gms | German Medical Science

57th Annual Meeting of the German Society of Neurosurgery
Joint Meeting with the Japanese Neurosurgical Society

German Society of Neurosurgery (DGNC)

11 - 14 May, Essen

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Emergency embolectomy for embolic occlusion of the middle cerebral artery after cerebral angiography: Neurosurgical past?

Notfall-Embolektomie bei embolischem Verschluss nach zerebraler Angiographie: Eine neurochirurgische Vergangenheit?

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  • corresponding author D. Hänggi - Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf
  • H.-J. Steiger - Neurochirurgische Klinik, Heinrich-Heine-Universität, Düsseldorf

Deutsche Gesellschaft für Neurochirurgie. Japanische Gesellschaft für Neurochirurgie. 57. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie e.V. (DGNC), Joint Meeting mit der Japanischen Gesellschaft für Neurochirurgie. Essen, 11.-14.05.2006. Düsseldorf, Köln: German Medical Science; 2006. DocP 10.165

The electronic version of this article is the complete one and can be found online at: http://www.egms.de/en/meetings/dgnc2006/06dgnc382.shtml

Published: May 8, 2006

© 2006 Hänggi et al.
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Outline

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Objective: Emergency treatment for embolic occlusion of cerebral arteries is nowadays achieved by systemic or intra-arterial thrombolysis and by various mechanical endovascular devices. This report illustrates a case resistant to interventional strategies. Early microsurgical embolectomy of the middle cerebral artery (MCA) could prevent major cerebral infarction.

Methods: A 44-year-old man with subarachnoid hemorrhage WFNS grade 1, Fisher grade 3 was admitted to our center. Angiography demonstrated a single ruptured anterior communicating artery (ACOM) aneurysm, and endovascular coiling was considered as the appropriate form of therapy. During positioning of the micro-catheter an embolus occluded the right MCA bifurcation. Immediate treatment with systemic and intra-arterial thrombolysis was instituted. Mechanical fragmentation using a balloon catheter was unsuccessful. The latest angiographic series showed partial patency of MCA so that the decision was to continue with systemic lysis. Follow-up angiogram four hours later documented a complete re-occlusion of the MCA at the bifurcation with insufficient leptomeningeal collateral flow. Therefore the decision for microsurgical embolectomy was made.

Results: The surgical procedure was performed in short time without complications. Following pterional craniotomy, isolation and temporary clipping of the MCA bifurcation and longitudinal arteriotomy, a Y-shaped embolus of 4 mm in length was removed. After closure of the arteriotomy with 8-0 polypropylene material vessel patency was documented with help of a microdoppler probe. The ACOM-aneurysm was subsequently clipped. Low dose heparin was given postoperatively. Angiography six hours later showed regular patency of the MCA bifurcation with normal flow and one small peripheral occlusion (temporal M3 -segment). CT-scan showed limited ischemic lesions temporal and frontal. The patient recovered well and left our department three weeks later with a moderate hemiparesis.

Conclusions: There are rare reports in the literature concerning surgical revascularisation of cerebral arteries after embolic occlusion (level of evidence III-V). The current case illustrates that the technique can still be useful today in cases resistant to endovascular methods.