title: Emergent surgical embolectomy for middle cerebral artery occlusion due to carotid plaque rupture followed by elective carotid endarterectomy.
abstract: Embolic intracranial large artery occlusion with severe neurological deficit is associated with an extremely poor prognosis. The safest and most effective treatment strategy has not yet been determined when such emboli are associated with unstable proximal carotid plaque. The authors performed emergent surgical embolectomy for left middle cerebral artery (MCA) occlusion, and the patient experienced marked neurological recovery without focal deficit and regained premorbid activity. Postoperative investigation revealed "vulnerable plaque" of the left internal carotid artery without apparent evidence of cardiac embolism, such as would be seen with atrial fibrillation. Specimens from subsequent elective carotid endarterectomy (CEA) showed ruptured vulnerable plaque that was histologically consistent as a source of the intracranial embolic specimen. Surgical embolectomy for MCA occlusion due to carotid plaque rupture followed by CEA could be a safer and more effective alternative to endovascular treatment from the standpoint of obviating the risk of secondary embolism that could otherwise occur as a result of the manipulation of devices through an extremely unstable portion of plaque. Further, this strategy is associated with a high probability of complete recanalization with direct removal of hard and large, though fragile, emboli.
authors.affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya City, Shizuoka, Japan.
authors.forename: Satoshi
authors.initials: S
authors.lastname: Kiyofuji
authors.forename: Tomohiro
authors.initials: T
authors.lastname: Inoue
authors.forename: Hirotaka
authors.initials: H
authors.lastname: Hasegawa
authors.forename: Akira
authors.initials: A
authors.lastname: Tamura
authors.forename: Isamu
authors.initials: I
authors.lastname: Saito
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery*; D003399:Craniotomy / Q000379:methods; D017128:Embolectomy / Q000379:methods*; D016894:Endarterectomy, Carotid / Q000379:methods*; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000209:etiology* / Q000601:surgery*; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D019635:Neurosurgical Procedures / Q000379:methods; D012421:Rupture / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: CAS = carotid artery stenting; CEA = carotid endarterectomy; DSA = digital subtraction angiography; DWI = diffusion-weighted imaging; ECG = electrocardiogram; ICA = internal carotid artery; MCA = middle cerebral artery; MRA = MR angiography; NIHSS = National Institutes of Health Stroke Scale; TIMI = Thrombolysis in Myocardial Infarction; acute ischemic stroke; carotid endarterectomy; embolectomy; internal carotid artery stenosis; intracranial embolism; vascular disorders