title: Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture.
abstract: Acute internal carotid artery (ICA) terminus occlusion is associated with extremely poor functional outcomes or mortality, especially when it is caused by plaque rupture of the cervical ICA with engrafted thrombus that elongates and extends into the ICA terminus. The goal of this study was to evaluate the efficacy and safety of surgical embolectomy in conjunction with carotid endarterectomy (CEA) for acute ICA terminus occlusion associated with cervical plaque rupture resulting in tandem occlusion. A retrospective review of medical records was performed. Clinical and radiographic characteristics were evaluated, including details of surgical technique, recanalization grade, recanalization time, complications, modified Rankin Scale (mRS) score at 3 months, and National Institutes of Health Stroke Scale (NIHSS) score improvement at 1 month. Three patients (mean age 77.3 years; median presenting NIHSS Score 22, range 19-26) presented with abrupt tandem occlusion of the cervical ICA and ICA terminus and were selected for surgery after confirmation of embolic high-density signal at the ICA terminus on CT and diffusion-weighted imaging (DWI)/magnetic resonance angiography (MRA) mismatch. All patients underwent craniotomy for surgical embolectomy of the ICA terminus embolus followed by cervical exposure, aspiration of long residual proximal embolus ranging from the cervical to cavernous ICA, and removal of ruptured unstable plaque by CEA. Postoperative MRA demonstrated Thrombolysis In Myocardial Infarction (TIMI) 3 recanalization in all patients (100%) without evidence of additional infarction according to DWI. Mean recanalization time from hospital arrival was 234 minutes and from start of surgery, 151 minutes. Serial postoperative CT and MRI studies showed no symptomatic hemorrhage, brain edema, or progression of infarction. The patients' mRS scores at 3 months were 3, 3, and 1. All 3 patients demonstrated marked improvements in NIHSS scores (median 17 points; range 13-23 points) at 1 month. Considering the dismal prognosis associated with ICA terminus occlusion, especially when accompanied by cervical plaque rupture, emergent surgical embolectomy in conjunction with CEA might be an effective and decisive treatment option with a high complete recanalization rate and acceptable safety profile.
authors.affiliation: Department of Neurosurgery, Fuji Brain Institute and Hospital, Shizuoka, Japan.
authors.forename: Hirotaka
authors.initials: H
authors.lastname: Hasegawa
authors.forename: Tomohiro
authors.initials: T
authors.lastname: Inoue
authors.forename: Akira
authors.initials: A
authors.lastname: Tamura
authors.forename: Isamu
authors.initials: I
authors.lastname: Saito
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000209:etiology / Q000601:surgery; D016893:Carotid Stenosis / Q000150:complications / Q000601:surgery*; D002533:Cerebral Angiography; D038524:Diffusion Magnetic Resonance Imaging; D017128:Embolectomy / Q000379:methods*; D004617:Embolism / Q000209:etiology; D016894:Endarterectomy, Carotid / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D058226:Plaque, Atherosclerotic / Q000150:complications / Q000601:surgery*; D012421:Rupture; D020521:Stroke / Q000209:etiology / Q000601:surgery; D016896:Treatment Outcome
keywords: ACoA = anterior communicating artery; CEA = carotid endarterectomy; DWI = diffusion-weighted imaging; ICA = internal carotid artery; MCA = middle cerebral artery; MRA = magnetic resonance angiography; NIHSS = National Institutes of Health Stroke Scale; PCoA = posterior communicating artery; TIMI = Thrombolysis In Myocardial Infarction; carotid artery stenosis; carotid endarterectomy; carotid terminus occlusion; embolectomy; mRS = modified Rankin Scale; plaque rupture; tPA = tissue plasminogen activator; vascular disorders