Microsurgical Thrombectomy: where the ancient art meets the new era

Microsurgical Thrombectomy: where the ancient art meets the new era | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Microsurgical Thrombectomy: where the ancient art meets the new era Nakao Ota, Arnau Benet, Muhammad Kusdiansah, Norio Miyoshi, Kenichi Haraguchi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3577955/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Jan, 2024 Read the published version in Neurosurgical Review → Version 1 posted 8 You are reading this latest preprint version Abstract Background Mechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option(developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world. Methods Clinical outcomes, procedural times and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST. Results One-hundred nine patients fulfilled the study criteria (77MTs vs 32STs). Factors driving outcome were age (aOR:0.95, 95%CI, 0.91-0.98), hemisphere side (aOR:0.38, 95%CI, 0.15-0.96), DWI-ASPECT (aOR:1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure(P=0.45), and start of procedure-recanalization(P=0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization(P=0.155) and outcome(P=0.221). Conclusions The prognosticator of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients. global neurosurgery surgical thrombectomy large vessel occlusion mechanical thrombectomy middle cerebral artery occlusion carotid endarterectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Endovascular treatment of large vessel occlusion (LVO) has changed stroke outcomes in a way few medical advances have in the history of medicine[ 1 – 3 ]. Nowadays, endovascular techniques have evolved where a TICI 2b-3 is expected, with full resolution of symptoms and a functional recovery[ 3 , 4 ]. Endovascular treatment of stroke may be performed by a variety of medical specialties (i.e. neurology, neurosurgery, interventional radiology), the regulations of which vary in each country (or state). Before the publication of the large randomized controlled trial on the efficacy of mechanical thrombectomy[ 1 ], the only established LVO treatment was intravenous administration of tissue plasminogen activator[ 5 ]. However, its effects were very limited, especially in the case of internal carotid or proximal middle cerebral artery occlusion[ 6 ]. Surgical thrombectomy was one of the treatment options for LVO, although its efficacy was reported only in limited case series and reports[ 7 – 11 ]. A recent randomized prospective study on the efficacy of microsurgical thrombectomy for LVO stroke after failed mechanical thrombectomy favored surgical thrombectomy as a rescue option[ 12 ]. In addition, surgical thrombectomy may play an important role in patients with LVO acute stroke with no feasible endovascular access route, a severe tandem lesion, or iodine allergy. In this study, we compared our experience treating acute LVO stroke through either mechanical thrombectomy (Endovascular) or surgical thrombectomy and discussed the potential role for surgical thrombectomy in the era of mechanical thrombectomy not only in developed countries but also in developing countries. This is the first report to directly compare mechanical and surgical thrombectomy. Materials and Methods The study received approval from the Institutional Review Board and the requirement for informed consent was waived for each patient. The clinical outcomes, procedural times and efficacy of treatment were compared between the endovascular mechanical thrombectomy and microsurgical embolectomy groups for patients presenting with acute large vessel occlusion in our institute between 2012 and 2022. An emergent computed tomography(CT) angiography from femoral artery to intracranial vessels was performed for preoperative treatment strategy; including mapping the arterial occlusion (e.g. location, size, parent arteries, etc.), defining important surrounding anatomy (e.g. ipsilateral superficial temporal artery), and determining access. Patients were initially assessed with head magnetic resonance imaging (MRI; DWI, FLAIR, T2 sequences) at arrival to the emergency department. The gold standard treatment for acute LVO in our institution was either medical management or microsurgical thrombectomy until 2017, when the endovascular mechanical thrombectomy became gold standard in the Japanese stroke management guidelines and thus our first line of therapy. Our institutional surgical thrombectomy protocol and indications (before 2017) included: tissue at risk within the common carotid, internal carotid, or proximal middle cerebral artery territories; arriving to the operating room within 4.5 hours of symptom onset; presence of DWI to clinical symptom mismatch; mRS < 3 before symptom onset; good surgical and anesthesia candidate. After 2017 we only performed surgical thrombectomy on patients that crossed over from a failed endovascular thrombectomy (TICI < 2) after reasonable effort. Exclusion criteria were a final TICI 0–1, mRS < 3 before symptom onset, posterior circulation occlusion, missing demographic or follow up data, unknown time of onset of symptoms (Fig. 1 ). A total of 109 patients fulfilled the study criteria (77 endovascular mechanical thrombectomy, 32 surgical thrombectomy). Patient demographics, clinical, and radiographic data were collected from hospital charts, telephone interviews, or patient letters. Patient characteristics, including age, sex, and comorbidities (hypertension, diabetes mellitus, and atrial fibrillation) at the time of LVO were recorded. The time of onset to emergency room (ER), time from ER to skin incision or puncture, and time of skin incision or puncture to recanalization were recorded. Affected vessel was classified to 1; Internal carotid artery, 2; middle cerebral artery and 3; Internal carotid and middle cerebral artery tandem lesion. Good clinical outcome was defined as mRS < 3 at 90 days after LVO. Statistical analysis Data are expressed as mean ± standard deviation, median (interquartile range), or number of patients (%), as appropriate. For continuous variables, normality of the data was evaluated using the Shapiro-Wilk test. Normally distributed continuous variables were compared using the Student’s t-test, and the rest were compared using the Mann-Whitney U-test. The chi-square test or Fisher’s exact test was used to analyze nominal variables, as appropriate. Treatment indications and patient conditions were not identical for the surgical and mechanical thrombectomy groups. Therefore, we conducted propensity score-matched analysis to adjust for bias in the total surgical embolectomy and mechanical thrombectomy groups. One-to-one matched analysis used the nearest-neighbor method without replacement with the closest estimated propensity score within a caliper (0.2 of the pooled standard deviation). Covariates used to calculate propensity score were age, sex, affected side, National Institutes of Helath Stroke Scale (NIHSS), diffusion weighted imaging Alberta Stroke Programe Early Computed Tomography (DWI ASPECT) score, affecting vessel, time of onset to door and commoribidity of hypertension, diabetes mellitus and atrial fibrillation. Any differences associated with good outcome that were statistically significant(P < 0.05) in univariate analyses and seemed to be clinically important such as time of onset to recanalization, tPA administration and treatment methods were further analyzed with a multivariate logistic regression adjustment. The goodness of fit of the regression model was confirmed by demonstrating a non-significant P-value in the Hosmer-Lemeshow test. Data were analyzed using IBM SPSS Statistics for Mac (version 27.0, IBM Corp.; Armonk, NY, USA). Differences with P < 0.05 were deemed statistically significant. Results Patient demographics are presented in Table 1 . Age, sex and comorbidity were not statistically different between treatment groups. Fewer patients received tPA administration in the surgical group (P < 0.001). Patients in the surgical group had a lower NIHSS (P = 0.003) and DWI-ASPECT (P = 0.034) scores. The modified Rankin scale score at 90 days of both mechanical and surgical treatment is illustrated in Fig. 2 . Table 1 Baseline characteristics of both treatment options. Variables Mechanical N = 77 Surgical N = 32 P value Age (median, IR) 75.0(19) 72.5(16) 0.300 Female sex 39(50.6) 12(37.5) 0.210 Hypertension 41(53.2) 22(68.8) 0.136 Diabetes Mellitus 19(24.7) 8(25.0) 0.971 Atrial fibrillation 45(58.4) 19(59.4) 0.928 tPA 50(64.9) 2(6.3) < 0.001 Left side 43(55.8) 13(40.6) 0.148 NIHSS 19.0(± 8.3) 14.0(± 6.5) 0.003 DWI ASPECT (median, IR) 9.0(3) 9.0(2) 0.034 Door to Puncture/ Door to Skin incision (median, IR) 69.0(23) 73.5(67) 0.450 Puncture to Recanalization/ Skin incision to Recanalization (median, IR) 42.0(36) 32.5(22) 0.133 Onset to Door (median, IR) 58.0(96) 58.5(114) 0.897 Door to recanalization (median, IR) 120.0 (46.5) 101.5 (93.8) 0.615 Onset to Recanalization (median, IR) 187.0(102) 231.5(170) 0.170 Affecting vessel Internal carotid artery 18 (23.4) 5 (15.6) Reference Middle cerebral artery 56 (72.7) 21 (65.6) 0.596 Tandem 3(3.9) 6(18.8) 0.023 Treatment Related complication 5(6.5) 6(18.8) 0.078 mRS at discharge (median, IR) 2.0(4) 2.0(4) 0.336 mRS at 3month (median, IR) 2.0(3) 2.5(2) 0.860 Good Outcome mRS 0–2 47(61.0) 20(62.5) 0.886 IR; interquartile range, NIHSS; National Institutes of Health Stroke Scale, tPA; tissue plasminogen activator, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography, mRS; modified Rankin Scale Complications after surgical thrombectomy occurred in 6 patients (18.8%). Of these, 4 required re-operation for 1 case of acute epidural hematoma, 1 case of acute subdural hematoma and 1 case of distal embolism fragmentation on post-operative MRI requiring re-thrombectomy for distal M2 segment. The other 3 cases were managed consecutively, 1 case of acute renal failure treated with hemodialysis, 1 case of congestive heart failure and 1 case of postoperative hyperperfusion syndrome. The box plot of both treatment groups is illustrated in Fig. 3 . A univariate analysis revealed that door to puncture/ skin incision (P = 0.450) and puncture/ skin incision to recanalization (P = 0.133) times were not statistically significant. There was a high variability in the time of door to skin incision in the surgical group and in the time of puncture to recanalization in the mechanical thrombectomy group. Factors driving good outcome Univariate analysis for the variable good outcome is shown in Table 2 . Age (P = 0.001), left hemisphere (P = 0.033), NIHSS score (P = 0.006) and DWI-ASPECT score (P = 0.012) were statistically significant drivers of outcome. On the other hand, the time of onset to recanalization were not statistically significant predictors of outcome (P = 0.610). Table 2 Univariate analysis of factors driving good outcome. Variables Good Outcome NO = 42 Good Outcome YES = 67 P value Age (median, IR) 81.0(13) 71.0(19) 0.001 Female SEX 23(54.8) 28(41.8) 0.187 Hypertension 25(59.5) 38(56.7) 0.773 Diabetes Mellitus 13(31.0) 14(20.9) 0.237 Atrial fibrillation 29(69.0) 35(52.2) 0.083 tPA 20(47.6) 32(47.8) 0.988 Left side 27(64.3) 29(43.3) 0.033 NIHSS 20.2(± 7.8) 15.9(± 7.9) 0.006 DWI ASPECT (median, IR) 8.0(3) 9.0(2) 0.012 Affecting vessel Internal carotid artery 12 (28.6) 11 (16.4) Reference Middle cerebral artery 27 (64.3) 50 (74.6) 0.144 Tandem lesion 3(7.1) 6(9.0) 0.342 Door to Puncture/ Door to Skin incision (median, IR) 67.0(23) 70.0(38) 0.349 Puncture to Recanalization/ Skin incision to Recanalization (median, IR) 43.5(42) 41.0(29) 0.755 Door to recanalization (median, IR) 107.0(68.5) 122.0(54.0) 0.513 Onset to Door (median, IR) 60.0(115) 55.0(78) 0.913 Onset to Recanalization (median, IR) 176.5(175) 199.0(113) 0.610 Treatment Related complication 7(16.7) 4(6.0) 0.102 Mechanical thrombectomy 30(71.4) 47(70.1) 0.886 IR; interquartile range, NIHSS; National Institutes of Health Stroke Scale, tPA; tissue plasminogen activator, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography, mRS; modified Rankin Scale Multivariate logistic regression analysis showen in Table 3 . Age (aOR 0.945, 95%CI[0.91–0.98]), hemisphere side (aOR 0.382, 95%CI[0.15–0.96]) and DWI ASPECT score (aOR 1.389, 95%CI [1.09–1.77]) were independent