Mechanical thrombectomy in tandem occlusion: procedural considerations and clinical results

Stenting Versus Non-stenting Strategy in Endovascular Treatment of Acute Anterior Ischemic Stroke Patients with Tandem Occlusion

BACKGROUND AND OBJECTIVES

The optimal endovascular treatment (EVT) strategy for acute tandem occlusion patients has not been decided yet, and a knowledge gap still exists in the literature. Therefore, we aimed to compare the two different interventional strategies, stenting and non-stenting, for the treatment of acute tandem occlusion patients.

METHODS

This was a single-center, retrospective, observational cohort study, which was conducted in a tertiary referral center. We reviewed all acute stroke patients between January 2016 and January 2024. We assessed the effects of the two strategies, stenting and non-stenting, on seven outcome measures, namely: hemorrhagic transformation after EVT, number of days in the neurology intensive care unit (N-ICU), number of days in the hospital, in-hospital mortality, functional outcome at discharge, 3-month functional outcome, and 3-month mortality.

RESULTS

We included 54 acute tandem occlusion patients who were treated with EVT in the study. Thirty-five (64.8%) patients underwent emergency carotid stenting during EVT and 19 patients (35.2%) did not receive emergency carotid stenting. Hemorrhagic transformation after EVT, number of days in N-ICU, number of days in the hospital, in-hospital mortality, functional outcome at discharge, and 3-month functional outcome did not differ between the two groups ( P > 0.05). Emergency stenting during EVT significantly reduced the probability of 3-month mortality (odds ratio = 0.21, confidence interval: 0.04 to 0.96, P = 0.04).

CONCLUSIONS

This study showed that emergency stenting in the acute tandem occlusion patients decreased the probability of mortality. Further research is needed on this.

Effects of Emergent Carotid Stenting Performed before or after Mechanical Thrombectomy in the Endovascular Management of Patients with Tandem Lesions: A Multicenter Retrospective Matched Analysis

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) along with emergent carotid stent placement (eCAS) has been suggested to have a greater benefit in patients with tandem lesions (TL), compared with other strategies of treatment. Nonetheless, there is no agreement on whether the intracranial occlusion should be treated before the cervical ICA lesion, or vice versa. In this retrospective multicenter study, we sought to compare clinical and procedural outcomes of the 2 different treatment approaches in patients with TL.

MATERIALS AND METHODS

The prospective databases of 17 comprehensive stroke centers were screened for consecutive patients with TL who received MT and eCAS. Patients were divided in 2 groups based on whether they received MT before eCAS (MT-first approach) or eCAS before MT (eCAS-first approach). Propensity score matching was used to estimate the effect of the retrograde-versus-anterograde approach on procedure-related and clinical outcome measures. These included the modified TICI score 2b-3, other procedure-related parameters and adverse events after the endovascular procedure, and the ordinal distribution of the 90-day mRS scores.

RESULTS

A total of 295 consecutive patients were initially enrolled. Among them, 208 (70%) received MT before eCAS. After propensity score matching, 56 pairs of patients were available for analysis. In the matched population, the MT-first approach resulted in a higher rate of successful intracranial recanalization (91% versus 73% in the eCAS-first approach, P = .025) and a mean shorter groin-to-reperfusion time (72 [SD, 38] minutes versus 93 [SD, 50] minutes in the anterograde approach, P = .017). Despite a higher rate of efficient recanalization in the MT-first group, we did not observe a significant difference regarding the ordinal distribution of the 90-day mRS scores. Rates of procedure-related adverse events and the occurrence of both parenchymal hemorrhage types 1 and 2 were comparable.

CONCLUSIONS

Our study demonstrates that in patients with TL undergoing endovascular treatment, prioritizing the intracranial occlusion is associated with an increased rate of efficient MT and faster recanalization time. However, this strategy does not have an advantage in long-term clinical outcome. Future controlled studies are needed to determine the optimal treatment technique.

