Direct Microsurgical Embolectomy for an Acute Distal Basilar Artery Occlusion

Microsurgical thrombectomy: where the ancient art meets the new era

Mechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option (developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world. Clinical outcomes, procedural times, and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST. One-hundred nine patients fulfilled the study criteria (77 MTs vs 32 STs). Factors driving outcome were age (aOR: 0.95, 95%CI, 0.91-0.98), hemisphere side (aOR: 0.38, 95%CI, 0.15-0.96), and DWI-ASPECT (aOR: 1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure (P = 0.45) and start of procedure-recanalization (P = 0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization (P = 0.155) and outcome (P = 0.221). The prognosticators of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side, and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients.

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.

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.

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.

Anterior temporal approach for clipping of ruptured basilar tip aneurysms: Surgical techniques and treatment outcomes

BACKGROUND

Basilar tip (BT) aneurysms are challenging to treat with microsurgical clipping, especially in subarachnoid hemorrhage cases. The anterior temporal approach is one of the surgical approaches for the treatment of aneurysms in this area. The majority of the previous reports on this approach have described unruptured cases. For the ruptured cases assessed in our study, the authors describe the surgical technique, patient characteristics, and surgical outcomes following the use of this technique.

METHODS

Fourteen patients with ruptured BT aneurysms who received aneurysm clipping with an anterior temporal approach between December 2015 and August 2019 were retrospectively evaluated. The surgical techniques are described, an illustrative case is shown.

RESULTS

The average patient age was 62.2 years (range: 46-78) for ten women and four men. Nine patients (64.3%) were classified as having a poor grade (World Federation of Neurosurgical Societies Grades 4 and 5) at the first presentation. All of the cases demonstrated complete aneurysm obliteration. Good outcomes (mRS 0 to 2) at 6 months were achieved in 58.3% of the patients and in 77.8% of the patients who had a good Glasgow Coma Score after resuscitation before surgery. Postoperative transient oculomotor nerve palsy and thalamic infarctions were detected in six patients (42.9%) and two patients (14.3%), respectively.

CONCLUSION

With appropriate case selection, the anterior temporal approach was effective and safe for the clipping of ruptured BT aneurysms.