Operative Technique

The Anterior Temporal Approach for

Microsurgical Thromboembolectomy of an Acute
Proximal Posterior Cerebral Artery Occlusion
Felix Goehre, MD*
Hiroyasu Kamiyama, MD‡
Akira Kosaka, MD‡
Toshiyuki Tsuboi, MD‡
Shiro Miyata, MD‡
Kosumo Noda, MD‡
Behnam Rezai Jahromi, MB§
Nakao Ohta, MD‡
Sadahisa Tokuda, MD‡
Juha Hernesniemi, MD, PhD§
Rokuya Tanikawa, MD‡
*Department of Neurosurgery, Stroke
Center, Bergmannstrost Hospital Halle,
Halle, Germany; ‡Department of Neuro-
surgery, Stroke Center, Sapporo Teishinkai
Hospital, Sapporo, Japan; §Department of
Neurosurgery, Helsinki University Central
Hospital, Helsinki, Finland
Correspondence:
Felix Goehre, MD,
Department of Neurosurgery,
Stroke Center,
Bergmannstrost Hospital Halle,
Merseburger Straße 165, 06112 Halle,
Germany.
E-mail: felix.goehre@iwmh.fraunhofer.de
Received, September 9, 2013.
Accepted, December 20, 2013.
Published Online, December 30, 2013.
BACKGROUND: In a short window of time, intravenous and intra-arterial thrombolysis
is the first treatment option for patients with an acute ischemic stroke caused by the
occlusion of one of the major brain vessels. Endovascular treatment techniques provide
additional treatment options. In selected cases, high revascularization rates following
microsurgical thromboembolectomy in the anterior circulation were reported. A tech-
nical note on successful thromboembolectomy of the proximal posterior cerebral artery
has not yet been published.
OBJECTIVE: To describe the technique of microsurgical thromboembolectomy of an
acute proximal posterior cerebral artery occlusion and the brainstem perforators via the
anterior temporal approach.
METHODS: The authors present a technical report of a successful thromboembolec-
tomy in the proximal posterior cerebral artery. The 64-year-old male patient had an
acute partial P1 thromboembolic occlusion, with contraindications for intravenous re-
combinant tissue plasminogen activator. The patient underwent an urgent microsur-
gical thromboembolectomy after a frontotemporal craniotomy.
RESULTS: The postoperative computerized tomography angiography showed com-
plete recanalization of the P1 segment and its perforators, which were previously
occluded. The early outcome after 1 month and 1 year follow-ups showed improvement
from modified Rankin scale 4 to modified Rankin scale 1.
CONCLUSION: Microsurgical thromboembolectomy can be an effective treatment
option for proximal occlusion of the posterior cerebral artery in selected cases and
experienced hands. Compared with endovascular treatment, direct visual control of
brainstem perforators is possible.
KEY WORDS: Anterior temporal approach, Microsurgical technique, P1, Posterior cerebral artery, Throm-
boembolectomy
Operative Neurosurgery 10:174–178, 2014 DOI: 10.1227/NEU.0000000000000284

F
Copyright © 2013 by the
or the treatment of acute ischemic stroke
Congress of Neurological Surgeons. presenting within a 3-hour time window,
the intravenous application of recombi-
nant tissue plasminogen activator (r-tPA) is
a level IA recommendation and has been
included in the treatment guidelines of several
countries.1-4 Occlusions of proximal intracra-
ABBREVIATIONS: ICG, indocyanine green; mRS,
modified Rankin scale; P1, precommunicating
segment of posterior cerebral artery; PCA, posterior
cerebral artery; r-tPA, recombinant tissue plasmin-
ogen activator
nial vessels do not respond well to systemic
intravenous thrombolysis.5 As a result, endo-
vascular therapies for these proximal cerebral
vessel occlusions have evolved over the past
few years. These newer therapies include intra-
arterial drug-related thrombolysis, stenting,
and mechanical thromboembolectomy or
embolectomy.6-12
The first surgical thromboembolectomy of an
intracranial vessel was reported by Welch in
1956.13 Since then, there have been several
promising reports of successful microsurgical
embolectomies in the anterior cerebral circula-
tion.14-18 As a result of their deep anatomic