Antiplatelet Agents in Endovascular Neurointerventional Procedures

Minimally invasive, image-guided endovascular procedures are becoming increasingly prevalent as techniques and technologies have advanced, particularly within the realm of neurovascular interventions. Endovascular approaches ubiquitously result in endothelial injury with subsequent risk of thromboembolic complications. Periprocedural antiplatelet agent use is an integral component of the management of patients undergoing endovascular neurointerventional procedures. This patient population has a unique risk profile encompassing thromboembolic and hemorrhagic complications simultaneously, and the precise balance of these risks impacts patient outcomes almost as much as the interventional procedure itself. Clinical experience and study consensus demonstrate overall improved outcomes with the use of periprocedural antiplatelet agents, though current practices remain highly institution and practitioner-dependent. This focused review will discuss the major mechanisms of action of antiplatelet agents, and their clinical indications and management in the periprocedural neurointerventional setting. Despite the importance of antiplatelet agents in the management of neurointerventional patients, many questions remain. Further research and clinical expertise are needed to establish standardized, procedure-specific, antiplatelet regimens as well as standardized monitoring of antiplatelet agent regimen efficacy and safety.

False Lumen Stenting to the Acute Occlusive Carotid Artery Dissection Combined With Intracranial Acute Embolic Stroke: A Case Report and Literature Review

Tandem occlusion due to acute cervical carotid artery dissection should be promptly treated with thrombectomy for reperfusion. If the cervical lesion has reached severe stenosis or complete occlusion, balloon angioplasty and, in certain cases, carotid artery stenting should be performed before thrombectomy for the intracranial lesion. Angioplasty or stent placement is performed in the true lumen, but securing the placement is challenging when the true lumen cannot be determined. In contrast, stenting in the false lumen of a carotid artery dissection is considered contraindicated. Although reports on a few similar cases have been published, no obvious complications are known, and the actual risks and outcomes remain unclear. We report the case of a 49-year-old woman with acute ischemic stroke who had tandem occlusion of the cervical internal carotid and middle cerebral arteries due to acute cervical dissection. The cervical lesion was completely occluded with no true lumen, and securing the true lumen proved extremely difficult. Therefore, we performed intracranial thrombectomy via the false lumen, followed by carotid artery stenting from the distal to the proximal true lumen via the false lumen. Six months later, follow-up examinations revealed no obvious complications. Our literature review identified only three reports of stenting in the false lumen of an acute carotid artery dissection, and no apparent complications were reported in any of these cases. Furthermore, the technique of recanalization through the false lumen is well established in chronic total occluded lesions of coronary or peripheral arteries when the true lumen cannot be secured. Therefore, access to the intracranial artery via the false lumen may be acceptable in situations of simultaneous intracranial arterial occlusion requiring rapid recanalization where securing a true lumen is challenging.

Repeated Re-occlusion during the Procedure of Mechanical Thrombectomy with Retrograde Approach for Tandem Occlusion Including T Occlusion: A Case Report

Objective

Two mechanical thrombectomy techniques are proposed for tandem occlusion of the anterior circulation: treating the extracranial carotid artery lesion first via an antegrade approach and treating the intracranial lesion first via a retrograde approach. Previous reports show that the retrograde approach has a shorter reperfusion time and a better prognosis, but re-occlusion of the intracranial lesion after recanalization may occur. We describe a case of tandem occlusion with repeated intracranial occlusions for mechanical thrombectomy using the retrograde approach and discuss possible countermeasures.

Case Presentation

A 94-year-old woman presented with acute cerebral ischemia due to tandem carotid T occlusion of the left internal carotid artery (ICA) and severe stenosis of the cervical carotid artery. Mechanical thrombectomy via a retrograde approach was performed using a stent retriever, resulting in complete recanalization of the anterior circulation through the ICA after 1 pass. The thrombus dispersed distally from the cervical artery and re-occluded the M1 twice, requiring thrombus re-retrieval each time.

