Emergency embolectomy for embolic occlusion of the middle cerebral artery-review of the literature and two illustrative cases.

With the increasing number of endovascular interventions during the last years, the number of procedure-related complications has risen accordingly. Despite sophisticated and effective endovascular treatments for acute thromboembolic events during intervention, vessel occlusion can remain refractory to medical and endovascular treatment. In case of failure of the endovascular revascularisation, microsurgical embolectomy in the anterior circulation can be a last therapeutic option, if case selection is adequate. To date, this rather aggressive form of treatment is still controversial, and there are only few series of reported surgical embolectomy. In the present review, we conducted a Medline (www.pubmed.org) search for reports or studies of microsurgical embolectomies using the keywords (1) middle cerebral artery (MCA) occlusion and (2) embolectomy. The most relevant factors for positive outcome were concluded as such: (1) vessel occlusion time, (2) collateral flow, (3) occlusion site and (4) thromboembolic origin. Additionally, we report on two illustrative cases from our department with acute MCA occlusion treated by emergency microsurgical embolectomy but with very contrary outcomes. Hence, emergency embolectomy in patients with MCA occlusion following endovascular treatment can be quite effective, if endovascular recanalisation options fail. Nevertheless, the decision-making process must be made critically, fast and based on factors such as vessel occlusion time, sufficient collateral flow, occlusion site and thrombus origin.