predictors of good outcome. Treatment modality (i.e. endovascular or surgical thrombectomy) did not have a statistically significantly different outcome (aOR 0.498, 95%CI [0.18–1.38]). The time from symptom onset to recanalization was not statistically significant for outcome in this series (aOR 1.000, 95%CI[0.997-1.000]). Table 3 Multivariate logistic regression analysis associated with good outcome. Characteristics Adjusted Odds ratio CI (95%) p-value Age (continuous variable) 0.95 0.91–0.98 0.004 Surgical Thrombectomy 0.50 0.18–1.38 0.180 Left side 0.38 0.15–0.96 0.041 NIHSS score per 1 point increment 0.96 0.90–1.02 0.144 DWI ASPECT score per 1 point increment 1.34 1.09–1.77 0.008 Onset to recanalization (min) 1.00 1.00–1.00 0.826 CI, confidence interval, NIHSS; National Institutes of Health Stroke Scale, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography Propensity score-matched analysis between mechanical and surgical thrombectomy Patient characteristics in the propensity score-matched analysis of mechanical and surgical thrombectomy are illustrated in Table 4 . Baseline population included 77 cases in mechanical thrombectomy and 32 cases in the surgical thrombectomy group. Propensity score-matched analysis compared 24 cases in each group. After propensity score-matching excluding tPA administration, the baseline characteristics of the patients were well balanced between the groups. The C statistic for goodness of fit was 0.77 (95% CI, 0.68–0.87). The proportions of time to recanalization (P = 0.155), Onset to recanalization (P = 0.821), treatment related complication (P = 0.174) and rate of good outcome (P = 0.221) were not statistically significant compared both groups. Table 4 Characteristics in the propensity score- matched patients by surgical embolectomy and mechanical thrombectomy Variables Mechanical N = 24 Surgical N = 24 P value Age(mean, SD) 73.1 (± 15.4) 71.0 (± 11.4) NA Female sex 15 (62.5) 11 (45.8) NA Hypertension 16 (66.7) 14 (58.3) NA Diabetes Mellitus 9 (37.5) 6 (25.0) NA Atrial fibrillation 11 (45.8) 14 (58.3) NA tPA 16 (66.7) 4 (16.7) < 0.001 Left side 7 (29.2) 8 (33.3) NA NIHSS 13.7 (± 8.0) 14.6 (± 6.6) NA DWI ASPECT (median, IR) 9.0 (2) 9.0 (3) NA Door to Puncture/ Door to Skin incision (median, IR) 73.5 (24) 60 (64) 0.403 Puncture to Recanalization/ Skin incision to Recanalization (median, IR) 41.0(37) 31.0 (19) 0.205 Onset to Door (median, IR) 77.0 (133) 53.5 (114) NA Door to recanalization (median, IR) 125.5 (56.0) 93.0 (81.0) 0.155 Onset to Recanalization (median, IR) 217.5(162) 216.5(174) 0.821 Affecting vessel NA Internal carotid artery 7 (29.2) 5 (20.8) Middle cerebral artery 16 (66.7) 17 (70.8) Tandem lesion 1 (4.2) 2 (8.3) Treatment Related complication 1 (4.2) 4 (16.7) 0.174 mRS at discharge (median, IR) 2.0 (2) 3.0 (2) 0.522 mRS at 3month (median, IR) 1.0 (4) 2.0 (4) 0.330 Good Outcome mRS 0–2 18 (75.0) 14 (58.3) 0.221 IR; interquartile range, NIHSS; National Institutes of Health Stroke Scale, tPA; tissue plasminogen activator, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography, mRS; modified Rankin Scale Cases of surgical or mechanical failure are reported in Supplemental material 1. Operative technique for emergent surgical thrombectomy: team efficiency was speed. The key to a fast surgical thrombectomy was specific distribution of sequential surgical steps by a team of 1 neurosurgeon experienced in surgical thrombectomy and at least 1 assistant (optimally 2). A curved pterional incision (1cm anterior to tragus until midline at hairline) was followed by elevation of a musculocutaneous flap and a modified pterional craniotomy (dissection by the primary neurosurgeon and constant hemostasis by the assistant were performed in simultaneous coordination). While the assistant maintained hemostasis of the middle meningeal artery, the primary neurosurgeon opened dura and incised the outer arachnoid membrane without delay. The key to speed was for the assisting surgeon(s) to continuously maintain hemostasis, which allowed the primary surgeon to focus on an uninterrupted dissection from dural incision until thrombectomy was finished. Sylvian fissure split was custom to the anticipated exposure needed (e.g. narrow for MCA, wider for upper basilar). Upon exposure of the occlusion site, the proximal (assistant) and distal (primary neurosurgeon) clips are applied simultaneously. Immediately after, a perpendicular arteriotomy revealed the thrombus. Release of the proximal clip allowed for anterograde blood flow to eject the thrombus until bleeding occurred, at which time the assistant closed the proximal clip while the primary neurosurgeon sutured the arteriotomy closed . Adoption of our operating room setup protocol for emergent surgical thrombectomy reduced door to treatment time by 1 hour. A dedicated surgical thrombectomy instrument set was always on stand-by, requiring only unboxing and sterile arrangement by trained scrubbed nurses. Team coordination also included patient transfer, emergency department personnel and radiologist, all of which were able to reduce door to treatment time to within 1 hour as previously reported[ 13 ]. An illustrative case of surgical thrombectomy is included in video and Supplementary Material 2. Discussion This study shows that the efficacy of surgical thrombectomy in achieving good outcomes after acute LVO is not inferior to that of the endovascular mechanical thrombectomy. Our results reveal that a surgical team experienced in the treatment of acute LVO can provide door to treatment and start of treatment to recanalization times similar to those of endovascular mechanical thrombectomy, and with full flow replacement (either through direct thrombectomy or bypass). Most failed endovascular treatments of acute LVO stroke were related to precipitating atherosclerotic intracranial disease or arterial dissection. Surgical rescue of such cases provided restoring flow via an emergent STA-MCA bypass. The main clinical outcome drivers in our study were age, hemisphere side, and DWI-ASPECT score at presentation. Few authors have reported their experience in the surgical treatment of acute LVO through single center case series or case reports[ 7 – 11 , 14 , 15 ]. The reported advantages of surgical thrombectomy include a high rate of recanalization[ 8 , 10 ] rare occurrence of distal migration or segmentation of the thrombus[ 8 , 16 ], the capacity to perform a simultaneous cervical carotid thrombectomy or CEA[ 15 ], and its role as rescue treatment for either failed endovascular mechanical thrombectomy or its contraindications (e.g. severe contrast allergy)[ 10 , 17 ]. The reported disadvantages of surgical embolectomy include postoperative intracerebral hematoma[ 10 , 14 ], minor subarachnoid hemorrhage[ 8 ], and subdural hematoma[ 10 ]. An effective surgical thrombectomy treatment of acute LVO stroke requires an experienced team, intentional hospital logistics and mastery of the microsurgical technique of the pterional-transsylvian approach. Our institute has an emergency stroke protocol that integrates the hospital logistics (stroke fast-track pathway in the emergency department); team communication (e.g. between the emergency department, neurosurgery and OR staff); stroke diagnostic guidelines; and OR setup for surgical embolectomy; all of which ensure the fastest management from patient arrival into the hospital to recanalization. Our institutional protocol is optimized to the geopolitical, cultural, and medical logistics of our territory. In addition to our protocol, the human factor is key to achieve such short patient management times. Our team experience in the management of acute LVO stroke and their adherence to the stroke protocol may be the underlying reason for the similar door to treatment times between treatment groups (i.e. endovascular = 69min; surgical = 73min, p = 0.45) in our institution. Although door to treatment time was not statistically different between groups, the time from door to skin incision (interquartile range(IR) = 67) was more variable than that of door to puncture (IR = 23). Such difference may inform of the time-consuming logistics inherent to the preparation for a surgical procedure for each patient, the nature of which was beyond this study. Inoue et.al. reported an onset to surgical recanalization time of 281 min. and a median surgical recanalization (skin incision to patent anterograde flow) time of 79min[ 8 ]. Park et.al. reported an onset to recanalization time of 360 min. with a surgical recanalization time of 90 min[ 14 ]. Our onset to surgical recanalization time was 231 min., with only 32.5 min. of surgical recanalization time, which were similar to those of the endovascular treatment group (onset to recanalization time = 187min, p = 0.17; endovascular recanalization time = 42min, p = 0.13). The reason underlying the variability in surgical recanalization times in the literature is in great part attributable to operative technique. We believe that a deliberate and customized pterional-transsylvian approach (video) combined with an intentional training on intracerebral revascularization may be key to achieving an efficient surgical treatment of acute LVO, and are transferrable to the developing countries. Surgical thrombectomy as a second line treatment The present study supports that both the surgical and endovascular treatment options for acute LVO stroke provided similar good clinical outcomes. Although our results show favorable outcomes in acute LVO patients treated with surgical thrombectomy, the literature strongly supports endovascular mechanical thrombectomy as the first line of treatment for these patients when reasonably available. Fiedler et al. reported a prospective two-center cohort study for patients with acute middle cerebral artery occlusion who failed mechanical thrombectomy[ 12 ]. They compared the microsurgical intervention group with the control group (medical treatment only). They found that microsurgical embolectomy (which included the option of extracranial-intracranial bypass) provided better outcomes (mRS score 0–2) at day 90 after stroke. Although this was a small sample and was not a multicenter randomized control trial, it showed that microsurgical revascularization even after mechanical failure may improve outcomes in patients with acute LVO. In addition, surgical thrombectomy could compensate the limitation of mechanical thrombectomy, which patients with mechanical failure, no access route or severe allergy to contrast material and later mentioned tandem lesion. Our results show that the efficacy of surgical thrombectomy is not inferior to mechanical thrombectomy when performed by a well-trained and organized surgical stroke team. The main challenge regarding indications of surgical embolectomy as a rescue to failed endovascular mechanical thrombectomy is the uncertainty of the length of the window of opportunity to prevent complete infarction of the tissue at risk. This window of opportunity for surgical rescue of failed endovascular acute LVO treatment depends on the presence of clinical to diffusion mismatch at the time of endovascular failure, rather than an onset to procedure time[ 2 ]. The clinical-to-diffusion mismatch may be directly related to the presence of collateral flow, rendering some patients with rich collateral vasculature good candidates for delayed rescue surgical thrombectomy. This patient-specific opportunity window opens the possibility for a true indication of surgical thrombectomy as a rescue option in the developed world, and a window of hope for the developing healthcare system. Surgical thrombectomy in developing countries: role and opportunities We believe that all patients should have access to the best treatment options regardless of their geopolitical and socioeconomic status. Endovascular thrombectomy is the gold standard treatment option for acute LVO stroke in the developed countries and can be performed by a variety of providers[ 1 , 3 , 4 ]. However, there is a pressing need for a short-term feasible treatment option for acute LVO stroke in the poor and developing countries, where access to endovascular treatment is both very limited and financially prohibitive[ 18 – 24 ]. Thus, surgeons capable of doing microsurgical thrombectomy can solve this complex geopolitical healthcare