Conclusion

The retrograde approach to tandem occlusion can result in repeated re-occlusion after recanalization of the intracranial lesion. Thrombi in cervical carotid lesions are usually fragile. Prior thrombus aspiration from the balloon guiding catheter at the carotid lesion may prevent re-occlusion after recanalization of the intracranial lesion without sacrificing the time advantage of early recanalization via the retrograde approach.

Enhancing recanalization success: Thrombectomy plus stent angioplasty by coaxial balloon technique for acute ischemic stroke with tandem occlusions

Recanalizing acute ischemic stroke with carotid tandem occlusion (CTO) is technically challenging because distal embolic migration during revascularization can significantly influence outcomes. In this study, we aimed to introduce our coaxial balloon technique using a balloon-guiding catheter (BCG), angioplasty catheter, and aspiration catheter sequentially to prevent thrombus migration to a new vascular territory. We used this technique for six patients with CTO. Technical success with good revascularization of the CTO was achieved in all six patients (100%) without neurological complications, including one and five cases of modified Thrombolysis in Cerebral Infarction 2b and 3, respectively. The median duration of the procedure was 61 (interquartile range, 52-90) min. The mean National Institutes of Health Stroke Scale score at discharge was 3.5 (2-8), with favorable clinical outcomes at 90 days for three of six patients (50%). The coaxial balloon technique for CTO is safe and effective for revascularization in patients with acute ischemic stroke. Thrombectomy before proximal stenting was associated with shorter reperfusion times and better clinical outcomes. Therefore, this approach is recommended for tandem occlusions requiring stent angioplasty.

Stenting with dual-layer CGuard stent in acute sub-occlusive carotid artery stenosis and in tandem occlusions: a monocentric study

PURPOSE

Double-layer design carotid stents have been cast in a negative light since several investigations reported high rates of in-stent occlusions, at least in the acute setting of tandem occlusions. CGuard is a new generation double-layered stent that was designed to prevent periinterventional embolic events. The aim of this study was to analyze the safety and efficacy of the CGuard in emergent CAS and for the acute treatment of tandem occlusions in comparison with the single-layer Carotid Wallstent (CWS) system.

METHODS

All patients who underwent CAS with CGuard or CWS after intracranial mechanical thrombectomy (MT) between 11/2018 and 12/2022 were identified from our local thrombectomy registry. Clinical, interventional and neuroimaging data were analyzed. Patency of the stent was assessed within 72 h. Intracranial hemorrhage and modified Rankin score (mRS) at discharge were the main endpoints.

RESULTS

In total, 86 stent procedures in 86 patients were included (CWS: 44, CGuard: 42). CGuard had a lower, but not statistically significant rate (p = 0.431) of in-stent occlusions (n = 2, 4.8%) when compared to the CWS (n = 4, 9.1%). Significant in-stent stenosis was found in one case in each group. There was no statistically significant difference in functional outcome at discharge between the two groups with a median mRS for CGuard of 2 (IQR:1-5) vs. CWS 3 (IQR:2-4).

CONCLUSION

In our series, the rate of in-stent occlusions after emergent CAS was lower with the dual-layer CGuard when compared to the monolayer CWS. Further data are needed to evaluate the potential benefit of the design in more detail.

Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions

Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.

Timing of acute carotid artery stenting for tandem lesions in patients with acute ischemic stroke: A Maastricht Stroke Quality Registry (MaSQ-Registry) study

BACKGROUND

To better understand the influence of treatment strategies on outcomes for patients with tandem lesions undergoing acute internal carotid artery (ICA) stenting during endovascular treatment (EVT), this study compared clinical, technical, and safety outcomes in patients with acute ischemic stroke due to a large vessel occlusion (LVO) who underwent ICA stenting before versus after intracranial thrombectomy.

METHODS

This single-center retrospective cohort study included patients who underwent EVT due to a LVO and periprocedural ICA stenting for significant ICA stenosis or occlusion between September 2020 and January 2023. Data were extracted from the Maastricht Stroke Quality Registry (MaSQ-Registry). Primary outcome was the modified Rankin Scale (mRS) at 3 months. Secondary outcomes included procedure times, number of total thrombectomy attempts, first-attempt excellent recanalization rates (extended Thrombolysis In Cerebral Infarction (eTICI) ≥ 2C after one thrombectomy attempt), and safety outcomes.

