Emergency embolectomy for treatment of acute middle cerebral artery occlusion

Object The authors evaluated the efficacy of emergency embolectomy in patients with acute middle cerebral artery occlusion (MCAO). Methods A retrospective review of the charts for patients undergoing embolectomy at the authors’ institution was performed. Between October 1997 and May 2004, 12 patients (mean age 70 years) with acute MCAO were treated using embolectomy. Local intraarterial fibrinolysis with urokinase was initially undertaken in eight of 12 patients. Sufficient recanalization was not achieved with fibrinolysis in any patient, and thus embolectomy was performed immediately thereafter. Recanalization by embolectomy was achieved in all patients (mean occlusion time 6 hours, 11 minutes). Each patient’s condition was evaluated on discharge. Outcomes in the 12 patients according to the Glasgow Outcome Scale were good recovery in five, moderate disability in two, severe disability in three, vegetative state in one, and death due to a cardiac complication in one. None of the 12 patients had symptomatic hemorrhagic infarction. Conclusions Emergency embolectomy can be performed in patients with MCAO with minimal morbidity and death. The procedure can be used to achieve good recovery even in patients in whom fibrinolysis is insufficient after acute MCAO and should be a part of the algorithm for the treatment of MCAO.

Utilization of Extracorporeal Pump during Local Intra-Arterial Fibrinolysis in the Treatment of Acute Cerebral Arterial Occlusion

Local intra-arterial fibrinolysis may improve the outcome of patients with ischemic cerebrovascular disease. A favorable prognosis is thought to be related to early re-establishment of blood flow into the affected brain. To minimize the time to revascularization during local intraarterial fibrinolysis, we employed an extracorporeal pump to deliver oxygenated blood into the affected brain through a microcatheter. The patient, a 57-year-old man, showed disturbance of consciousness with left hemiparesis and was admitted to our hospital one hour after onset of symptoms. Cerebral angiography demonstrated an acute occlusion of the right middle cerebral artery, and the patient underwent local intra-arterial fibrinolysis with an extracorporeal pump. Oxygenated blood was successfully delivered through a microcatheter into the affected brain before recanalization. Subsequently, recanalization was obtained by intra-arterial fibrinolysis with a tissue plasminogen activator. The outcome of this patient was excellent. Thus, local intra-arterial thrombolysis with extracorporeal pump may be an effective method by which to increase the residual blood flow and widen the therapeutic window for fibrinolysis.