inequality. For example, in the Indonesian National Brain Center, the largest high-volume stroke center in the country, more than 4000 stroke patients are treated yearly, but the data shows a surprisingly low number of patients who underwent endovascular thrombectomy (< 0,5%). Many factors other than treatment affordability also contribute to this condition, including the lack of access to stroke-ready hospitals, causing patients to come beyond treatment opportunity (minimal penumbra, fully developed stroke). In the rural area, the cost of building an endovascular suite is considerably higher than providing a surgical operating room with a neurosurgical microscope and optimal equipment for bypass. With the aim not to replace endovascular thrombectomy, providing microsurgical thrombectomy can act as a temporary bridging strategy while the Indonesian government is investing in strategies to optimize access to endovascular treatment for most patients. When endovascular treatment becomes available as first line therapy to all Indonesian patients, the surgeon will already have developed the skill to treat failed endovascular cases (e.g., difficult access) or perform salvage treatment such as extracranial to intracranial bypass. Performing surgical thrombectomy in the developing countries requires intentional logistics and a well-trained neurosugeons and neurosurgical team. Surgical thrombectomy may be a realistic and logistically feasible first line of treatment for acute LVO stroke in the developing countries if decisive and intentional action is taken. Most major city hospitals in the developing countries have at least 1 functional CT scanner capable of performing CT angiograms[ 18 , 22 – 25 ]. There is raising awareness of the importance of universal access to acute neurosurgical care in several developing countries, and several governmental agencies are taking action. The Ministry of Health of Indonesia is developing a strategic plan to build centers of neurosurgical excellence in key islands capable of providing emergent care to all patients in their over 10,000 inhabited islands[ 25 ]. Such plan includes diagnostic imaging capabilities (CT, MRI, X-Ray) and operating rooms with basic neurosurgical equipment, including a surgical microscope. In addition, we believe that the training passionate and committed neurosurgeons from developing countries to perform surgical thrombectomy is also realistic. Global neurosurgery efforts and clinical fellowships are key to enable and perfect the skillset of neurosurgeons with intentional goal to bridging the gap of inequality to LVO stroke care. Surgical thrombectomy as a first line treatment for tandem cervical ICA and MCA lesion Endovascular treatment of tandem acute LVO (i.e. cervical carotid plus intracranial carotid with or without MCA thrombi) does not have the same level of evidence to single LVO. Many randomized clinical trials supporting the endovascular treatment of acute LVO excluded tandem lesions[ 1 , 26 ]. HERMES and MR CLEAN trials included tandem lesions but excluded severe cervical carotid stenosis (< 70–80%)[ 1 , 27 ]. Zhu et.al. reported good outcomes for the endovascular treatment of tandem lesions[ 28 , 29 ]. However, there is a concern about CAS in the hyperacute stage, it means routine dual antiplatelet before CAS were not possible. Slawski et al reported the comparison of CAS with mechanical thrombectomy and CEA with mechanical thrombectomy[ 30 ]. There was no statistical difference between both treatment, however, death, re-occlusion, internal carotid artery dissection and symptomatic bleeding occurred in CAS with mechanical thrombectomy group. In general, CAS in acute phase has a risk because the pre-procedural dual antiplatelet loading is impossible for acute LVO patients. Similarly, Hasegawa et.al. described their experience and surgical technique for the treatment of tandem lesions starting from the cranial site followed by the neck[ 15 ]. We described our simultaneous approach to a tandem lesion representative of our series (video) with a skin to final recanalization of 34 minutes (cranial = 26min; cervical = 34min). This procedure is superior in terms of recanalization time and allows CEA to be performed instead of CAS. The risk of intracerebral hemorrhage should be reduced. Because CEA should not need to use dual antiplatelet therapy in the hyperacute phase of cerebral embolism. On the other hand, CAS must continue dual antiplatelet therapy to avoid acute stent occlusion, but there should be increased risk of cerebral hemorrhage because cerebral infarction will occur to a greater or lesser extent after thrombectomy. The preferred treatment modality for tandem acute LVO in the developed world varies by country and stroke center, and the final verdict requires inclusion of challenging cervical cases (e.g. complete cervical ICA occlusion, video) in future prospective randomized multicentric clinical trials. Study limitations We included consecutive surgical cases with strict selection criteria to minimize sampling and confounding bias. However, there are methodological limitations inherent to the retrospective nature of this study, which used a highly selected patient population. Our study was based on a refined institutional protocol (Fig. 5 ) and large cerebrovascular surgical experience, which we believe influenced our results for the surgical thrombectomy group. Therefore, our results may be difficult to replicate by other institutions. However, both a protocol and experience are intangible resources that, when applied intentionally, may improve our reported results or constantly improve the efficacy of surgical thrombectomy over time (learning curve). Future prospective multicentric studies are required to define the role of surgical thrombectomy on failed endovascular mechanical thrombectomies and complex tandem lesions. Conclusions Clinical outcomes relative to acute LVO treatment strategy (surgical vs endovascular thrombectomy) were not statistically significantly different. There may be a role for surgical thrombectomy in cases of failed endovascular thrombectomy or tandem cervical ICA and MCA occlusion, and in developing countries where endovascular therapy is not a reasonable option. Surgical thrombectomy may provide a short- to mid-term solution to acute LVO stroke in poor and developing countries if strategic hospital logistics and intentional neurosurgical training is taken. Abbreviations Non-standard Abbreviations and Acronyms: aOR= adjusted odds ratio, CEA=carotid endarterectomy, CT=computed tomography, DWI=diffusion weighted imaging, DWI-ASPECT= diffusion weighted imaging- Alberta Stroke Programe Early Computed Tomography, ER=emergency room, FLAIR=fluid attenuated inversion recovery, ICA=internal carotid artery, IR=interquartile range, mRS = modified Rankin Scale score, LVO=large vessel occlusion, MCA=middle cerebral artery, MRI=magnetic resonance imaging, NIHSS=National Institutes of Helath Stroke Scale (NIHSS), OR = operating room, SD = standard deviation, STA=superficial temporal artery, TICI=Thrombolysis in cerebral infarction, tPA=tissue plasminogen activator Declarations Acknowledgements: None Conflict of interest: None Ethical Approval The study received approval from the Institutional Review Board and the requirement for informed consent was waived for each patient. Funding All authors have no funding related to this study. Availability of data and materials Data from this study are available from the corresponding author on reasonable request. References Goyal M, Menon BK, van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723-1731. https://doi.org/10.1016/S0140-6736(16)00163-X Nogueira RG, Jadhav AP, Haussen DC et al (2018) Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 378:11-21. https://doi.org/10.1056/NEJMoa1706442 Sarraj A, Hassan AE, Abraham MG et al (2023) Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med 388:1259-1271. https://doi.org/10.1056/NEJMoa2214403 Olthuis SGH, Pirson FAV, Pinckaers FME et al (2023) Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial. Lancet 401:1371-1380. https://doi.org/10.1016/S0140-6736(23)00575-5 Lees KR, Bluhmki E, von Kummer R et al (2010) Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 375:1695-1703. https://doi.org/10.1016/S0140-6736(10)60491-6 Kimura K, Iguchi Y, Shibazaki K, Watanabe M, Iwanaga T, Aoki J (2009) M1 susceptibility vessel sign on T2* as a strong predictor for no early recanalization after IV-t-PA in acute ischemic stroke. Stroke 40:3130-3132. https://doi.org/10.1161/STROKEAHA.109.552588 Welch K (1956) Excision of occlusive lesions of the middle cerebral artery. J Neurosurg 13:73-80. https://doi.org/10.3171/jns.1956.13.1.0073 Inoue T, Tamura A, Tsutsumi K, Saito I, Saito N (2015) Surgical embolectomy for internal carotid artery terminus occlusion. Neurosurg Rev 38:661-669. https://doi.org/10.1007/s10143-015-0640-4 Goehre F, Yanagisawa T, Kamiyama H et al (2016) Direct Microsurgical Embolectomy for an Acute Distal Basilar Artery Occlusion. World Neurosurg 86:497-502. https://doi.org/10.1016/j.wneu.2015.09.053 Horiuchi T, Nitta J, Miyaoka Y, Nagm A, Tsutsumi K, Ito K, Hongo K (2017) Open Embolectomy of Large Vessel Occlusion in the Endovascular Era: Results of a 12-Year Single-Center Experience. World Neurosurg 102:65-71. https://doi.org/10.1016/j.wneu.2017.02.108 Ota N, Okada Y, Noda K, Tanikawa R (2020) Microsurgical embolectomy with superficial temporal artery-middle cerebral artery bypass for acute internal carotid artery dissection: A technical case report. Surg Neurol Int 11:223. https://doi.org/10.25259/SNI_300_2020 Fiedler J, Roubec M, Grubhoffer M et al (2023) Emergent microsurgical intervention for acute stroke after mechanical thrombectomy failure: a prospective study. J Neurointerv Surg 15:439-445. https://doi.org/10.1136/neurintsurg-2022-018643 Ota N, Noda K, Chida D et al (2022) Emergent Subarachnoid Clot Removal with Aneurysm Repair for Subarachnoid Hemorrhage Might Improves Clinical Outcome. World Neurosurg 167:e100-e109. https://doi.org/10.1016/j.wneu.2022.07.151 Park J, Hwang YH, Kim Y (2009) Extended superciliary approach for middle cerebral artery embolectomy after unsuccessful endovascular recanalization therapy: technical note. Neurosurgery 65:E1191-1194; discussion E1194. https://doi.org/10.1227/01.NEU.0000351783.00831.BB Hasegawa H, Inoue T, Tamura A, Saito I (2015) Emergent intracranial surgical embolectomy in conjunction with carotid endarterectomy for acute internal carotid artery terminus embolic occlusion and tandem occlusion of the cervical carotid artery due to plaque rupture. J Neurosurg 122:939-947. https://doi.org/10.3171/2014.11.JNS132855 Matano F, Mizunari T, Kominami S et al (2017) Retrograde suction decompression of a large internal carotid aneurysm using a balloon guide catheter combined with a blood-returning circuit and STA-MCA bypass: a technical note. Neurosurg Rev 40:351-355. https://doi.org/10.1007/s10143-016-0808-6 Matano F, Tamaki T, Yamazaki M et al (2021) Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages. J Clin Neurosci 89:206-210. https://doi.org/10.1016/j.jocn.2021.05.003 Durai Pandian J, Padma V, Vijaya P, Sylaja PN, Murthy JM (2007) Stroke and thrombolysis in developing countries. Int J Stroke 2:17-26. https://doi.org/10.1111/j.1747-4949.2007.00089.x Hashmi M, Khan M, Wasay M (2013) Growing burden of stroke in Pakistan: a review of progress and limitations. Int J Stroke 8:575-581. https://doi.org/10.1111/j.1747-4949.2012.00827.x Wasay M, Khatri IA, Kaul S (2014) Stroke in South Asian countries. Nat Rev Neurol 10:135-143. https://doi.org/10.1038/nrneurol.2014.13 Tsang ACO, Yang IH, Orru E et al (2020) Overview of endovascular thrombectomy accessibility gap for acute ischemic stroke in Asia: A multi-national survey. Int J Stroke 15:516-520. https://doi.org/10.1177/1747493019881345 Collantes MV, Zuniga YH, Granada CN et al (2021) Current State of Stroke Care in the Philippines. Front Neurol 12:665086. https://doi.org/10.3389/fneur.2021.665086 Collantes ME, Navarro J, Belen A, Gan R (2022) Stroke systems of care in the Philippines: Addressing gaps and developing strategies. Front Neurol 13:1046351. https://doi.org/10.3389/fneur.2022.1046351 Gordon Perue G, Then R, Gayle F et al (2023) Mission thrombectomy 2020 (MT2020+) surveys of Caribbean stroke services: A call for action in our region. J Neurol Sci 449:120640. https://doi.org/10.1016/j.jns.2023.120640 Ministry of Health R, National Healthcare Transformation Report , Ministry of Health RoI, Editor. 