Recanalization of long-lasting middle cerebral artery occlusion by a combination of surgical and interventional approaches: technical case report.
OBJECTIVE
In strictly selected cases of middle cerebral artery (MCA) occlusion, revascularization by extracranial-intracranial (EC-IC) bypass can be considered. The interventional recanalization of the occlusion under direct surgical control has not been reported in the literature so far.


METHODS
A 39-year-old Caucasian female patient had experienced an ischemic stroke 15 years before she came to our attention. At that time, occlusion of the right MCA was diagnosed by angiography. Her neurological deficit resolved within 6 months. Fifteen years later, the patient experienced repeated numbness of her left-sided extremities, which was refractory to medical treatment. Angiography revealed an occluded M1 segment of the MCA. Perfusion computed tomography without and after CO2 stimulation disclosed impaired cerebrovascular capacity.


METHODS
The patient was scheduled for EC-IC bypass. The MCA tree was exposed, and the occluded portion was found to be 10 mm long. We then decided to reopen the vessel by balloon dilation under direct visual control. A catheter was advanced to the M1 origin, where a glidewire was passed into the vessel lumen. With only a little help from the surgeon, it was surprisingly easy to direct the glidewire through the occluded segment. At this time, flow through the M1 segment was re-established. Flow through the MCA that had occluded for 15 years was re-established.


CONCLUSIONS
On the basis of our experience, in nonatherosclerotic occlusions, intravascular intervention may be considered.
Benes
Vladimir
V
Department of Neurosurgery, Charles University, First Faculty of Medicine, Central Military Hospital, Prague, Czech Republic. vladimir.benes@uvn.cz
Netuka
David
D
Charvát
Frantisec
F
Mohapl
Milan
M
D000328:Adult; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D002533:Cerebral Angiography / Q000379:methods; D002548:Cerebral Revascularization / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000601:surgery*; D018810:Magnetic Resonance Angiography; D014057:Tomography, X-Ray Computed / Q000379:methods