Successful Emergency Rescue Open Embolectomy for Failed Endovascular Thrombectomy in Acute Ischemic Stroke: 2-Dimensional Operative Video

Abstract

This operative video demonstrates an open surgical thrombectomy for a 61-yr-old woman with failed endovascular embolectomy in acute ischemic stroke. Good functional outcome can be achieved when this operation is timely performed within the therapeutic window. This patient has atrial fibrillation. She was admitted for sudden onset of left-sided hemiplegia and aphasia. National Institutes of Health Stroke Scale (NIHSS) was 20/42 before the operation. Computed tomography (CT) cerebral angiogram showed right internal cerebral artery (ICA) occlusion from the cervical portion. Urgent intra-arterial (IA) thrombectomy was started 2 h after symptom onset, but failed despite the use of a stentriver and a large-bore aspiration catheter together. Emergency rescue open thrombectomy was performed with right pterional craniotomy 6 h after symptom onset. Sylvian fissure was dissected to expose the supraclinoid ICA, ICA bifurcation, A1, and M1. A transverse arteriotomy was made at the ICA bifurcation and open surgical thrombectomy was performed. Reperfusion was established in 86 min after skin incision. Intraoperative indocyanine green video-angiography showed patent flow over ICA bifurcation to M1 and A1. She had a good recovery with the return of the left-sided power and was discharged home. At 2-mo postoperative assessment, she was able to walk unaided independently. The modified Barthel Index (BI) was 74/100. Her activity of daily living was independent. We must emphasize IA thrombectomy is the standard treatment, and the role of open surgery remains a potential rescue procedure. Good functional outcome can be achieved when emergency rescue open thrombectomy is performed within the therapeutic window.

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

“…Emergency intra-arterial thrombolysis commenced 2 hours post-symptom onset but was unsuccessful. 64 Subsequently, a right lateral pterygoid point craniotomy for embolization was performed 4 hours later, including a transverse arteriotomy at the ICA bifurcation after dissecting the lateral fissure. The surgery proceeded smoothly, resulting in the patient regaining functional independence and walking ability postoperatively.…”

“…David reported a case of open surgical thrombolysis following failed MT for AIS in a 61-year-old woman with right internal carotid artery (ICA) occlusion. Emergency intra-arterial thrombolysis commenced 2 hours post-symptom onset but was unsuccessful 64 . Subsequently, a right lateral pterygoid point craniotomy for embolization was performed 4 hours later, including a transverse arteriotomy at the ICA bifurcation after dissecting the lateral fissure.…”