2022, Ministry of Health, Republic of Indonesia: Jakarta, Indonesia. Bracard S, Ducrocq X, Mas JL et al (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15:1138-1147. https://doi.org/10.1016/S1474-4422(16)30177-6 Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11-20. https://doi.org/10.1056/NEJMoa1411587 Zhu F, Labreuche J, Haussen DC et al (2019) Hemorrhagic Transformation After Thrombectomy for Tandem Occlusions. Stroke 50:516-519. https://doi.org/10.1161/STROKEAHA.118.023689 Zhu F, Piotin M, Steglich-Arnholm H et al (2019) Periprocedural Heparin During Endovascular Treatment of Tandem Lesions in Patients with Acute Ischemic Stroke: A Propensity Score Analysis from TITAN Registry. Cardiovasc Intervent Radiol 42:1160-1167. https://doi.org/10.1007/s00270-019-02251-4 Slawski DE, Jumaa MA, Salahuddin H et al (2018) Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion. J Vasc Surg 68:1047-1053. https://doi.org/10.1016/j.jvs.2017.12.077 Video Video: The following is the link to the video file. https://www.dropbox.com/scl/fi/q6zt4qkxe71wo5qoyeoe5/Video.mp4?rlkey=lxgo1tb39eus517inaeuglmo5&dl=0 Additional Declarations No competing interests reported. Supplementary Files Supplementalmaterial1.docx Supplementalmaterial2.docx Cite Share Download PDF Status: Published Journal Publication published 15 Jan, 2024 Read the published version in Neurosurgical Review → Version 1 posted Editorial decision: Revision requested 16 Dec, 2023 Reviews received at journal 25 Nov, 2023 Reviewers agreed at journal 16 Nov, 2023 Reviewers agreed at journal 16 Nov, 2023 Reviewers invited by journal 14 Nov, 2023 Editor assigned by journal 13 Nov, 2023 Submission checks completed at journal 13 Nov, 2023 First submitted to journal 08 Nov, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3577955","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":248938328,"identity":"a045304a-1d83-4533-b07b-13b7051bc6c6","order_by":0,"name":"Nakao Ota","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYFACNiA2sJFjY28AMSyI1VKQZszPcwCkRYJYLR8OJ86ckQDiEaHFnP1Y4ocPBoeNDW4+v7rhR4EEA397dwJeLZY9aYclZxikyxnczim72QN0mMSZsxvwajE4kN4gzWNgbQzUknaDB6jFQCKXgJbzz5t/8xgwJ264eSbt5h+itNxIOwa0xRnoffZjt4mz5cazNMsZBqBAzmG7LWMgwUPYL+fTjG98+AOKyuPPbr4BMvjbe/FrQQI8BmCSWOUgwP6AFNWjYBSMglEwggAA9ZRJa6x6wtsAAAAASUVORK5CYII=","orcid":"","institution":"Sapporo Teishinkai Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Nakao","middleName":"","lastName":"Ota","suffix":""},{"id":248938329,"identity":"dd747695-af9c-4a35-8e49-c3f11e79d9be","order_by":1,"name":"Arnau Benet","email":"","orcid":"","institution":"Barrow Neurological Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Arnau","middleName":"","lastName":"Benet","suffix":""},{"id":248938330,"identity":"b4e227f1-fdb8-49f6-917d-9c04894d7cb2","order_by":2,"name":"Muhammad Kusdiansah","email":"","orcid":"","institution":"Sapporo Teishinkai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"","lastName":"Kusdiansah","suffix":""},{"id":248938331,"identity":"6ae7b54e-7a23-4d65-b2af-fc2f63bc8c6d","order_by":3,"name":"Norio Miyoshi","email":"","orcid":"","institution":"Sapporo Teishinkai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Norio","middleName":"","lastName":"Miyoshi","suffix":""},{"id":248938332,"identity":"502affea-0090-4e39-82c7-9d401f0355e5","order_by":4,"name":"Kenichi Haraguchi","email":"","orcid":"","institution":"Sapporo Teishinkai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kenichi","middleName":"","lastName":"Haraguchi","suffix":""},{"id":248938333,"identity":"ab7b5d9e-9a25-4af2-ab39-c3eab744c9f0","order_by":5,"name":"Kosumo Noda","email":"","orcid":"","institution":"Sapporo Teishinkai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kosumo","middleName":"","lastName":"Noda","suffix":""},{"id":248938334,"identity":"8edb3704-2e16-47f8-a56c-cff0b295d42c","order_by":6,"name":"Michael T Lawton","email":"","orcid":"","institution":"Barrow Neurological Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Michael","middleName":"T","lastName":"Lawton","suffix":""},{"id":248938335,"identity":"05a6e510-ea82-4f81-bc49-2204ff7a797d","order_by":7,"name":"Rokuya Tanikawa","email":"","orcid":"","institution":"Sapporo Teishinkai Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rokuya","middleName":"","lastName":"Tanikawa","suffix":""}],"badges":[],"createdAt":"2023-11-08 07:44:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3577955/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3577955/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10143-024-02281-8","type":"published","date":"2024-01-15T15:01:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":46514618,"identity":"cc98a460-9610-49a7-9b74-aa2ef3006161","added_by":"auto","created_at":"2023-11-15 21:29:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":271738,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the study population.\u003c/p\u003e\n\u003cp\u003emRS; modified Rankin Scale, TICI; Thrombolysis in Cerebral Infarction, BA; basilar artery, PCA; posterior cerebral artery, ACA; anterior cerebral artery\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/f486675fe5b23667c2747e67.jpg"},{"id":46513388,"identity":"3dfd5959-f323-4b30-a002-c147b227030d","added_by":"auto","created_at":"2023-11-15 21:13:54","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171706,"visible":true,"origin":"","legend":"\u003cp\u003eModified Rankin Scale score 90 days after onset between the endovascular and surgical modalities of acute large vessel occlusion treatment.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/ab40110040957e3d9ffa27db.jpg"},{"id":46513391,"identity":"358ea2a1-1a3b-40b7-bd44-02c252ee8f8c","added_by":"auto","created_at":"2023-11-15 21:13:54","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":82780,"visible":true,"origin":"","legend":"\u003cp\u003eBox plot of treatment time (in min.) both mechanical and surgical thrombectomy. Left panel, door to start of treatment time (puncture or skin incision); Right panel, start of procedure to recanalization time. Both time comparisons were not statistically significantly different between treatment modalities, but high variability were identified in the time of door to skin incision in the surgical group and in the time of puncture to recanalization in the mechanical thrombectomy group.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/08794db5de2a8913dacfc266.jpg"},{"id":46513392,"identity":"af735fe5-21f8-4cb6-aad4-8e974654466c","added_by":"auto","created_at":"2023-11-15 21:13:55","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":595553,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the surgical treatment of a tandem large vessel occlusion of the cervical internal carotid artery and M1-2 segments of the middle cerebral artery. The cranial site illustrates a left pterional craniotomy with extraction of a occluding thrombus at the M1-2 segments of the middle cerebral artery. The neck illustration depicts a surgical thrombectomy with retrograde flow suction of a cervical internal carotid artery occlusion. Both procedures may be performed simultaneously (video) or in sequence, starting at the cranial site. A carotid endarterectomy followed the cervical internal carotid artery thrombectomy. Printed with permission of author MK.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/943665d8dfb6fd484f5c4296.jpg"},{"id":46513866,"identity":"ee1d8457-5480-4015-9a0a-8aea68bb301e","added_by":"auto","created_at":"2023-11-15 21:21:54","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":455065,"visible":true,"origin":"","legend":"\u003cp\u003eOur institutional workflow for surgical and mechanical thrombectomy is depicted in this diagram. The emergency medical technician communicates directly with the on-call neurosurgeon after assessing the patient with suspicion of acute stroke. If the clinical presentation and preliminary data strongly suggests acute stroke, the neurosurgeon on call activates the stroke protocol through the emergency department while the patient is in route. The emergency department nurse communicates with radiology on call and the stroke recanalization team, who is alert and ready for either operative room/ endovascular setup. The equipment for both mechanical thrombectomy or surgical thrombectomy is already set in the room but not opened. The first thorough assessment is done by the on call neurosurgeon at the emergency room on patient’s arrival. The patient undergoes emergent imaging to determine absence of intracranial hemorrhage and assess for core ischemial and penumbra. The on call neurosurgeon and emergency nurse assess the MRI finding in the console room, and immediately after DWI and MRangiography, the decision of tPA administration, mechanical thrombectomy/ surgical thrombectomy are made. The decision is immediately communicated to stroke team nursing on call to setup either interventional radiology or operative room instruments. The surgical instruments for acute surgical thrombectomy, which have been previously packaged and sterilized, are then setup along with anesthesia setup. Anesthesia is performed by an on-call physician (in-house or within 20 minutes of the hospital).\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/c9e2522d0550a95a16c45dcf.jpg"},{"id":49978792,"identity":"c26e927b-b5ea-4f5e-af01-e053d4327425","added_by":"auto","created_at":"2024-01-22 15:09:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":737307,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/ee32370c-ecb1-41ed-a515-7307e90f84c8.pdf"},{"id":46513393,"identity":"70314c65-fd94-46a4-b727-a3591ceba93d","added_by":"auto","created_at":"2023-11-15 21:13:55","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":15078,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/73d49a6d9447a55941ab3b5e.docx"},{"id":46513867,"identity":"c6e6f35e-f191-4361-a7c7-bcbaee95b79e","added_by":"auto","created_at":"2023-11-15 21:21:54","extension":"docx","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":17888,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial2.docx","url":"https://assets-eu.researchsquare.com/files/rs-3577955/v1/16e93dd70b9edc754acee1f2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Microsurgical Thrombectomy: where the ancient art meets the new era","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndovascular treatment of large vessel occlusion (LVO) has changed stroke outcomes in a way few medical advances have in the history of medicine[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Nowadays, endovascular techniques have evolved where a TICI 2b-3 is expected, with full resolution of symptoms and a functional recovery[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Endovascular treatment of stroke may be performed by a variety of medical specialties (i.e. neurology, neurosurgery, interventional radiology), the regulations of which vary in each country (or state).