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Emergent surgical embolectomy in conjunction with cervical internal carotid ligation and superficial temporal artery-middle cerebral artery bypass to treat acute tandem internal carotid and middle cerebral artery occlusion due to cervical internal carotid artery dissection.

Inoue T, Saito I, Tamura A - Surg Neurol Int (2015)

Bottom Line: The cervical ICA was exposed, and dissection was confirmed.Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia.Surgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, 418-0021, Japan.

ABSTRACT

Background: Acute tandem cervical dissecting internal carotid artery (ICA) occlusion and intracranial embolic middle cerebral artery (MCA) occlusion can be devastating, and the optimal treatment strategy for this condition has not been established yet.

Case description: A 45-year-old male presented with aphasia and right hemiparesis preceded by neck pain. Computed tomography showed a high-density signal along the left MCA, suggesting extensive emboli. Magnetic resonance angiography demonstrated tandem occlusion of the left cervical ICA and intracranial MCA with minimal diffusion-weighted imaging lesion. Emergent surgical embolectomy was performed, and long intracranial MCA emboli were retrieved with collateral cross-flow restoration. The cervical ICA was exposed, and dissection was confirmed. The cervical ICA was ligated, and superficial temporal artery (STA)-MCA anastomosis was added. Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia. At the 6(th) postoperative month, follow-up studies demonstrated a robustly patent STA-MCA bypass and no additional ischemic lesion on T2-weighted imaging.

Conclusions: Surgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.

No MeSH data available.


Related in: MedlinePlus

Intraoperative photographs demonstrate extensive bluish discoloration due to emboli in the M1–M2 bifurcation (a), up to the distal superior trunk (b) and distally into the inferior trunk (c). Cervical internal carotid artery with blue vessel tape (d) shows dark discoloration, suggestive of dissection
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Figure 3: Intraoperative photographs demonstrate extensive bluish discoloration due to emboli in the M1–M2 bifurcation (a), up to the distal superior trunk (b) and distally into the inferior trunk (c). Cervical internal carotid artery with blue vessel tape (d) shows dark discoloration, suggestive of dissection

Mentions: Under general anesthesia, a standard frontotemporal craniotomy was performed. After introduction of the microscope, the Sylvian fissure was opened to expose the M1–M2 portion of the MCA [Figure 3]. Then, the emboli were retrieved through a transverse arteriotomy made near the distal end of the M1 and through two other arteriotomies at the superior trunk. Emboli extended far into the inferior trunk, and two additional arteriotomies were required to retrieve the entire clot. Thus, a total of five transverse arteriotomies were performed. All arteriotomies were sutured with 9-0 nylon by intermittent stitches. Restoration of collateral flow was observed via the anterior communicating artery, and a microvascular Doppler assessment confirmed that C2 portion of the ICA was still occluded. Next, the cervical carotid artery was exposed. The cervical ICA showed discoloration suggestive of dissection [Figure 3]. The cervical ICA was opened via a longitudinal arteriotomy. Although the true lumen was identified for shunt insertion, no substantial backflow was aspirated. Rather, copious continuous bleeding from the pseudolumen was observed, indicating that dissection was extensive and restoring anterograde flow would not be possible. The cervical ICA was ligated. Then, the STA was exposed from a skin flap. Two STA branches were prepared, and STA-MCA double anastomosis was performed. Good bypass flow was confirmed by microvascular Doppler assessment [Video 1].


Emergent surgical embolectomy in conjunction with cervical internal carotid ligation and superficial temporal artery-middle cerebral artery bypass to treat acute tandem internal carotid and middle cerebral artery occlusion due to cervical internal carotid artery dissection.

Inoue T, Saito I, Tamura A - Surg Neurol Int (2015)

Intraoperative photographs demonstrate extensive bluish discoloration due to emboli in the M1–M2 bifurcation (a), up to the distal superior trunk (b) and distally into the inferior trunk (c). Cervical internal carotid artery with blue vessel tape (d) shows dark discoloration, suggestive of dissection
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4697205&req=5

Figure 3: Intraoperative photographs demonstrate extensive bluish discoloration due to emboli in the M1–M2 bifurcation (a), up to the distal superior trunk (b) and distally into the inferior trunk (c). Cervical internal carotid artery with blue vessel tape (d) shows dark discoloration, suggestive of dissection
Mentions: Under general anesthesia, a standard frontotemporal craniotomy was performed. After introduction of the microscope, the Sylvian fissure was opened to expose the M1–M2 portion of the MCA [Figure 3]. Then, the emboli were retrieved through a transverse arteriotomy made near the distal end of the M1 and through two other arteriotomies at the superior trunk. Emboli extended far into the inferior trunk, and two additional arteriotomies were required to retrieve the entire clot. Thus, a total of five transverse arteriotomies were performed. All arteriotomies were sutured with 9-0 nylon by intermittent stitches. Restoration of collateral flow was observed via the anterior communicating artery, and a microvascular Doppler assessment confirmed that C2 portion of the ICA was still occluded. Next, the cervical carotid artery was exposed. The cervical ICA showed discoloration suggestive of dissection [Figure 3]. The cervical ICA was opened via a longitudinal arteriotomy. Although the true lumen was identified for shunt insertion, no substantial backflow was aspirated. Rather, copious continuous bleeding from the pseudolumen was observed, indicating that dissection was extensive and restoring anterograde flow would not be possible. The cervical ICA was ligated. Then, the STA was exposed from a skin flap. Two STA branches were prepared, and STA-MCA double anastomosis was performed. Good bypass flow was confirmed by microvascular Doppler assessment [Video 1].

Bottom Line: The cervical ICA was exposed, and dissection was confirmed.Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia.Surgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya-shi, Shizuoka, 418-0021, Japan.

ABSTRACT

Background: Acute tandem cervical dissecting internal carotid artery (ICA) occlusion and intracranial embolic middle cerebral artery (MCA) occlusion can be devastating, and the optimal treatment strategy for this condition has not been established yet.

Case description: A 45-year-old male presented with aphasia and right hemiparesis preceded by neck pain. Computed tomography showed a high-density signal along the left MCA, suggesting extensive emboli. Magnetic resonance angiography demonstrated tandem occlusion of the left cervical ICA and intracranial MCA with minimal diffusion-weighted imaging lesion. Emergent surgical embolectomy was performed, and long intracranial MCA emboli were retrieved with collateral cross-flow restoration. The cervical ICA was exposed, and dissection was confirmed. The cervical ICA was ligated, and superficial temporal artery (STA)-MCA anastomosis was added. Postoperatively, the patient demonstrated recovery from right hemiparesis and aphasia. At the 6(th) postoperative month, follow-up studies demonstrated a robustly patent STA-MCA bypass and no additional ischemic lesion on T2-weighted imaging.

Conclusions: Surgical embolectomy in conjunction with ligation of the cervical ICA followed by STA-MCA bypass might be a safe alternative method to endovascular recanalization, when the cervical dissection is extensive and when huge secondary emboli are present along the MCA.

No MeSH data available.


Related in: MedlinePlus