Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study

Abstract

BackgroundDespite all the gains that have been achieved with endovascular mechanical thrombectomy revascularization and intravenous thrombolysis logistics since 2015, there is still a subgroup of patients with salvageable brain tissue for whom persistent emergent large vessel occlusion portends a catastrophic outcome.ObjectiveTo test the safety and efficacy of emergent microsurgical intervention in patients with acute ischemic stroke and symptomatic middle cerebral artery occlusion after failure of mechanical thrombectomy.MethodsA prospective two-center cohort study was conducted. Patients with acute ischemic stroke and middle cerebral artery occlusion for whom recanalization failed at center 1 were randomly allocated to the microsurgical intervention group (MSIG) or control group 1 (CG1). All similar patients at center 2 were included in the control group 2 (CG2) with no surgical intervention. Microsurgical embolectomy and/or extracranial–intracranial bypass was performed in all MSIG patients at center 1.ResultsA total of 47 patients were enrolled in the study: 22 at center 1 (12 allocated to the MSIG and 10 to the CG1) and 25 patients at center 2 (CG2). MSIG group patients showed a better clinical outcome on day 90 after the stroke, where a modified Rankin Scale score of 0–2 was reached in 7 (58.3%) of 12 patients compared with 1/10 (10.0%) patients in the CG1 and 3/12 (12.0%) in the CG2.ConclusionsThis study demonstrated the potential for existing microsurgical techniques to provide good outcomes in 58% of microsurgically treated patients as a third-tier option.

Pitfalls in the diagnosis of post‐TAVI (transcatheter aortic valve implantation) stroke

“…Mechanical thrombectomy, particularly the combined technique, remains the mainstay of treatment for calcified cerebral embolus, 9 and surgical embolectomy may be considered as a rescue measure for those with a large calcified embolus refractory to MT, 10 as seen in this case.…”

“…While the choice of imaging modality for MT (i.e., CT vs. MRI) may not influence the patient outcomes in ordinary ischemic stroke patients 8 and the modality with the greater impact on the selection of major treatment strategies better be chosen in principle, CT/CTA may be given priority in the initial evaluation of patients suspected of post‐TAVI stroke, considering poor detectability of calcification on MRI. Mechanical thrombectomy, particularly the combined technique, remains the mainstay of treatment for calcified cerebral embolus, 9 and surgical embolectomy may be considered as a rescue measure for those with a large calcified embolus refractory to MT, 10 as seen in this case.…”

Ischemic Stroke due to Intracranial Embolization of a Pelvic Phlebolith in a Pregnant Patient Successfully Treated by Surgical Embolectomy following Attempted Endovascular Thrombectomy

“…Surgical embolectomy of calcified cerebral embolus has rarely been reported; however, excellent outcomes are possible [ 7 ]. A recent article by Fiedler et al demonstrated that microsurgical intervention, including embolectomy, bypass, or a combination of the techniques, may be a promising third-tier treatment in patients with persistent large vessel occlusion and failed endovascular thrombectomy, not limited to only calcified emboli [ 8 ].…”

The progression of surgical intervention for arterial reocclusion after mechanical thrombectomy for acute cerebral infarction

“…Fiedler reported 75% recanalization (mTICI score 2b-3) in 47 patients in either the microsurgical intervention group (MSIG) or control group (CG). 63 Clinical experience indicates MIRSE's effectiveness in revascularizing patients with acute ischemic stroke. Thus, microsurgery should be considered a potential treatment for AIS patients with large vessel occlusion and failed MT, though currently underutilized.…”

“…Three-month mRS scores were 1 (n=2), 2 (n=1), and 3 (n=1). Fiedler reported 75% recanalization (mTICI score 2b-3) in 47 patients in either the microsurgical intervention group (MSIG) or control group (CG) 63 . Clinical experience indicates MIRSE’s effectiveness in revascularizing patients with acute ischemic stroke.…”