\u003c/p\u003e \u003cp\u003eBefore the publication of the large randomized controlled trial on the efficacy of mechanical thrombectomy[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the only established LVO treatment was intravenous administration of tissue plasminogen activator[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, its effects were very limited, especially in the case of internal carotid or proximal middle cerebral artery occlusion[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Surgical thrombectomy was one of the treatment options for LVO, although its efficacy was reported only in limited case series and reports[\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recent randomized prospective study on the efficacy of microsurgical thrombectomy for LVO stroke after failed mechanical thrombectomy favored surgical thrombectomy as a rescue option[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In addition, surgical thrombectomy may play an important role in patients with LVO acute stroke with no feasible endovascular access route, a severe tandem lesion, or iodine allergy. In this study, we compared our experience treating acute LVO stroke through either mechanical thrombectomy (Endovascular) or surgical thrombectomy and discussed the potential role for surgical thrombectomy in the era of mechanical thrombectomy not only in developed countries but also in developing countries. This is the first report to directly compare mechanical and surgical thrombectomy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e The study received approval from the Institutional Review Board and the requirement for informed consent was waived for each patient. The clinical outcomes, procedural times and efficacy of treatment were compared between the endovascular mechanical thrombectomy and microsurgical embolectomy groups for patients presenting with acute large vessel occlusion in our institute between 2012 and 2022. An emergent computed tomography(CT) angiography from femoral artery to intracranial vessels was performed for preoperative treatment strategy; including mapping the arterial occlusion (e.g. location, size, parent arteries, etc.), defining important surrounding anatomy (e.g. ipsilateral superficial temporal artery), and determining access. Patients were initially assessed with head magnetic resonance imaging (MRI; DWI, FLAIR, T2 sequences) at arrival to the emergency department. The gold standard treatment for acute LVO in our institution was either medical management or microsurgical thrombectomy until 2017, when the endovascular mechanical thrombectomy became gold standard in the Japanese stroke management guidelines and thus our first line of therapy. Our institutional surgical thrombectomy protocol and indications (before 2017) included: tissue at risk within the common carotid, internal carotid, or proximal middle cerebral artery territories; arriving to the operating room within 4.5 hours of symptom onset; presence of DWI to clinical symptom mismatch; mRS\u0026thinsp;\u0026lt;\u0026thinsp;3 before symptom onset; good surgical and anesthesia candidate. After 2017 we only performed surgical thrombectomy on patients that crossed over from a failed endovascular thrombectomy (TICI\u0026thinsp;\u0026lt;\u0026thinsp;2) after reasonable effort. Exclusion criteria were a final TICI 0\u0026ndash;1, mRS\u0026thinsp;\u0026lt;\u0026thinsp;3 before symptom onset, posterior circulation occlusion, missing demographic or follow up data, unknown time of onset of symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A total of 109 patients fulfilled the study criteria (77 endovascular mechanical thrombectomy, 32 surgical thrombectomy).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatient demographics, clinical, and radiographic data were collected from hospital charts, telephone interviews, or patient letters. Patient characteristics, including age, sex, and comorbidities (hypertension, diabetes mellitus, and atrial fibrillation) at the time of LVO were recorded. The time of onset to emergency room (ER), time from ER to skin incision or puncture, and time of skin incision or puncture to recanalization were recorded.\u003c/p\u003e \u003cp\u003eAffected vessel was classified to 1; Internal carotid artery, 2; middle cerebral artery and 3; Internal carotid and middle cerebral artery tandem lesion. Good clinical outcome was defined as mRS\u0026thinsp;\u0026lt;\u0026thinsp;3 at 90 days after LVO.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, median (interquartile range), or number of patients (%), as appropriate. For continuous variables, normality of the data was evaluated using the Shapiro-Wilk test. Normally distributed continuous variables were compared using the Student\u0026rsquo;s t-test, and the rest were compared using the Mann-Whitney U-test. The chi-square test or Fisher\u0026rsquo;s exact test was used to analyze nominal variables, as appropriate.\u003c/p\u003e \u003cp\u003eTreatment indications and patient conditions were not identical for the surgical and mechanical thrombectomy groups. Therefore, we conducted propensity score-matched analysis to adjust for bias in the total surgical embolectomy and mechanical thrombectomy groups. One-to-one matched analysis used the nearest-neighbor method without replacement with the closest estimated propensity score within a caliper (0.2 of the pooled standard deviation). Covariates used to calculate propensity score were age, sex, affected side, National Institutes of Helath Stroke Scale (NIHSS), diffusion weighted imaging Alberta Stroke Programe Early Computed Tomography (DWI ASPECT) score, affecting vessel, time of onset to door and commoribidity of hypertension, diabetes mellitus and atrial fibrillation.\u003c/p\u003e \u003cp\u003eAny differences associated with good outcome that were statistically significant(P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in univariate analyses and seemed to be clinically important such as time of onset to recanalization, tPA administration and treatment methods were further analyzed with a multivariate logistic regression adjustment. The goodness of fit of the regression model was confirmed by demonstrating a non-significant P-value in the Hosmer-Lemeshow test. Data were analyzed using IBM SPSS Statistics for Mac (version 27.0, IBM Corp.; Armonk, NY, USA). Differences with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were deemed statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePatient demographics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Age, sex and comorbidity were not statistically different between treatment groups. Fewer patients received tPA administration in the surgical group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients in the surgical group had a lower NIHSS (P\u0026thinsp;=\u0026thinsp;0.003) and DWI-ASPECT (P\u0026thinsp;=\u0026thinsp;0.034) scores. The modified Rankin scale score at 90 days of both mechanical and surgical treatment is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of both treatment options.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMechanical\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;77\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e75.0(19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.5(16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39(50.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12(37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.210\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41(53.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22(68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19(24.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8(25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.971\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45(58.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19(59.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.928\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etPA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50(64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2(6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43(55.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13(40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.0(\u0026plusmn;\u0026thinsp;8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.0(\u0026plusmn;\u0026thinsp;6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDWI ASPECT (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.0(3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.0(2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.034\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to Puncture/ Door to Skin incision (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.0(23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73.5(67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture to Recanalization/ Skin incision to Recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42.0(36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.5(22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to Door (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58.0(96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58.5(114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120.0 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101.5 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.615\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to Recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e187.0(102)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e231.5(170)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffecting vessel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal carotid artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (23.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle cerebral artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTandem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Related complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5(6.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS at discharge (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0(4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0(4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS at 3month (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0(3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5(2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Outcome\u003c/p\u003e \u003cp\u003emRS 0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47(61.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20(62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIR; interquartile range, NIHSS; National Institutes of Health Stroke Scale, tPA; tissue plasminogen activator, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography, mRS; modified Rankin Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComplications after surgical thrombectomy occurred in 6 patients (18.8%). Of these, 4 required re-operation for 1 case of acute epidural hematoma, 1 case of acute subdural hematoma and 1 case of distal embolism fragmentation on post-operative MRI requiring re-thrombectomy for distal M2 segment.\u003c/p\u003e \u003cp\u003eThe other 3 cases were managed consecutively, 1 case of acute renal failure treated with hemodialysis, 1 case of congestive heart failure and 1 case of postoperative hyperperfusion syndrome.\u003c/p\u003e \u003cp\u003eThe box plot of both treatment groups is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. A univariate analysis revealed that door to puncture/ skin incision (P\u0026thinsp;=\u0026thinsp;0.450) and puncture/ skin incision to recanalization (P\u0026thinsp;=\u0026thinsp;0.133) times were not statistically significant. There was a high variability in the time of door to skin incision in the surgical group and in the time of puncture to recanalization in the mechanical thrombectomy group.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFactors driving good outcome\u003c/h2\u003e \u003cp\u003eUnivariate analysis for the variable good outcome is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Age (P\u0026thinsp;=\u0026thinsp;0.001), left hemisphere (P\u0026thinsp;=\u0026thinsp;0.033), NIHSS score (P\u0026thinsp;=\u0026thinsp;0.006) and DWI-ASPECT score (P\u0026thinsp;=\u0026thinsp;0.012) were statistically significant drivers of outcome. On the other hand, the time of onset to recanalization were not statistically significant predictors of outcome (P\u0026thinsp;=\u0026thinsp;0.610).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate analysis of factors driving good outcome.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGood Outcome\u003c/p\u003e \u003cp\u003eNO\u0026thinsp;=\u0026thinsp;42\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood Outcome\u003c/p\u003e \u003cp\u003eYES\u0026thinsp;=\u0026thinsp;67\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81.0(13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.0(19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale SEX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23(54.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28(41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25(59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38(56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.773\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13(31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14(20.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29(69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35(52.