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
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka,
- Department of Neurosurgery, NTT Medical Center, Shinagawa,
- Department of Neurosurgery, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan.
Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka,
DOI:10.25259/SNI_627_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Yudai Hirano1, Hideaki Ono1, Tomohiro Inoue2, Tomohiro Mitani3, Takeo Tanishima1, Akira Tamura1, Isamu Saito1. 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. 04-Dec-2020;11:420
How to cite this URL: Yudai Hirano1, Hideaki Ono1, Tomohiro Inoue2, Tomohiro Mitani3, Takeo Tanishima1, Akira Tamura1, Isamu Saito1. 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. 04-Dec-2020;11:420. Available from: https://surgicalneurologyint.com/?post_type=surgicalint_articles&p=10425
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.
Keywords: Acute ischemic stroke, Cerebral angiography, Embolectomy, Intracranial embolism, Unruptured aneurysm
Recently, new modalities such as three-dimensional (3D) computed tomography angiography (CTA, 3D-CTA) and magnetic resonance imaging/angiography (MRI/A) have emerged instead of digital subtraction angiography (DSA) for diagnostic studies of patients with cerebral aneurysms or intracranial vascular lesions.[
A 68-year-old man with a medical history of hypertension and hyperuricemia was incidentally found to have unruptured aneurysms of the ACoA and right internal carotid artery (ICA) – posterior communicating artery (PCoA) bifurcation. His head computed tomography (CT) and MRI/A showed no abnormal findings except for the aneurysms. The ACoA aneurysm had a maximum diameter of 7 mm [
Preoperative imaging. (a-c) Magnetic resonance angiography (MRA) showed an unruptured aneurysm of anterior communicating artery, 7 mm in maximum diameter (a), which was protruding upward (b) and located over 10 mm above the frontal base (c). (d and e) M3 portion of middle cerebral artery was occluded in MRA (e, arrow) performed just after the three-dimensional digital subtraction angiography (3D-DSA), which was patent in 3D-DSA (d, arrowhead). (f) No cerebral infarction in diffusion-weighted imaging.
Neuroanesthesia was induced, and the patient was placed in the supine position. The operation was started 80 min after onset. Motor evoked potentials of the right upper limb were monitored. The left frontotemporal craniotomy was performed, and the Sylvian fissure was opened widely from the distal portion under the operating microscope. The M2 superior trunk was identified, and the M2-3 bifurcation was obstructed by an embolus [
Intraoperative photographs. (a) Intra-arterial embolus at M2-3 bifurcation (arrow: M2, arrowhead: M3) of the middle cerebral artery. (b) White color clot (arrow) was removed from the artery and blood flow spouted due to recanalization of occluded vessel. (c) Thrombus (arrow) at the distal M3 was also removed. (d) Anterior communicating artery complex and the aneurysm. (e) Clipping the aneurysm with straight clip. (f) Final view.
The postoperative course was good. Postoperative MRA revealed recanalization of the occluded MCA and DWI demonstrated a small infarction of the left frontal lobe and insula [
Etiology of cerebral infarction related to DSA
DSA is used to examine and treat many types of cerebrovascular diseases.[
DSA may cause various complications, although infrequently. The frequency of neurological complications is about 1–3%, which is decreasing every year, and most of them are transient.[
Multiple mechanisms of neurological complications during DSA have been proposed, which include thrombosis from the catheter and guide wire,[
As far as we know, there have been no previous reports on removing an embolus related to DSA. Macroscopically, the embolus was white and soft; pathologically, it was a fresh thrombus containing a very small amount of red blood cells, without any vascular wall component, and was classified as fibrin-dominant clots.[
Treatment of acute cerebral embolism
The rate of poor outcomes in patients with distal MCA occlusion is reported to be as high as 47.4%, and the rate tends to be higher (64.7%) for a left side occlusion.[
Clipping for the unruptured aneurysm of ACoA
As ACoA aneurysms have a higher rate of rupture than aneurysms in other parts,[
In this case, the left MCA occlusion occurred, and surgical embolectomy was performed. We opened the Sylvian fissure widely from the distal portion identify the occluded M2-3 portion. We also split the interhemispheric fissure widely from the base to identify the neck of the aneurysm, A1, and bilateral A2 without strong retraction of the frontal lobe. As a result, the ACoA complex was clearly confirmed, and clipping was performed safely through the left pterional approach, although the aneurysm was located at a relatively high position.
The limitation of this study is that an endovascular team was not available in our hospital or region while treating this case. If an endovascular team had been available, we would have considered endovascular thrombectomy as the first option.
Emergent surgical embolectomy for MCA occlusion related to DSA 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.
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