EXTENDED SUPERCILIARY APPROACH FOR MIDDLE CEREBRAL ARTERY EMBOLECTOMY AFTER UNSUCCESSFUL ENDOVASCULAR RECANALIZATION THERAPY

OBJECTIVE: Although an intra-arterial mechanical embolectomy extends the therapeutic time window for restoration of the cerebral blood flow, its suboptimal recanalization rate also necessitates a salvage procedure if the patient is still within the therapeutic time window. As such, a surgical embolectomy can be performed in a rapid and less invasive manner for an acute middle cerebral artery (MCA) occlusion. The technical details of this procedure are discussed and demonstrated. METHODS: Four patients with an acute MCA occlusion were treated using a novel surgical embolectomy technique after unsuccessful intra-arterial mechanical recanalization therapy. Unique to the proposed surgical technique are a laterally extended superciliary approach, small (3-mm) arteriotomy, and closure of the arteriotomy using an aneurysm clip after removal of the intravascular embolus. RESULTS: Occluded MCAs were successfully recanalized using the present technique, and the operative time from skin incision to recanalization was 1 to 1.5 hours in each patient. One to 3 arteriotomies were made in each patient. Six of the 8 arteriotomies in the present series were closed using an aneurysm clip, whereas the other 2 arteriotomies were repaired using microsutures. Postoperative angiograms demonstrated patent MCAs without remarkable clip-induced stenosis. The successful recanalization provided considerable neurological improvement in all patients without procedural complications, except for 1 patient with a fatal putaminal hemorrhage resulting from a reperfusion injury. CONCLUSION: A laterally extended superciliary approach and clip application for arteriotomy closure enable a surgical embolectomy to become a rapid and less invasive procedure.