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etPA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20(47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32(47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27(64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29(43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20.2(\u0026plusmn;\u0026thinsp;7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.9(\u0026plusmn;\u0026thinsp;7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDWI ASPECT (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.0(3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.0(2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffecting vessel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal carotid artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle cerebral artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50 (74.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTandem lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3(7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6(9.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to Puncture/ Door to Skin incision (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e67.0(23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.0(38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture to Recanalization/ Skin incision to Recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43.5(42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.0(29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.755\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e107.0(68.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122.0(54.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to Door (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60.0(115)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.0(78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.913\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to Recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e176.5(175)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e199.0(113)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.610\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Related complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7(16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4(6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMechanical thrombectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30(71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47(70.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIR; interquartile range, NIHSS; National Institutes of Health Stroke Scale, tPA; tissue plasminogen activator, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography, mRS; modified Rankin Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariate logistic regression analysis showen in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Age (aOR 0.945, 95%CI[0.91\u0026ndash;0.98]), hemisphere side (aOR 0.382, 95%CI[0.15\u0026ndash;0.96]) and DWI ASPECT score (aOR 1.389, 95%CI [1.09\u0026ndash;1.77]) were independent predictors of good outcome. Treatment modality (i.e. endovascular or surgical thrombectomy) did not have a statistically significantly different outcome (aOR 0.498, 95%CI [0.18\u0026ndash;1.38]). The time from symptom onset to recanalization was not statistically significant for outcome in this series (aOR 1.000, 95%CI[0.997-1.000]).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic regression analysis associated with good outcome.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted Odds ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCI (95%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (continuous variable)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.95\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.91\u0026ndash;0.98\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Thrombectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.18\u0026ndash;1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.15\u0026ndash;0.96\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS score per 1 point increment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.90\u0026ndash;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDWI ASPECT score per 1 point increment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e1.34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1.09\u0026ndash;1.77\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to recanalization (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.00\u0026ndash;1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.826\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eCI, confidence interval, NIHSS; National Institutes of Health Stroke Scale, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePropensity score-matched analysis between mechanical and surgical thrombectomy\u003c/h2\u003e \u003cp\u003ePatient characteristics in the propensity score-matched analysis of mechanical and surgical thrombectomy are illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Baseline population included 77 cases in mechanical thrombectomy and 32 cases in the surgical thrombectomy group. Propensity score-matched analysis compared 24 cases in each group. After propensity score-matching excluding tPA administration, the baseline characteristics of the patients were well balanced between the groups. The C statistic for goodness of fit was 0.77 (95% CI, 0.68\u0026ndash;0.87). The proportions of time to recanalization (P\u0026thinsp;=\u0026thinsp;0.155), Onset to recanalization (P\u0026thinsp;=\u0026thinsp;0.821), treatment related complication (P\u0026thinsp;=\u0026thinsp;0.174) and rate of good outcome (P\u0026thinsp;=\u0026thinsp;0.221) were not statistically significant compared both groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics in the propensity score- matched patients by surgical embolectomy and mechanical thrombectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMechanical\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgical\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(mean, SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.1 (\u0026plusmn;\u0026thinsp;15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.0 (\u0026plusmn;\u0026thinsp;11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (62.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (37.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etPA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNIHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7 (\u0026plusmn;\u0026thinsp;8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6 (\u0026plusmn;\u0026thinsp;6.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDWI ASPECT (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.0 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to Puncture/ Door to Skin incision (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.5 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePuncture to Recanalization/ Skin incision to Recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.0(37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.0 (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to Door (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.0 (133)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.5 (114)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoor to recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125.5 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.0 (81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnset to Recanalization (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217.5(162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e216.5(174)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.821\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAffecting vessel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal carotid artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle cerebral artery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (70.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTandem lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment Related complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS at discharge (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.0 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.0 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emRS at 3month (median, IR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.330\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood Outcome\u003c/p\u003e \u003cp\u003emRS 0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (75.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eIR; interquartile range, NIHSS; National Institutes of Health Stroke Scale, tPA; tissue plasminogen activator, DWI; diffusion weighted imaging, ASPECT; Alberta Stroke Programme Early Computed tomography, mRS; modified Rankin Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCases of surgical or mechanical failure are reported in Supplemental material 1.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperative technique for emergent surgical thrombectomy: team efficiency was speed.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe key to a fast surgical thrombectomy was specific distribution of sequential surgical steps by a team of 1 neurosurgeon experienced in surgical thrombectomy and at least 1 assistant (optimally 2). A curved pterional incision (1cm anterior to tragus until midline at hairline) was followed by elevation of a musculocutaneous flap and a modified pterional craniotomy (dissection by the primary neurosurgeon and constant hemostasis by the assistant were performed in simultaneous coordination). While the assistant maintained hemostasis of the middle meningeal artery, the primary neurosurgeon opened dura and incised the outer arachnoid membrane without delay. The key to speed was for the assisting surgeon(s) to continuously maintain hemostasis, which allowed the primary surgeon to focus on an uninterrupted dissection from dural incision until thrombectomy was finished. Sylvian fissure split was custom to the anticipated exposure needed (e.g. narrow for MCA, wider for upper basilar). Upon exposure of the occlusion site, the proximal (assistant) and distal (primary neurosurgeon) clips are applied simultaneously. Immediately after, a perpendicular arteriotomy revealed the thrombus. Release of the proximal clip allowed for anterograde blood flow to eject the thrombus until bleeding occurred, at which time the assistant closed the proximal clip while the primary neurosurgeon sutured the arteriotomy closed .\u003c/p\u003e \u003cp\u003eAdoption of our operating room setup protocol for emergent surgical thrombectomy reduced door to treatment time by 1 hour. A dedicated surgical thrombectomy instrument set was always on stand-by, requiring only unboxing and sterile arrangement by trained scrubbed nurses. Team coordination also included patient transfer, emergency department personnel and radiologist, all of which were able to reduce door to treatment time to within 1 hour as previously reported[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. An illustrative case of surgical thrombectomy is included in video and Supplementary Material 2.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study shows that the efficacy of surgical thrombectomy in achieving good outcomes after acute LVO is not inferior to that of the endovascular mechanical thrombectomy. Our results reveal that a surgical team experienced in the treatment of acute LVO can provide door to treatment and start of treatment to recanalization times similar to those of endovascular mechanical thrombectomy, and with full flow replacement (either through direct thrombectomy or bypass). Most failed endovascular treatments of acute LVO stroke were related to precipitating atherosclerotic intracranial disease or arterial dissection. Surgical rescue of such cases provided restoring flow via an emergent STA-MCA bypass. The main clinical outcome drivers in our study were age, hemisphere side, and DWI-ASPECT score at presentation.