- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, 418-0021, Japan
Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, 418-0021, Japan
DOI:10.4103/2152-7806.172536Copyright: © 2015 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 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: Inoue T, Saito I, Tamura A. 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. Surg Neurol Int 24-Dec-2015;6:191
How to cite this URL: Inoue T, Saito I, Tamura A. 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. Surg Neurol Int 24-Dec-2015;6:191. Available from: http://surgicalneurologyint.com/surgicalint_articles/emergent-surgical-embolectomy-in-conjunction-with-cervical-internal-carotid-ligation-and-superficial-temporal-artery%e2%80%91middle-cerebral-artery-bypass-to-treat-acute-tandem-internal-carotid-and-3/
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 6th 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.
Keywords: Dissection, internal carotid artery, superficial temporal artery-middle cerebral artery bypass, surgical embolectomy
Acute tandem cervical dissecting internal cerebral artery (ICA) occlusion and intracranial embolic middle cerebral artery (MCA) occlusion can be devastating. Although endovascular cervical stenting followed by retrieval of intracranial emboli can be an effective alternative to intravenous tissue plasminogen activator (tPA),[
An endovascular approach using MERCI, Penumbra, or stent retrievers can be performed in stroke centers equipped with an interventional neuroradiological service on a 24-h basis, but there is no such center available in our geographic district (Eastern Shizuoka Prefecture, Japan). Our service (Department of Neurosurgery, Fuji Brain Institute and Hospital) can perform microsurgery on a 24-h basis, but there is no endovascular referral center for severe stroke patients in this district of approximately 500,000 inhabitants. Therefore, we have been performing surgical embolectomy as a first-line treatment for patients with intracranial large emboli after excluding malignant profile based on magnetic resonance imaging (MRI).[
The present study describes a case of ICA/MCA tandem occlusion due to cervical dissection that was treated with emergent surgical embolectomy in conjunction with ligation of the cervical ICA followed by superficial temporal artery (STA)-MCA bypass.
History and examination
A 45-year-old male with no particular past medical history was transferred to our department by ambulance after the sudden onset of nausea, aphasia, and right hemiparesis. The patient's family reported that he had been complaining of neck pain for several days prior to admission. Neurological examination revealed right hemiparesis, aphasia, and slight disturbance of consciousness. The National Institutes of Health Stroke Scale score was 10 points. Computed tomography revealed a high-density signal along the left MCA from the M1 portion up to the distal M2 portion, suggesting long and extensive emboli [
Preoperative intracranial magnetic resonance angiography (a) and left cervical magnetic resonance angiography (b) shows tandem occlusion of the cervical internal carotid artery and middle cerebral artery. Magnetization-prepared rapid acquisition gradient echo (c) reveals a high-intensity signal along the left cervical, middle cerebral artery. Arterial spin labeling (d) demonstrates decreased cerebral blood flow in the left middle cerebral artery area. Diffusion-weighted imaging (e) shows a high-intensity lesion in the left parasylvian area
Under general anesthesia, a standard frontotemporal craniotomy was performed. After introduction of the microscope, the Sylvian fissure was opened to expose the M1–M2 portion of the MCA [
Intraoperative photographs demonstrate extensive bluish discoloration due to emboli in the M1–M2 bifurcation (a), up to the distal superior trunk (b) and distally into the inferior trunk (c). Cervical internal carotid artery with blue vessel tape (d) shows dark discoloration, suggestive of dissection
Immediate postoperative as well as postoperative day 1 MRI studies showed a slightly increased DWI lesion in the basal ganglia, patent whole left MCA branches, and patent STA-MCA bypass. ASL showed slightly increased CBF in the left MCA area when compared with that on the contralateral side [
Magnetic resonance imaging studies on postoperative day 1. Intracranial magnetic resonance angiography (upper left) shows complete recanalization of the left middle cerebral artery as well as a robustly patent superficial temporal artery-middle cerebral artery bypass. Arterial spin labeling (upper right) demonstrates slightly increased cerebral blood flow in the left middle cerebral artery area when compared with that on the contralateral side. Diffusion-weighted imaging (lower) shows a high-intensity lesion in the left parasylvian area and basal ganglia
Magnetic resonance imaging studies at the 6th postoperative months. Intracranial magnetic resonance angiography (upper left) shows a robustly patent superficial temporal artery-middle cerebral artery bypass. Arterial spin labeling (upper right) demonstrates symmetrical cerebral blood flow in the bilateral middle cerebral artery area. T2-weighted imaging (lower) shows no additional ischemic lesion
Spontaneous dissection of the internal carotid artery (ICA) is one of the main cause of ischemic stroke in young- to middle-aged patients.[
Endovascular treatment with stent deployment to recanalize cervical carotid dissection followed by intracranial emboli retrieval promises alternative treatment. Lavallée et al. compared clinical outcomes in consecutive patients presenting with cervical ICA dissection and tandem MCA occlusion who were treated either by endovascular stent-assisted thrombectomy or intravenous tPA. Of 10 patients, 6 were treated with endovascular therapy, and 4 were treated with intravenous tPA. In the endovascular group, all patients achieved recanalization of tandem occlusion, and 4 out of 6 patients had favorable outcomes (modified Ranking score = 0). In the intravenous tPA group, 1 out of 4 patients showed recanalization, and 3 patients had dismal outcomes. Those investigators concluded that most patients with acute symptoms of tandem ICA/MCA occlusion and cervical ICA dissection had poor outcomes when treated with intravenous tPA, whereas most patients treated with stent-assisted endovascular thrombectomy showed marked improvement.[
However, theoretically, stent deployment for cervical ICA dissection could cause distal migration of secondary emboli, vessel laceration, and in-stent thrombosis. Therefore, when cervical ICA dissection is extensive with large secondary distal emboli migration (as in the present case), endovascular stent deployment and recanalization of the cervical ICA might be difficult. Furthermore, recurrent intracranial distal emboli migration from residual intramural or intravascular cervical ICA emboli is also possible.
When the intracranial embolic occlusion is caused by an extremely high clot burden (as in the present case), and when the response to intravenous tPA therapy is expected to be poor, we utilize surgical embolectomy as the first-line treatment after excluding malignant profile (i.e., minimal DWI lesion less than one-third of the entire MCA region despite large ICA/MCA occlusion on MRA).[
The carotid occlusion surgery study failed to show a benefit for the surgical group when compared with the medical treatment group with respect to ipsilateral stroke recurrence at 2 years after treatment.[
Therefore, surgical embolectomy in conjunction with cervical carotid ligation and STA-MCA bypass might provide an advantage over endovascular embolectomy in patients with extensive cervical ICA dissection with huge distal embolic occlusion.
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Conflicts of interest
There are no conflicts of interest.
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