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location, the main trunks of the vertebrobasilar system,
including the posterior cerebral artery (PCA), are more difficult
to approach surgically.19-22 To date, there have been no detailed
reports in the literature of a successful embolectomy of the PCA.
The preservation of midbrain and perforating branches to the
brainstem from the P1 segment (the precommunicating
segment of PCA) is critical for the revascularization of the
proximal PCA.21
The objective of this technical report is to present the
microsurgical technique for a thromboembolectomy of a right-
sided P1 segment of the PCA under direct visual control of the
perforating branches via the anterior temporal approach.
ILLUSTRATIVE CASE
History and Examination
A 64-year-old man became suddenly unconscious while
watching television, and was immediately transferred to our
hospital. On arrival he was comatose, and National Institutes of
Health stroke scale score was 40. He had been taking warfarin for
5 years for atrial fibrillation, and was found to have an
international normalized ratio of 2.5. The warfarin effect was
slowly reversed with vitamin K. The magnetic resonance
angiography reconstruction displayed a flow reduction in
P1 segment (Figure 1A), the diffusion weight image indicated
no pathological changes (Figure 1B), and, in axial magnetic
resonance angiography, an embolus short before the P1/2
junction was visible (Figure 1C). Single photon emission
computed tomography was not performed. Shortly before the
patient arrived at our hospital, an endovascular procedure for
another patient had begun in our angiography room; conse-
quently, there were no immediate facilities to perform a further
endovascular revascularization procedure. Therefore, the deci-
sion was made to perform a microsurgical embolectomy.
FIGURE 1. A, the preoperative MRA reconstruction (reveals a flow reduction to the right proximal posterior cerebral artery (arrows). B, the preoperative diffusion-weighted
image indicates no pathological changes. C, the embolus (arrow) is visible short before the right P1/2 junction in axial MRA. MRA, magnetic resonance angiography.
OPERATIVE NEUROSURGERY
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P1 EMBOLECTOMY
SURGICAL TECHNIQUE
Positioning and Craniotomy
The patient was placed in the supine position with the head
rotated 30° to the left using a Mayfield clamp. The head was
slightly elevated above the heart level. A fast 1-layer skin-muscle
flap followed by a regular frontotemporal craniotomy was
performed.
Intracranial Dissection
The proximal portion of the sylvian fissure was carefully
dissected. The M1 portion of the right middle cerebral artery
was exposed with respect to the letriculostriatal perforators. The
temporal uncus was then retracted posteriorly via an anterior
temporal approach. The oculomotor nerve and the posterior
communicating artery were visible in the carotid-oculomotor-
triangle (Figure 2, Figure 3A). Indocyanine green (ICG) video-
angiography was performed for the distal segments of PCA filling
via posterior communicating artery. A thrombus was found to
occlude the P1 segment of the PCA, where no intraluminal flow
was visible inside the affected segment (Figure 3B). One
dominant perforating branch of the P1 segment was filled.
Arteriotomy and Embolectomy
Under direct visual control, temporary microclips can be placed
on the PCA for the distal and proximal occlusion of the affected
P1 segment. The arteriotomy was performed in the transverse
direction (Figure 3C). The thrombus material was carefully
removed from the vessel lumen (Figure 3D), and the exposed P1
segment inside was irrigated. Afterward, the distal temporary clip,
followed by the proximal temporary clip, was partially opened in
order to wash out the remaining intraluminal thrombi through
the arteriotomy. The arteriotomy was closed with 3 interrupted
sutures using 10-0 microthread (Figure 3E).
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GOEHRE ET AL

Postoperative Course
The patient was woken just after the surgery. The postoperative
computerized tomography angiography show a reconstructed
PCA angioarchitecture (Figure 4). Although the diffusion weight
image revealed a small high-signal area in the right thalamus, no
additional ischemic lesions had appeared. The patient was
discharged 1 month later after the onset prognosis with a modified
Rankin scale (mRS) of 4. After 1 year of rehabilitation, he made
a good recovery, improving to mRS 1.

FIGURE 2. Schematic drawing of the PCoA complex showing the transverse
arteriotomy for the microsurgical P1 segment thromboembolectomy. A1, anterior
cerebral artery A1 segment; E, embolus occlusion; ICA, internal carotid artery;
M1, middle cerebral artery; P, midbrain perforating branches; P1, posterior
cerebral artery P1 segment; P2, posterior cerebral artery P2 segment; PCoA,
posterior communicating artery; TC, temporary clip; arrow, transverse arterio-
tomy.
Intraoperative ICG Videoangiography
Postembolectomy ICG videoangiography provided real-time
images of the blood flow inside the recanalized P1 segment (Figure
3F). All midbrain-perforating branches were preserved.
Operation Time
The operation began 3.5 hours after the onset of symptoms.
The right PCA was recanalized (Figure 3F, Figure 4) after
30 minutes, and the entire surgery was finished in 70 minutes.
DISCUSSION
Ischemic stroke is now a leading cause of death and disabil-
ity.23,24 The development of medical imaging and physiological
investigations during the last century have led to a better
understanding of the pathophysiology of the underlying causal
diseases.25,26 In addition, effective treatment and prevention
strategies have been developed. More recently, cardiac arrhyth-
mias and coagulopathic diseases can be effectively treated to
prevent the event of a stroke.27
Acute stroke is an emergency requiring a thorough knowledge of
the duration of symptoms, a short rescue time, and prompt in-
hospital treatment, the treatment goal being to prevent secondary
and continuous brain damage.28 The required logistic for the pre-
and in-hospital rescue management, which is necessary for the
stroke management method that we have described, is the
limiting factor in many regions worldwide.
Various studies have demonstrated the benefits of intravenous
application of r-tPA in a 3-hour window in acute stroke therapy.1-4
Subsequently, the use of systemic r-tPA, when strict suitability
criteria are fulfilled, became a level IA recommendation for the

FIGURE 3. After dissecting the proximal PCA (A) an ICG videoangiography shows a distal P1 segment occlusion (B) A transverse arteriotomy is performed (C) and the
embolus is removed (D) from the vessel lumen. The arteriotomy is closed with interrupted sutures (E). The second ICG videoangiography (F) demonstrates open perforators from
the initial occluded distal P1 segment. ICG, indocyanine green; PCA, posterior cerebral artery.