RESULTS

This study included 50 patients. Thirty-one patients (62%) underwent ICA stenting before intracranial thrombectomy. No significant differences between both groups were found regarding mRS, total procedure time, number of total thrombectomy attempts, first-attempt excellent recanalization, or complications. Time between groin puncture and recanalization (reperfusion time) was significantly longer in patients who had ICA stenting before intracranial thrombectomy versus after intracranial thrombectomy (45 min versus 28 min, P = 0.004).

CONCLUSION

ICA stenting after intracranial thrombectomy in patients with tandem lesions undergoing EVT did not lead to better patient outcomes compared to stenting before intracranial thrombectomy, despite shorter reperfusion times.

Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience

BACKGROUND

Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO).

METHODS

We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups.

RESULTS

A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0-2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35-2.05; aOR 0.93, 95% CI 0.35-2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496).

CONCLUSION

Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO.

Bridging techniques compared with direct endovascular therapy for stroke due to tandem occlusion: A systematic review and meta-analysis

The superiority of the bridging strategy of intravenous thrombolysis (IVT) plus endovascular therapy (EVT) to EVT alone for the anterior circulation with tandem vascular occlusion (TO) has not been specifically addressed by a single randomized trial. Analysis of 15 studies (n = 1857 patients) revealed that 90 Day good functional outcomes (MRS≤2) were better for bridging therapy (IVT + EVT) than for dEVT (OR:1.39, 95%CI: 1.09-1.79, p = 0.008); 90-day mortality was lower for IVT + EVT than for dEVT (OR: 0.57; 95%CI: 0.40-0.81, p = 0.002) and rates of successful recanalization were higher for IVT + EVT than for dEVT (OR: 1.79, 95%CI: 1.36-2.36, p<0.0001). However, there was no significant difference in the incidence of symptomatic. intracranial hemorrhage (sICH) between groups (OR 0.91, 95%CI 0.64-1.31, p = 0.62).In conclusion, Patients receiving IVT + EVT have a better functional outcome, lower death rate and a higher rate of successful recanalization than those receiving dEVT but there was no difference in sICH risk between the two treatments.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BACKGROUND

The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS.

METHODS

We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented.

RESULTS

34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT.

CONCLUSIONS

In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.

A novel fully automated method for measuring ASPECTS to improve stroke diagnosis: Comparison to traditional ASPECTS

BACKGROUND AND PURPOSE

To compare the accuracy of subjective Alberta Stroke Program Early CT Score (sASPECTS) evaluation and that of an automated prototype software (aASPECTS) on nonenhanced CT (NECT) in patients with early anterior territory stroke and controls using side-to-side quantification of hypoattenuated brain areas.

METHODS

We retrospectively analyzed the NECT scans of 42 consecutive patients with ischemic stroke before reperfusion and 42 controls using first sASPECTS and subsequently aASPECTS. We assessed the differences in Alberta Stroke Program Early CT Score (ASPECTS) and calculated the sensitivity and specificity of NECT with CT perfusion, whereas cerebral blood volume (CBV) served as the reference standard for brain infarction.

RESULTS

The clot was located in the middle cerebral artery (MCA) in 47.6% of cases and the internal carotid artery (ICA) in 28.6% of cases. Ten cases presented combined ICA and MCA occlusions. The stroke was right sided in 52.4% of cases and left sided in 47.6%. Reader-based NECT analysis yielded a median sASPECTS of 10. The median CBV-based ASPECTS was 7. Compared to the area of decreased CBV, sASPECTS yielded a sensitivity of 12.5% and specificity of 86.8%. The software prototype (aASPECTS) yielded an overall sensitivity of 65.5% and a specificity of 92.2%. The interreader agreement for ASPECTS evaluation of admission NECT and follow-up CT was almost perfect (κ = .93). The interreader agreement of the CBV color map evaluation was substantial (κ = .77).

