- Department of Neurosurgery, Abashiri Neurosurgical and Rehabilitation Hospital, Abashiri, Hokkaido, Japan
Department of Neurosurgery, Abashiri Neurosurgical and Rehabilitation Hospital, Abashiri, Hokkaido, Japan
DOI:10.4103/2152-7806.134520Copyright: © 2014 Katsuno M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Katsuno M, Kawasaki K, Izumi N, Hashimoto M. Surgical embolectomy for middle cerebral artery occlusion after thrombolytic therapy: A report of two cases. Surg Neurol Int 13-Jun-2014;5:93
How to cite this URL: Katsuno M, Kawasaki K, Izumi N, Hashimoto M. Surgical embolectomy for middle cerebral artery occlusion after thrombolytic therapy: A report of two cases. Surg Neurol Int 13-Jun-2014;5:93. Available from: http://sni.wpengine.com/surgicalint_articles/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.
Keywords: Cerebral infarction, middle cerebral artery, surgical embolectomy
Early recanalization of an occluded artery leads to better clinical outcomes in patients with acute ischemic stroke through protection of the time-sensitive penumbra. Administration of intravenous recombinant tissue plasminogen activator (IV-rt-PA) within 4.5 h from onset has been the standard treatment for acute ischemic stroke; however, the rate of IV-rt-PA induced revascularization is less than 25%.[
A 70-year-old man presented with left hemiparesis of sudden onset. He was admitted to our hospital after 1.5 h from onset and his National Institute of Health Stroke Scale (NIHSS) score on admission was 17. Magnetic resonance (MR) angiography demonstrated occlusion of the right horizontal segment of MCA (M1) [
Case 1. (a, b) Preoperative MR angiography and DWI demonstrating right M1 occlusion and cerebral infarction affecting only part of precentral and central artery territories. (c) Preoperative SPECT showing reduction of the cerebral blood flow in the whole MCA territory. (d) Intraoperative photograph showing an embolus being extracted; (arrowhead) the arteriotomy site and embolus. (e, f) Postoperative MR angiography and DWI demonstrating complete recanalization and no additional cerebral infarction
A 74-year-old woman with left hemiparesis was transferred to our hospital at 4 h from onset. Her NIHSS score on admission was 11 and electrocardiogram showed atrial fibrillation. MR angiography demonstrated right distal M1 occlusion [
Case 2. (a, b) Preoperative MR angiography and DWI demonstrating right M1 occlusion and cerebral infarction that extended from the basal ganglia to the corona radiata. (c) Preoperative MR perfusion image showing reduction of the cerebral blood flow in the whole MCA territory. (d) Intraoperative photograph showing an embolus being extracted; (arrowhead) the arteriotomy site and embolus. (e, f) Postoperative MR angiography and DWI demonstrating complete recanalization and no additional cerebral infarction
Although the efficacy of surgical embolectomy for large vessel occlusion has already been reported by studies involving a small number of patients,[
The median time to achieve partial recanalization by PS was reported to be 97 ± 37 min from initial parenchymography.[
Accordingly, surgical embolectomy might be a more effective procedure than PS from the viewpoint of complete recanalization rate and time. In the present cases, complete recanalization was achieved within 1 h by surgical embolectomy and the outcomes were good, as indicated by the low mRS score.
Nevertheless, the surgeon must pay attention to prevent the occurrence of surgical complications at the arteriotomy site after suturing it and hemorrhagic complications. First, anastomotic leakage or dissection can be prevented by correct intima-to-intima suturing of the vessel wall under high magnification. Second, stenosis can be prevented by transverse arteriotomy and intermittent suture with fine bites. Although some reports of surgical embolectomy have described the usefulness of longitudinal arteriotomy,[
The embolus can be directly and rapidly detected on computed tomography scan by the presence of a hyperdense MCA and on T2*-GRE by a hypointense signal. The deoxygenated hemoglobin in red thrombi result in hypointense signals on T2*-GRE. The radiological finding that red thrombi in occluded vessels result in hypointense signals on T2*-GRE is known as GRE SVS.[
We think surgical embolectomy can be a very effective and safe revascularization procedure when the embolus is not long and when no response to thrombolytic therapy is obtained in the very early stage after onset.
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