Abstract
Acute ischemic stroke attributable to cervical internal carotid artery (ICA) occlusion is frequently associated with severe disability or death and is usually caused by atherosclerosis. By contrast, the cardioembolic cervical ICA occlusion is rare, and feasibility of urgent recanalization remains unclear. We present the first study in the literature that focuses on urgent open embolectomy for the treatment of cardioembolic cervical ICA occlusion. A retrospective review of the charts for patients undergoing open embolectomy was performed. Between April 2006 and September 2007, 640 consecutive patients with acute ischemic stroke were treated. Of them, three patients (0.47%) with the acute complete cardioembolic cervical ICA occlusion underwent urgent open embolectomy. All patients presented with profound neurological deficits and atrial fibrillation. The urgent open embolectomy achieved complete recanalization in all patients without any complications. All emboli in three patients were very large and fibrinous in histological findings. Two of three patients showed rapid improvement in neurological functions after surgical treatments. The cardioembolic occlusion of the cervical ICA is rare, but its possibility should be considered in patients with acute ischemic stroke suffering profound neurological deficits and atrial fibrillation. Urgent open embolectomy may be a treatment option to obtain successful recanalization for cardioembolic cervical ICA occlusion and is recommended because it is technically easier and similar to carotid endarterectomy.
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Taketo Hatano, Kyoto, Japan
Murata et al. present three patients who underwent microsurgical revascularization for cardioembolic occlusion of the cervical internal carotid artery. The occluded arteries were re-canalized completely without any complications. This is the first report to describe in detail the technique and results of an emergency open embolectomy for cardioembolic ICA occlusion. This report highlights a microsurgical embolectomy as a potentially effective treatment for cardioembolic ICA occlusion. The effectiveness and the risk of this treatment mainly depend on the collateral flow and the time to re-canalization. Therefore, the authors suggest that stricter patient selection criteria, including the evaluation of the cerebral blood flow, may be necessary. One of the disadvantages of an open embolectomy is that it takes a relatively long time to prepare and perform the procedure (the mean admission-to-re-canalization time was 4 hours 30 minutes at the authors’ institution). Recently, endovascular treatments with various techniques and devices, has also become an alternative treatment for these lesions. Therefore, although I endorse the necessity to perform aggressive treatment for cervical internal carotid artery occlusion with serious or progressing neurological symptoms, further study should be undertaken to clarify the effectiveness of performing a direct embolectomy and endovascular treatment.
Christopher M. Loftus. Philadelphia, USA
Murata et al., from Shinshu University, have tremendous experience with stroke, carotid disease, and carotid reconstruction. In this excellent report, they discuss three cases (out of 640 retrospectively screened chart files) where carotid occlusion was caused by a cardiogenic embolus that lodged at the carotid bifurcation. In their three surgical cases all patients did well, most likely because of strict selection criteria, skilled surgery, and careful management.
As I review this scholarly contribution there remain several unanswered questions for me. First, it seems difficult that the surgeons can ascertain preoperatively whether the carotid occlusions were from a cardiogenic source. The angiographic images just show complete occlusion, which in my mind could develop from atheromatous disease and plaque rupture, and of course floating thrombus can form from atheromatous disease as well. The fibrinous nature of the clot, once it has been removed, suggests a cardiac origin, but I am not certain that this can be determined before surgical exploration, except perhaps by inference in patients with known atrial fibrillation and known cardiac atrial thrombi.
This is an interesting academic distinction, but it doesn’t really affect clinical decision making. The most important contribution from this paper is that an extremely rare phenomenon, cervical carotid occlusion from cardiac thrombus, has been beautifully studied and documented, that large emboli originating from cardiac origin can lodge at the carotid bifurcation and threaten stroke, and that well-selected patients can make good recoveries from a simple exploration. It is unclear whether other potential interventions, such as TPA or mechanical endovascular retrieval, could be as effective or as rapid as surgery in reversing stroke-like symptoms. I suspect they would not be as good.
The real message for surgeons here is that acute carotid occlusion, no matter what the cause, is a surgical disease, and that selected patients can have favorable outcomes from an aggressive approach to diagnosis, imaging, and surgical intervention.
I congratulate these authors for their rigorous analysis and their valuable contribution to our understanding of the broad spectrum of carotid disease.
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Murata, T., Horiuchi, T., Nitta, J. et al. Urgent open embolectomy for cardioembolic cervical internal carotid artery occlusion. Neurosurg Rev 33, 341–348 (2010). https://doi.org/10.1007/s10143-010-0252-y
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DOI: https://doi.org/10.1007/s10143-010-0252-y