Surgical and Nonsurgical Treatment for Acute Occlusion of the Middle Cerebral Artery

Prognostic factors were studied in 31 cases of acute occlusion of the middle cerebral artery (MCA). Sixteen were treated with thrombolysis, 4 with embolectomy, 2 with STA-MCA anastomosis and 9 with conservative therapy. Urokinase up to 48×104 IU was administered intraarterilly or prourokinase 1500 IU was injected through the microcatheter introduced proximal and distal to the occlusion site. MCA was recanalized in 8 patients completely and in 4 partially while no recanalization was occured in 4 patients. Complete patency of the MCA was achieved by embolectomy and STA-MCA anastomosis. Good outcome were obtained in the patients with good collateral circulation. Early recanalization in less than 6 hours from onset of symptoms showed favorable outcome except for 1 severely disabled patient in whom thrombolysis was completed 4 hours after occlusion. Sixty percent of cases of occlusion of the proximal M1 that resulted in ischemia of the territory of the perforating arteries showed poor outcome. Even in cases of good recovery from M1 proximal occlusion CT scan revealed infarction in the basal ganglia indicating rapid irreversible change develops after ischemic insult in this area. These results suggest that in cases without low densities on CT, early and complete recanalization of the MCA by thrombolysis, especially M1 segment including perforators, is the best treatment of occlusion of the MCA before completion of ischemic lesions. Embolectomy and STA-MCA anastomosis are recommended in some cases with incomplete recanalization by thrombolysis.