mismatch with the finding of acute cerebral infarction and delay of time to peak in the left MCA territory. F: Left ICA angiogram, anteroposterior view, disclosing a left terminal ICA occlusion ("T" occlusion).

• 

  Fig. 2 Case 1. A and B: Intraoperative photographs showing the occluded terminal ICA. Asterisk indicates the embolus; arrowhead, arteriotomy site. C: Postoperative left ICA angiogram, anteroposterior view, revealing successful ICA recanalization and mild M1 stenosis at the arteriotomy site (arrow). ICA: internal carotid artery.

• 

  Fig. 3 Case 2. A: Right ICA angiogram, anteroposterior view, showing a right M2 occlusion. B: Right ICA angiogram, after injection of urokinase, revealing recanalization of the M2 branch. C: Follow-up brain CT scan demonstrating an acute subdural hematoma at the left frontotemporoparietal area with a mild mass effect. ICA: internal carotid artery.

• 

  Fig. 4 Case 2. A: Brain CT angiography (CTA) on the ninth hospital day revealing a right MCA occlusion. B and C: Intraoperative photographs showing the occluded MCA. Asterisk indicates the embolus. D: Postoperative brain diffusion MRI showing a high signal intensity at the right periventricular area (arrow). E: Follow-up CTA showing sufficient blood flow in the right MCA.

Reference

1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995. 333:1581–1587.

2. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. Prolyse in Acute Cerebral Thromboembolism. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. JAMA. 1999. 282:2003–2011.

3. Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: a guideline from the American heart association/American stroke association stroke council, clinical cardiology council, cardiovascular radiology and intervention council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: the American academy of neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007. 38:1655–1711.

4. Choi JC, Kang SY, Kang JH, Ko YJ, Bae JM. Are in-Hospital delays important obstacles in thrombolytic therapy following acute ischemic stroke? J Clin Neurol. 2007. 3:71–78.

5. Gagliardi R, Benvenuti L, Guizzardi G. Acute operation in cases of middle cerebral artery occlusion. Neurosurgery. 1983. 12:636–639.

6. Garrido E, Stein BM. Middle cerebral artery embolectomy. Case report. J Neurosurg. 1976. 44:517–521.

7. Khodadad G. Middle cerebral artery embolectomy and prolonged widespread vasospasm. Stroke. 1973. 4:446–450.

8. Meyer FB, Piepgras DG, Sundt TM Jr, Yanagihara T. Emergency embolectomy for acute occlusion of the middle cerebral artery. J Neurosurg. 1985. 62:639–647.

9. Welch K. Excision of occlusive lesions of the middle cerebral artery. J Neurosurg. 1956. 13:73–80.

10. Gobin YP, Starkman S, Duckwiler GR, Grobelny T, Kidwell CS, Jahan R, et al. MERCI 1: a phase 1 study of Mechanical Embolus Removal in Cerebral Ischemia. Stroke. 2004. 35:2848–2854.

11. Smith WS, Sung G, Starkman S, Saver JL, Kidwell CS, Gobin YP, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke. 2005. 36:1432–1438.

12. Touho H, Morisako T, Hashimoto Y, Karasawa J. Embolectomy for acute embolic occlusion of the internal carotid artery bifurcation. Surg Neurol. 1999. 51:313–320.

13. Qureshi AI. Endovascular treatment of cerebrovascular diseases and intracranial neoplasms. Lancet. 2004. 363:804–813.

14. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008. 39:1205–1212.

15. Jansen O, von Kummer R, Forsting M, Hacke W, Sartor K. Thrombolytic therapy in acute occlusion of the intracranial internal carotid artery bifurcation. AJNR Am J Neuroradiol. 1995. 16:1977–1986.

16. Horiuchi T, Nitta J, Sakai K, Tanaka Y, Hongo K. Emergency embolectomy for treatment of acute middle cerebral artery occlusion. J Neurosurg. 2007. 106:257–262.