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FIGURE 4. The postoperative computerized tomography angiography shows
a reconstructed angioarchitecture of the right posterior cerebral artery (arrows).
29
treatment of acute strokes in several countries. The occlusion of
larger proximal intracranial vessels does not respond well to
systemic intravenous thrombolysis.5 This has led to further
development of endovascular methods for these proximal cerebral
vessel occlusions, including intra-arterial drug-related thrombol-
ysis, stenting, and mechanical thromboembolectomy or embo-
lectomy.6-12
Several reports on successful microsurgical embolectomies in
the anterior cerebral circulation have been published, with the first
by Welch in 1956.13 A high recanalization rate of up to 100% was
reported in a few case series.17,30 Over the following years,
microsurgical revascularization procedures were extensively tested
in laboratory and animal trials.31,32 As a result, new revascular-
ization techniques were established.18 The outcome was not only
related to recanalization, but also to other factors such as timing
of surgery, localization of the vessel occlusion, and collateral flow
having a high impact.30 The following complications were
reported: obstruction of the vessel, cortical, subcortical cerebral
infarction, hemorrhagic transformation of infarction area, uncal
herniation, and lack of symptomatic improvement.17
Open microsurgical thromboembolectomy of the upper poste-
rior circulation is a challenging surgical procedure.33 The
preservation of all midbrain and brainstem perforating branches
of the P1 segment is critical for the revascularization of the
proximal PCA. The surgical field has to be approached through
a deep, narrowed corridor surrounded by several sensitive
structures.21,22,34,35 This approach provides enough work space
for fine instrument movements and microsutures without intense
brain tissue retraction.36,37 Because of modern microsurgical
OPERATIVE NEUROSURGERY
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
P1 EMBOLECTOMY
techniques, this approach has become a relatively safe procedure
in experienced hands.36,37 The microsurgical intracranial dissec-
tion is performed through the subarachnoid space, almost
without affecting the neural tissue. Intraoperative ICG video-
angiography provides real-time images of blood flow and allows
an immediate evaluation of recanalization.38
As a result, in our case, the thromboembolus was removed from
the vessel lumen without any technical problem. In addition, the
arteriotomy was closed by interrupted sutures without constrin-
gence of the vessel lumen. A complete revascularization of the
affected PCA was achieved, and no perioperative complications
were observed.
CONCLUSION
Microsurgical thromboembolectomy is a viable treatment option
for the recanalization of the proximal PCA in experienced hands.
With the use of modern microsurgical techniques, a safe approach is
possible. Compared with endovascular treatment, the important
perforating branches can be preserved under direct visual control. A
critical preoperative decision-making process is needed based on
various factors such as vessel occlusion time, collateral flow,
anatomic characteristics of the PCA, and microsurgical skills.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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COMMENTS
T
his article reports the well-known technique of thromboembolectomy
applied for the first time at the level of the P1 segment of the posterior
cerebral artery. The use of intravenous systemic thrombolysis and the
advent of endovascular drug and mechanical therapies will limit the
application of such surgical techniques. Thromboembolectomy can
nevertheless be extremely valuable in some selected indications.
Michaël Bruneau
Brussels, Belgium
T
he authors report on the first successful case of a surgical P1 segment
embolectomy. The endovascular suite was not available, and, there-
fore, the patient was expeditiously taken to the operating room 3.5 hours
after the ictus where a craniotomy and embolectomy were performed
within 30 minutes. At 1-year follow-up the patient recovered from an
mRS of 4 to an mRS of 1. They are to be commended on their surgical
skills and speedy reestablishment of blood flow through that segment. As
illustrated in this report, reestablishment of blood flow to the P1 segment
perforators is vital to patient recovery. Direct surgical embolectomy is still
a viable option, especially when endovascular intervention is not available.
The administration of IV tPA could have been another option, now that
the time window for IV tPA administration in an acute stroke has been
extended from 3 to 4.5 hours.
Jafar Jewad Jafar
New York, New York
T
he authors have presented a case of posterior cerebral artery embo-
lectomy, about 3 and 1/2 hours after the acute ictus. The authors and
their operative team are to be commended for this. However, in most
institutions, endovascular retrieval of clot can be done more quickly than
surgical embolectomy. Just to set up the operation takes about 30 minutes,
and another 30 to 60 minutes are needed in order to get down to the artery
in question. Therefore, endovascular embolectomy is much more practical
than surgical embolectomy. In rare situations, when the endovascular
technique fails, surgery may be performed, if the patient is still in the
window for revascularization, and major stroke has not occurred. Tech-
nically, it is quite easy to get down to the PCA P2 segment when the basilar
artery bifurcation is in a normal position (not very high or very low). Also,
embolic occlusion must be carefully distinguished from local atheroscle-
rotic occlusion, the latter is not amenable to microsurgical or even
endovascular reopening.
Laligam N. Sekhar
Seattle, Washington
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