\u003c/p\u003e \u003cp\u003eFew authors have reported their experience in the surgical treatment of acute LVO through single center case series or case reports[\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The reported advantages of surgical thrombectomy include a high rate of recanalization[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] rare occurrence of distal migration or segmentation of the thrombus[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], the capacity to perform a simultaneous cervical carotid thrombectomy or CEA[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and its role as rescue treatment for either failed endovascular mechanical thrombectomy or its contraindications (e.g. severe contrast allergy)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The reported disadvantages of surgical embolectomy include postoperative intracerebral hematoma[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], minor subarachnoid hemorrhage[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and subdural hematoma[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn effective surgical thrombectomy treatment of acute LVO stroke requires an experienced team, intentional hospital logistics and mastery of the microsurgical technique of the pterional-transsylvian approach. Our institute has an emergency stroke protocol that integrates the hospital logistics (stroke fast-track pathway in the emergency department); team communication (e.g. between the emergency department, neurosurgery and OR staff); stroke diagnostic guidelines; and OR setup for surgical embolectomy; all of which ensure the fastest management from patient arrival into the hospital to recanalization. Our institutional protocol is optimized to the geopolitical, cultural, and medical logistics of our territory. In addition to our protocol, the human factor is key to achieve such short patient management times. Our team experience in the management of acute LVO stroke and their adherence to the stroke protocol may be the underlying reason for the similar door to treatment times between treatment groups (i.e. endovascular\u0026thinsp;=\u0026thinsp;69min; surgical\u0026thinsp;=\u0026thinsp;73min, p\u0026thinsp;=\u0026thinsp;0.45) in our institution. Although door to treatment time was not statistically different between groups, the time from door to skin incision (interquartile range(IR)\u0026thinsp;=\u0026thinsp;67) was more variable than that of door to puncture (IR\u0026thinsp;=\u0026thinsp;23). Such difference may inform of the time-consuming logistics inherent to the preparation for a surgical procedure for each patient, the nature of which was beyond this study. Inoue et.al. reported an onset to surgical recanalization time of 281 min. and a median surgical recanalization (skin incision to patent anterograde flow) time of 79min[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Park et.al. reported an onset to recanalization time of 360 min. with a surgical recanalization time of 90 min[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our onset to surgical recanalization time was 231 min., with only 32.5 min. of surgical recanalization time, which were similar to those of the endovascular treatment group (onset to recanalization time\u0026thinsp;=\u0026thinsp;187min, p\u0026thinsp;=\u0026thinsp;0.17; endovascular recanalization time\u0026thinsp;=\u0026thinsp;42min, p\u0026thinsp;=\u0026thinsp;0.13). The reason underlying the variability in surgical recanalization times in the literature is in great part attributable to operative technique. We believe that a deliberate and customized pterional-transsylvian approach (video) combined with an intentional training on intracerebral revascularization may be key to achieving an efficient surgical treatment of acute LVO, and are transferrable to the developing countries.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical thrombectomy as a second line treatment\u003c/h2\u003e \u003cp\u003eThe present study supports that both the surgical and endovascular treatment options for acute LVO stroke provided similar good clinical outcomes. Although our results show favorable outcomes in acute LVO patients treated with surgical thrombectomy, the literature strongly supports endovascular mechanical thrombectomy as the first line of treatment for these patients when reasonably available. Fiedler et al. reported a prospective two-center cohort study for patients with acute middle cerebral artery occlusion who failed mechanical thrombectomy[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. They compared the microsurgical intervention group with the control group (medical treatment only). They found that microsurgical embolectomy (which included the option of extracranial-intracranial bypass) provided better outcomes (mRS score 0\u0026ndash;2) at day 90 after stroke. Although this was a small sample and was not a multicenter randomized control trial, it showed that microsurgical revascularization even after mechanical failure may improve outcomes in patients with acute LVO. In addition, surgical thrombectomy could compensate the limitation of mechanical thrombectomy, which patients with mechanical failure, no access route or severe allergy to contrast material and later mentioned tandem lesion. Our results show that the efficacy of surgical thrombectomy is not inferior to mechanical thrombectomy when performed by a well-trained and organized surgical stroke team.\u003c/p\u003e \u003cp\u003eThe main challenge regarding indications of surgical embolectomy as a rescue to failed endovascular mechanical thrombectomy is the uncertainty of the length of the window of opportunity to prevent complete infarction of the tissue at risk. This window of opportunity for surgical rescue of failed endovascular acute LVO treatment depends on the presence of clinical to diffusion mismatch at the time of endovascular failure, rather than an onset to procedure time[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The clinical-to-diffusion mismatch may be directly related to the presence of collateral flow, rendering some patients with rich collateral vasculature good candidates for delayed rescue surgical thrombectomy. This patient-specific opportunity window opens the possibility for a true indication of surgical thrombectomy as a rescue option in the developed world, and a window of hope for the developing healthcare system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSurgical thrombectomy in developing countries: role and opportunities\u003c/h2\u003e \u003cp\u003eWe believe that all patients should have access to the best treatment options regardless of their geopolitical and socioeconomic status. Endovascular thrombectomy is the gold standard treatment option for acute LVO stroke in the developed countries and can be performed by a variety of providers[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, there is a pressing need for a short-term feasible treatment option for acute LVO stroke in the poor and developing countries, where access to endovascular treatment is both very limited and financially prohibitive[\u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22 CR23\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Thus, surgeons capable of doing microsurgical thrombectomy can solve this complex geopolitical healthcare inequality. For example, in the Indonesian National Brain Center, the largest high-volume stroke center in the country, more than 4000 stroke patients are treated yearly, but the data shows a surprisingly low number of patients who underwent endovascular thrombectomy (\u0026lt;\u0026thinsp;0,5%). Many factors other than treatment affordability also contribute to this condition, including the lack of access to stroke-ready hospitals, causing patients to come beyond treatment opportunity (minimal penumbra, fully developed stroke). In the rural area, the cost of building an endovascular suite is considerably higher than providing a surgical operating room with a neurosurgical microscope and optimal equipment for bypass. With the aim not to replace endovascular thrombectomy, providing microsurgical thrombectomy can act as a temporary bridging strategy while the Indonesian government is investing in strategies to optimize access to endovascular treatment for most patients. When endovascular treatment becomes available as first line therapy to all Indonesian patients, the surgeon will already have developed the skill to treat failed endovascular cases (e.g., difficult access) or perform salvage treatment such as extracranial to intracranial bypass.\u003c/p\u003e \u003cp\u003ePerforming surgical thrombectomy in the developing countries requires intentional logistics and a well-trained neurosugeons and neurosurgical team. Surgical thrombectomy may be a realistic and logistically feasible first line of treatment for acute LVO stroke in the developing countries if decisive and intentional action is taken. Most major city hospitals in the developing countries have at least 1 functional CT scanner capable of performing CT angiograms[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. There is raising awareness of the importance of universal access to acute neurosurgical care in several developing countries, and several governmental agencies are taking action. The Ministry of Health of Indonesia is developing a strategic plan to build centers of neurosurgical excellence in key islands capable of providing emergent care to all patients in their over 10,000 inhabited islands[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Such plan includes diagnostic imaging capabilities (CT, MRI, X-Ray) and operating rooms with basic neurosurgical equipment, including a surgical microscope. In addition, we believe that the training passionate and committed neurosurgeons from developing countries to perform surgical thrombectomy is also realistic. Global neurosurgery efforts and clinical fellowships are key to enable and perfect the skillset of neurosurgeons with intentional goal to bridging the gap of inequality to LVO stroke care.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical thrombectomy as a first line treatment for tandem cervical ICA and MCA lesion\u003c/h3\u003e\n\u003cp\u003eEndovascular treatment of tandem acute LVO (i.e. cervical carotid plus intracranial carotid with or without MCA thrombi) does not have the same level of evidence to single LVO. Many randomized clinical trials supporting the endovascular treatment of acute LVO excluded tandem lesions[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. HERMES and MR CLEAN trials included tandem lesions but excluded severe cervical carotid stenosis (\u0026lt;\u0026thinsp;70\u0026ndash;80%)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Zhu et.al. reported good outcomes for the endovascular treatment of tandem lesions[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, there is a concern about CAS in the hyperacute stage, it means routine dual antiplatelet before CAS were not possible. Slawski et al reported the comparison of CAS with mechanical thrombectomy and CEA with mechanical thrombectomy[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. There was no statistical difference between both treatment, however, death, re-occlusion, internal carotid artery dissection and symptomatic bleeding occurred in CAS with mechanical thrombectomy group. In general, CAS in acute phase has a risk because the pre-procedural dual antiplatelet loading is impossible for acute LVO patients. Similarly, Hasegawa et.al. described their experience and surgical technique for the treatment of tandem lesions starting from the cranial site followed by the neck[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We described our simultaneous approach to a tandem lesion representative of our series (video) with a skin to final recanalization of 34 minutes (cranial\u0026thinsp;=\u0026thinsp;26min; cervical\u0026thinsp;=\u0026thinsp;34min). This procedure is superior in terms of recanalization time and allows CEA to be performed instead of CAS. The risk of intracerebral hemorrhage should be reduced. Because CEA should not need to use dual antiplatelet therapy in the hyperacute phase of cerebral embolism. On the other hand, CAS must continue dual antiplatelet therapy to avoid acute stent occlusion, but there should be increased risk of cerebral hemorrhage because cerebral infarction will occur to a greater or lesser extent after thrombectomy. The preferred treatment modality for tandem acute LVO in the developed world varies by country and stroke center, and the final verdict requires inclusion of challenging cervical cases (e.g. complete cervical ICA occlusion, video) in future prospective randomized multicentric clinical trials.