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Minimally invasive and rapid surgical embolectomy (MIRSE) as rescue treatment following failed endovascular recanalization for acute ischemic stroke

  • Clinical Article - Vascular
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Abstract

Background

An intra-arterial (IA) mechanical thrombectomy has increased the recanalization rates for acute occlusion of proximal intracranial arteries. However, the current failure rate of endovascular recanalization remains at approximately 10 %, resulting in the need for surgical rescue treatment. The authors applied a minimally invasive and rapid surgical embolectomy (MIRSE) as a final rescue treatment after the failure of endovascular recanalization, and investigated the incidence, technical feasibility, and treatment results.

Methods

For two years, from 2012 to 2013, a total of 131 patients with acute occlusion of proximal intracranial arteries underwent an IA mechanical thrombectomy using a Penumbra System and a Solitaire stent, yet ten (7.6 %) patients still experienced final recanalization failure. Four (40 %) of these ten patients subsequently underwent a MIRSE consisting of a superciliary keyhole approach, arteriotomy to remove the embolus, and arteriotomy repair techniques using aneurysm clips as the final repair material, or a temporary compartmentalizing clip.

Results

Four patients aged 39 to 78 years with an embolic occlusion in the middle cerebral artery (n = 1) and internal carotid artery (n = 3) were treated using a MIRSE. Complete recanalization was achieved in all four patients, and the time from skin incision to reperfusion was 40–50 minutes. The modified Rankin Scale (mRS) scores at 3 months after surgery were 1 (n = 2), 2 (n = 1), and 3 (n = 1), respectively.

Conclusions

A MIRSE can be an effective rescue treatment after the failure of endovascular recanalization therapies for acute occlusion of proximal intracranial arteries if the patient is within the therapeutic time window.

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Conflicts of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Research Center for Neurosurgical Robotic Systems, Kyungpook National University, 50, Samduk 2-Ga, Jung-Gu, Daegu, 700-721, Republic of Korea

    Jaechan Park

  2. Department of Neurology, Kyungpook National University, Daegu, Republic of Korea

    Yang-Ha Hwang

  3. Department of Surgery, Kyungpook National University, Daegu, Republic of Korea

    Seung Huh

  4. Department of Radiology, Kyungpook National University, Daegu, Republic of Korea

    Dong-Hun Kang & Yongsun Kim

Authors
  1. Jaechan Park
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  2. Yang-Ha Hwang
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  3. Seung Huh
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  4. Dong-Hun Kang
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  5. Yongsun Kim
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Correspondence to Jaechan Park.

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Comment

This is a well written and concise report of surgical embolecomy after endovascular initial and rescue treatment failure. The technique is not novel, and has been described before. Only 4 out of 10 patients who had endovascular failure were appropriate candidate for surgery and the results are very acceptable considering the potential dramatic complication of a definitive stroke. Although I applaud the authors for optimizing this effective technique, there are practical issues with performing this procedure in the ideal 8h time frame after the initial symptoms. This further emphasizes the need for hybrid operating theatre where combined endovascular and surgical treatment can be performed in a subset of patients who might benefit from these challenging procedures where time is of utmost importance.

Amir Dehdashti

NY, USA

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Park, J., Hwang, YH., Huh, S. et al. Minimally invasive and rapid surgical embolectomy (MIRSE) as rescue treatment following failed endovascular recanalization for acute ischemic stroke. Acta Neurochir 156, 2041–2049 (2014). https://doi.org/10.1007/s00701-014-2179-5

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  • DOI: https://doi.org/10.1007/s00701-014-2179-5

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