Urgent Middle Cerebral Artery Embolectomy of Calcified Embolus After Intravenous Thrombolysis: 2-Dimensional Operative Video
Abstract
This video shows an urgent microsurgical embolectomy of the inferior division of the left middle cerebral artery in a patient treated by intravenous thrombolysis (IVT). Patient was eligible for endovascular mechanical thrombectomy1; however, the interventional radiologist was not comfortable performing the procedure given prior unsuccessful attempts to remove a calcified cerebral embolus.(2) A 75-yr-old female presented with an acute ischemic stroke with isolated aphasia (NIHSS 9).
Using the drip-and-ship concept, IVT (0.9 mg/kg rt-PA) was administered in a regional hospital. Fifty-five minutes after a complete recovery following IVT, multiple transient ischemic attacks of aphasia were observed.
While the patient was a candidate for mechanical thrombectomy based on CT perfusion imaging, given the unsuccessful reports in the literature and the interventional radiol-ogist's experience, the decision was made to offer microsurgical embolectomy of the calcified cerebral embolus.(3) Informed consent for the procedure was obtained directly from the patient. Calcified, crumbly embolus was removed from a 5 mm longitudinal arteriotomy.
The arteriotomy was sutured with interrupted 10-0 suture. Initial flow after the embolectomy was 6.5 mL/min.
Upon inspection, a distal kink was found in the M2 and after repositioning, flow improved to 35 mL/min. Postoperative CT angiography documented complete recanalization.
The clinical findings completely resolved (NIHSS 0) within 12 hr and remained unchanged at 3 mo and 1 yr. Informed consent was obtained fromthe patient for use of media for educational and publication purposes.