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Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion

  • Clinical Article - Vascular
  • Published:
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Abstract

Background

Acute extracranial internal carotid artery (ICA) occlusion by a huge cardiogenic embolus is rare, but can be catastrophic.

Methods

Seven patients with acute ischemic stroke due to embolic occlusion of extracranial ICA who underwent emergent cervical surgical embolectomy were retrospectively reviewed. Diagnosis was made in six patients with magnetic resonance imaging (MRI) with optional digital subtraction angiography (DSA), while computed tomography (CT) and DSA were used in one patient with an implanted pacemaker. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month were evaluated.

Results

Complete recanalization was obtained in seven patients (100 %). Median recanalization time from symptom onset and from start of surgery was 402 and 40 min, respectively. All seven patients showed severe left ventricular hypertrophy (LVH) according to an increased cardiothoracic ratio (CTR) ≥50 %. Complications included recurrence of cardioembolic stroke with the right middle cerebral artery occlusion, minimal expansion of infarction, and aggravation of heart failure, each in one patient, respectively. Four (57.1 %) patients had a history or postoperative recurrence of cardioembolic stroke. Median NIHSS at 1 month was 2 (range, 0–30). Median mRS at 3 months was 2 (range, 0–5). Five patients (71.4 %) had a favorable outcome (mRS2).

Conclusions

Cervical surgical embolectomy for acute extracranial ICA occlusion resulted in a high complete recanalization rate with an acceptable safety profile. A possible association between severe cardiac illness and huge embolus occluding proximal large artery was suggested.

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Conflicts of interest

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Authors and Affiliations

  1. Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya City, 270-12 Sugita, Fujinomiya City, Shizuoka, 418-0021, Japan

    Satoshi Kiyofuji, Tomohiro Inoue, Akira Tamura & Isamu Saito

Authors
  1. Satoshi Kiyofuji
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  2. Tomohiro Inoue
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  3. Akira Tamura
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  4. Isamu Saito
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Corresponding author

Correspondence to Satoshi Kiyofuji.

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Comment

The authors describe the open surgical embolectomy of extra-cranial ICA after acute occlusion due to cardiac source large embolus. From a large cohort of stroke patients, seven patients were selected who met this specific criteria. They achieved 100 % re-canalization rate and four patients had recurrent emboli with a median NHISS score of 2 and median mRS score of 2. Considering the fact that without this intervention, the only chance of a good outcome in a symptomatic patient is a robust collateral circulation, this procedure should be considered among the treatment arm for this particular subset of stroke patients. A direct comparison of surgical embolectomy to endovascular treatment is difficult due to limited number of patients in this specific setting but ultimately one could argue that all of these patients would benefit from a rapid endovascular recanalization even in very proximal ICA occlusions.

Amir Dehdashti

NY, USA

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Kiyofuji, S., Inoue, T., Tamura, A. et al. Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion. Acta Neurochir 157, 1313–1319 (2015). https://doi.org/10.1007/s00701-015-2478-5

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  • DOI: https://doi.org/10.1007/s00701-015-2478-5

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