Open Microvascular Thrombectomy for Acute Intracranial Large Vessel Occlusion: Microsurgery in the Endovascular Thrombectomy Era

Background: Open microsurgical thrombectomy for acute intracranial large vessel occlusion (LVO) has been the subject of dozens of case reports and series. However, no clear indications exist to define its role in the management of acute ischemic stroke. Our aim was to review all the available data on open microsurgical thrombectomy, for both spontaneous as well as iatrogenic intracranial vessel occlusion, in terms of indication and results. Methods: Of the 390 articles screened, 33 were included after full text screening. Results: A total of 232 patients were reported, of whom 208 received microsurgical thrombectomy and 24 received bypass for large vessel occlusion. Patients were divided into a historic cohort (before 2002) and a recent cohort (articles published after 2002). Patients from the historic cohort were younger: median age, 55 years (interquartile range, 34–57 years) versus 69 years (interquartile range, 63–75 years) in the recent cohort (P < 0.01). The procedure was successful more often in the recent cohort (65% of patients in the historic cohort vs. 98% of patients in the recent cohort) and more patients experienced neurologic improvement (56% of patients in the historic cohort vs. 69% in the recent cohort). Conclusions: In the era of endovascular thrombectomy, open microsurgical techniques might still play a role in highly selected patients. The reported patients show that microsurgical thrombectomy seems efficient and effective in improving patient outcome. Ideally, a multidisciplinary approach with vascular neurosurgeons trained and skilled in microvascular techniques is recommended.