Minimally invasive and rapid surgical embolectomy (MIRSE) as rescue treatment following failed endovascular recanalization for acute ischemic stroke

Background: An intra-arterial (IA) mechanical thrombectomy has increased the recanalization rates for acute occlusion of proximal intracranial arteries. However, the current failure rate of endovascular recanalization remains at approximately 10 %, resulting in the need for surgical rescue treatment. The authors applied a minimally invasive and rapid surgical embolectomy (MIRSE) as a final rescue treatment after the failure of endovascular recanalization, and investigated the incidence, technical feasibility, and treatment results.

Methods: For two years, from 2012 to 2013, a total of 131 patients with acute occlusion of proximal intracranial arteries underwent an IA mechanical thrombectomy using a Penumbra System and a Solitaire stent, yet ten (7.6 %) patients still experienced final recanalization failure. Four (40 %) of these ten patients subsequently underwent a MIRSE consisting of a superciliary keyhole approach, arteriotomy to remove the embolus, and arteriotomy repair techniques using aneurysm clips as the final repair material, or a temporary compartmentalizing clip.

Conclusions: A MIRSE can be an effective rescue treatment after the failure of endovascular recanalization therapies for acute occlusion of proximal intracranial arteries if the patient is within the therapeutic time window.

Results: Four patients aged 39 to 78 years with an embolic occlusion in the middle cerebral artery (n = 1) and internal carotid artery (n = 3) were treated using a MIRSE. Complete recanalization was achieved in all four patients, and the time from skin incision to reperfusion was 40–50 minutes. The modified Rankin Scale (mRS) scores at 3 months after surgery were 1 (n = 2), 2 (n = 1), and 3 (n = 1), respectively.