A blood clot in the brain (cerebral thrombosis or embolism) is a life-threatening medical emergency. This obstruction, which prevents blood flow to brain tissue in an ischemic stroke, or the resulting pooled blood from a ruptured vessel in a hemorrhagic stroke, can lead to irreversible damage. Surgical intervention is a time-sensitive necessity for certain patients to physically remove the clot or relieve dangerous pressure, offering the best chance to salvage brain function. Treatment urgency is paramount, as every minute without proper blood flow or with excessive intracranial pressure significantly worsens the neurological outcome.
Determining Eligibility for Surgical Intervention
The decision to proceed with surgery is made rapidly based on patient evaluation and detailed imaging results. Initial diagnosis relies on rapid imaging, primarily a non-contrast Computed Tomography (CT) scan, to quickly differentiate between an ischemic stroke (blockage) and a hemorrhagic stroke (bleeding). A CT angiography (CTA) is then performed to visualize the blood vessels, pinpointing the exact location and size of any large vessel occlusion accessible for clot retrieval.
For ischemic stroke, the treatment window for mechanical clot removal has been extended, often up to 24 hours after the patient was last known to be well, based on advanced imaging. Advanced imaging, such as CT Perfusion (CTP) or Magnetic Resonance Imaging (MRI), helps determine the volume of already damaged brain tissue (infarct core) versus the surrounding tissue that is still salvageable (penumbra). The severity of the neurological deficit (measured by NIHSS score) and the extent of early ischemic changes (assessed by ASPECTS) are also used to confirm eligibility and predict potential benefit.
Mechanical Thrombectomy for Acute Clot Removal
Mechanical thrombectomy is a minimally invasive, catheter-based procedure designed to remove a clot causing an acute ischemic stroke and restore blood flow. The procedure begins with the neurointerventionalist gaining arterial access, typically through a puncture in the femoral artery (groin) or the radial artery (wrist). Through this access point, specialized catheters and guidewires are carefully navigated through the major blood vessels until they reach the blocked artery within the brain.
Once the catheter reaches the blockage, the clot is physically extracted using one of two primary methods, or sometimes a combination of both. One technique employs a stent retriever, a wire-mesh device deployed across the clot to capture it, and then retracted, pulling the clot out of the vessel. The second technique uses a large-bore aspiration catheter positioned directly against the clot, utilizing powerful suction to vacuum the thrombus out of the artery. The goal is achieving successful reperfusion, measured by the modified Thrombolysis in Cerebral Infarction (mTICI) score, to maximize saved brain tissue.
Craniotomy and Hematoma Evacuation
Craniotomy and hematoma evacuation is an open surgical approach addressing pooled blood (hematoma) resulting from a hemorrhagic stroke or severe trauma. This procedure differs fundamentally from a thrombectomy because its purpose is not to unblock an artery but to relieve dangerously high intracranial pressure (ICP) caused by the mass of clotted blood pushing on the brain. The surgery involves making an incision in the scalp and temporarily removing a section of the skull bone (the “craniotomy” component) to allow direct access to the brain’s surface.
With the skull bone flap removed, the neurosurgeon opens the dura mater (the tough membrane covering the brain) and uses specialized tools to access and remove the underlying hematoma. The physical removal of the clot reduces the mass effect, immediately dropping the intracranial pressure to prevent further secondary brain injury. For very large hemorrhages or severe brain swelling, the bone flap may be left out temporarily in a procedure called a decompressive craniectomy. Once the hematoma is evacuated and bleeding is controlled, the bone flap is typically secured back in place.
Immediate Recovery and Rehabilitation
Following surgery, the patient is transferred to a specialized Neuro-Intensive Care Unit (Neuro-ICU) for continuous monitoring. In this setting, the medical team closely watches for potential post-operative complications, such as rebleeding, cerebral swelling, or infection at the surgical site. Monitoring blood pressure, controlling intracranial pressure, and managing any resulting brain edema are constant priorities during the first several days of recovery.
Hospitalization time varies, often lasting from a few days to a couple of weeks, depending on the severity of the event and the extent of the procedure. Once medically stable, rehabilitation begins. This comprehensive plan involves a coordinated team of specialists, including physical, occupational, and speech therapists, who help the patient regain lost function and adapt to deficits. The recovery process is highly individualized, requiring sustained effort and a tailored strategy that often extends over many months as the brain slowly heals and reorganizes.