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eWe included consecutive surgical cases with strict selection criteria to minimize sampling and confounding bias. However, there are methodological limitations inherent to the retrospective nature of this study, which used a highly selected patient population. Our study was based on a refined institutional protocol (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) and large cerebrovascular surgical experience, which we believe influenced our results for the surgical thrombectomy group. Therefore, our results may be difficult to replicate by other institutions. However, both a protocol and experience are intangible resources that, when applied intentionally, may improve our reported results or constantly improve the efficacy of surgical thrombectomy over time (learning curve). Future prospective multicentric studies are required to define the role of surgical thrombectomy on failed endovascular mechanical thrombectomies and complex tandem lesions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eClinical outcomes relative to acute LVO treatment strategy (surgical vs endovascular thrombectomy) were not statistically significantly different. There may be a role for surgical thrombectomy in cases of failed endovascular thrombectomy or tandem cervical ICA and MCA occlusion, and in developing countries where endovascular therapy is not a reasonable option. Surgical thrombectomy may provide a short- to mid-term solution to acute LVO stroke in poor and developing countries if strategic hospital logistics and intentional neurosurgical training is taken.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eNon-standard Abbreviations and Acronyms:\u003c/strong\u003e aOR= adjusted odds ratio, CEA=carotid endarterectomy, CT=computed tomography, DWI=diffusion weighted imaging, DWI-ASPECT= diffusion weighted imaging- Alberta Stroke Programe Early Computed Tomography, ER=emergency room, FLAIR=fluid attenuated inversion recovery, ICA=internal carotid artery, IR=interquartile range, mRS = modified Rankin Scale score, LVO=large vessel occlusion, MCA=middle cerebral artery, MRI=magnetic resonance imaging, NIHSS=National Institutes of Helath Stroke Scale (NIHSS), OR = operating room, SD = standard deviation, STA=superficial temporal artery, TICI=Thrombolysis in cerebral infarction, tPA=tissue plasminogen activator\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements:\u003c/em\u003e\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of interest:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical Approval\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study received approval from the Institutional Review Board and the requirement for informed consent was waived for each patient.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have no funding related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData from this study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGoyal M, Menon BK, van Zwam WH et al (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387:1723-1731. https://doi.org/10.1016/S0140-6736(16)00163-X\u003c/li\u003e\n\u003cli\u003eNogueira RG, Jadhav AP, Haussen DC et al (2018) Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med 378:11-21. https://doi.org/10.1056/NEJMoa1706442\u003c/li\u003e\n\u003cli\u003eSarraj A, Hassan AE, Abraham MG et al (2023) Trial of Endovascular Thrombectomy for Large Ischemic Strokes. N Engl J Med 388:1259-1271. https://doi.org/10.1056/NEJMoa2214403\u003c/li\u003e\n\u003cli\u003eOlthuis SGH, Pirson FAV, Pinckaers FME et al (2023) Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial. Lancet 401:1371-1380. https://doi.org/10.1016/S0140-6736(23)00575-5\u003c/li\u003e\n\u003cli\u003eLees KR, Bluhmki E, von Kummer R et al (2010) Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 375:1695-1703. https://doi.org/10.1016/S0140-6736(10)60491-6\u003c/li\u003e\n\u003cli\u003eKimura K, Iguchi Y, Shibazaki K, Watanabe M, Iwanaga T, Aoki J (2009) M1 susceptibility vessel sign on T2* as a strong predictor for no early recanalization after IV-t-PA in acute ischemic stroke. Stroke 40:3130-3132. https://doi.org/10.1161/STROKEAHA.109.552588\u003c/li\u003e\n\u003cli\u003eWelch K (1956) Excision of occlusive lesions of the middle cerebral artery. J Neurosurg 13:73-80. https://doi.org/10.3171/jns.1956.13.1.0073\u003c/li\u003e\n\u003cli\u003eInoue T, Tamura A, Tsutsumi K, Saito I, Saito N (2015) Surgical embolectomy for internal carotid artery terminus occlusion. 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J Clin Neurosci 89:206-210. https://doi.org/10.1016/j.jocn.2021.05.003\u003c/li\u003e\n\u003cli\u003eDurai Pandian J, Padma V, Vijaya P, Sylaja PN, Murthy JM (2007) Stroke and thrombolysis in developing countries. Int J Stroke 2:17-26. https://doi.org/10.1111/j.1747-4949.2007.00089.x\u003c/li\u003e\n\u003cli\u003eHashmi M, Khan M, Wasay M (2013) Growing burden of stroke in Pakistan: a review of progress and limitations. Int J Stroke 8:575-581. https://doi.org/10.1111/j.1747-4949.2012.00827.x\u003c/li\u003e\n\u003cli\u003eWasay M, Khatri IA, Kaul S (2014) Stroke in South Asian countries. Nat Rev Neurol 10:135-143. https://doi.org/10.1038/nrneurol.2014.13\u003c/li\u003e\n\u003cli\u003eTsang ACO, Yang IH, Orru E et al (2020) Overview of endovascular thrombectomy accessibility gap for acute ischemic stroke in Asia: A multi-national survey. Int J Stroke 15:516-520. https://doi.org/10.1177/1747493019881345\u003c/li\u003e\n\u003cli\u003eCollantes MV, Zuniga YH, Granada CN et al (2021) Current State of Stroke Care in the Philippines. Front Neurol 12:665086. https://doi.org/10.3389/fneur.2021.665086\u003c/li\u003e\n\u003cli\u003eCollantes ME, Navarro J, Belen A, Gan R (2022) Stroke systems of care in the Philippines: Addressing gaps and developing strategies. Front Neurol 13:1046351. https://doi.org/10.3389/fneur.2022.1046351\u003c/li\u003e\n\u003cli\u003eGordon Perue G, Then R, Gayle F et al (2023) Mission thrombectomy 2020 (MT2020+) surveys of Caribbean stroke services: A call for action in our region. J Neurol Sci 449:120640. https://doi.org/10.1016/j.jns.2023.120640\u003c/li\u003e\n\u003cli\u003eMinistry of Health R, \u003cem\u003eNational Healthcare Transformation Report\u003c/em\u003e, Ministry of Health RoI, Editor. 2022, Ministry of Health, Republic of Indonesia: Jakarta, Indonesia.\u003c/li\u003e\n\u003cli\u003eBracard S, Ducrocq X, Mas JL et al (2016) Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol 15:1138-1147. https://doi.org/10.1016/S1474-4422(16)30177-6\u003c/li\u003e\n\u003cli\u003eBerkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11-20. https://doi.org/10.1056/NEJMoa1411587\u003c/li\u003e\n\u003cli\u003eZhu F, Labreuche J, Haussen DC et al (2019) Hemorrhagic Transformation After Thrombectomy for Tandem Occlusions. Stroke 50:516-519. https://doi.org/10.1161/STROKEAHA.118.023689\u003c/li\u003e\n\u003cli\u003eZhu F, Piotin M, Steglich-Arnholm H et al (2019) Periprocedural Heparin During Endovascular Treatment of Tandem Lesions in Patients with Acute Ischemic Stroke: A Propensity Score Analysis from TITAN Registry. Cardiovasc Intervent Radiol 42:1160-1167. https://doi.org/10.1007/s00270-019-02251-4\u003c/li\u003e\n\u003cli\u003eSlawski DE, Jumaa MA, Salahuddin H et al (2018) Emergent carotid endarterectomy versus stenting in acute stroke patients with tandem occlusion. J Vasc Surg 68:1047-1053. https://doi.org/10.1016/j.jvs.2017.12.077\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Video","content":"\u003cp\u003e\u003cspan\u003eVideo: The following is the link to the video file.\u003c/span\u003e\u003cbr\u003ehttps://www.dropbox.com/scl/fi/q6zt4qkxe71wo5qoyeoe5/Video.mp4?rlkey=lxgo1tb39eus517inaeuglmo5\u0026amp;dl=0\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"global neurosurgery, surgical thrombectomy, large vessel occlusion, mechanical thrombectomy, middle cerebral artery occlusion, carotid endarterectomy ","lastPublishedDoi":"10.21203/rs.3.rs-3577955/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3577955/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMechanical thrombectomy (MT) is the leading treatment for acute large vessel occlusion (LVO). However, surgical thrombectomy (ST) may have a role in well selected LVO patients where MT failed to re-establish flow, the endovascular route is inaccessible, or where MT is a financially prohibitive or absent option(developing and poor countries). We compared the efficacy and efficiency between ST and MT, and described our operative experience and its potential application in the developing world.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical outcomes, procedural times and efficacy of treatment were compared between the MT and ST of acute LVO between 2012 and 2022. Propensity score-matched analysis was also conducted to compare MT and ST.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne-hundred nine patients fulfilled the study criteria (77MTs vs 32STs). Factors driving outcome were age (aOR:0.95, 95%CI, 0.91-0.98), hemisphere side (aOR:0.38, 95%CI, 0.15-0.96), DWI-ASPECT (aOR:1.39, 95%CI, 1.09-1.77) at presentation by the multivariate analysis. Times from door-start of procedure(P=0.45), and start of procedure-recanalization(P=0.13) were similar between treatment options. Propensity score-matched analysis found no significant difference for 2 treatment methods about time of door to recanalization(P=0.155) and outcome(P=0.221).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prognosticator of thrombectomy for acute LVO in patients with successful recanalization were age, affected hemisphere side and DWI-ASPECT score. Our evidence shows that the efficacy of ST is similar to that of MT. There should be a place of ST for cases of mechanical failure or tandem cervical ICA and MCA occlusion. ST may be a temporizing LVO treatment option in healthcare systems where MT is inexistent or financially prohibitive to patients.\u003c/p\u003e","manuscriptTitle":"Microsurgical Thrombectomy: where the ancient art meets the new era","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-15 21:13:50","doi":"10.21203/rs.3.rs-3577955/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2023-12-16T15:24:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-25T13:52:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"db364d0f-7b2d-4533-a92b-95796dabd29f","date":"2023-11-16T22:42:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"c5126b25-2b0c-4bb6-812a-66f3eb7eb9b7","date":"2023-11-16T08:35:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-11-14T11:08:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-11-14T01:48:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-11-13T16:43:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Neurosurgical Review","date":"2023-11-08T07:31:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"neurosurgical-review","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nrev","sideBox":"Learn more about [Neurosurgical Review](https://www.springer.com/journal/10143)","snPcode":"10143","submissionUrl":"https://submission.nature.com/new-submission/10143/3","title":"Neurosurgical Review","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b8d89d83-c2f7-47af-ae0d-f478cc12337e","owner":[],"postedDate":"November 15th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-01-22T15:05:20+00:00","versionOfRecord":{"articleIdentity":"rs-3577955","link":"https://doi.org/10.1007/s10143-024-02281-8","journal":{"identity":"neurosurgical-review","isVorOnly":false,"title":"Neurosurgical Review"},"publishedOn":"2024-01-15 15:01:44","publishedOnDateReadable":"January 15th, 2024"},"versionCreatedAt":"2023-11-15 21:13:50","video":"","vorDoi":"10.1007/s10143-024-02281-8","vorDoiUrl":"https://doi.org/10.1007/s10143-024-02281-8","workflowStages":[]},"version":"v1","identity":"rs-3577955","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3577955","identity":"rs-3577955","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}