CONCLUSIONS

aASPECTS of NECT can outperform sASPECTS for stroke detection.

Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study

BACKGROUND

Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment.

METHODS

Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups.

RESULTS

Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency.

CONCLUSIONS

Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.

Diagnosis and management of tandem occlusion in acute ischemic stroke

Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.

Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke

BACKGROUND

Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists.

OBJECTIVE

To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion.

METHODS

A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed.

RESULTS

Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection.

CONCLUSION

The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.

Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke: results from the MR CLEAN Registry

BACKGROUND

The optimal management of ipsilateral extracranial internal carotid artery (ICA) stenosis during endovascular treatment (EVT) is unclear. We compared the outcomes of two different strategies: EVT with vs without carotid artery stenting (CAS).

METHODS

In this observational study, we included patients who had an acute ischaemic stroke undergoing EVT and a concomitant ipsilateral extracranial ICA stenosis of ≥50% or occlusion of presumed atherosclerotic origin, from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry (2014-2017). The primary endpoint was a good functional outcome at 90 days, defined as a modified Rankin Scale score ≤2. Secondary endpoints were successful intracranial reperfusion, new clot in a different vascular territory, symptomatic intracranial haemorrhage, recurrent ischaemic stroke and any serious adverse event.

RESULTS

Of the 433 included patients, 169 (39%) underwent EVT with CAS. In 123/168 (73%) patients, CAS was performed before intracranial thrombectomy. In 42/224 (19%) patients who underwent EVT without CAS, a deferred carotid endarterectomy or CAS was performed. EVT with and without CAS were associated with similar proportions of good functional outcome (47% vs 42%, respectively; adjusted OR (aOR), 0.90; 95% CI, 0.50 to 1.62). There were no major differences between the groups in any of the secondary endpoints, except for the increased odds of a new clot in a different vascular territory in the EVT with CAS group (aOR, 2.96; 95% CI, 1.07 to 8.21).

CONCLUSIONS

Functional outcomes were comparable after EVT with and without CAS. CAS during EVT might be a feasible option to treat the extracranial ICA stenosis but randomised studies are warranted to prove non-inferiority or superiority.

Conservative versus aggressive antiplatelet strategy for emergent carotid stenting during stroke thrombectomy

BACKGROUND

There is no consensus regarding optimal antiplatelet regimen for emergent carotid stenting during stroke thrombectomy. We aimed to assess the safety and efficacy of an aggressive periprocedural antiplatelet strategy focused on preserving stent patency, in comparison with conservative antiplatelet strategy consisting of aspirin monotherapy.

MATERIALS AND METHODS

Retrospective review of a prospectively collected database in a comprehensive stroke center, including all cases of emergent carotid stenting for tandem lesions stroke between 01.03.2012-01.06.2021. Aggressive antiplatelet strategy consisted of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel loading doses, with added intravenous (IV) tirofiban if in-stent thrombosis was observed during thrombectomy. Clinical and radiological outcomes were compared between conservative and aggressive antiplatelet treatment groups using inverse probability of treatment weighting (IPTW) analysis based on propensity scores.

RESULTS

We included 132 cases (76.5% atheroma, 22.7% dissection, 0.7% carotid web). Forty-five patients (34%) cases received conservative antiplatelet therapy. The remaining 87 (65.9%) received aggressive antiplatelet therapy: 66 (75.8%) treated with DAPT, 21 (24.1%) with DAPT and tirofiban. Periprocedural heparin was avoided in all cases. In adjusted analysis of the weighted samples, aggressive antiplatelet strategy was associated with improved carotid stent patency (aOR 0.23, 95% CI 0.07-0.80, p = 0.021), higher proportion of moderate clinical outcome (mRS ≤ 3, aOR 2.72, 95% CI 1.01-7.30, p = 0.04), with no significant differences in mortality and hemorrhagic transformation (HT) rates.

CONCLUSIONS

In this retrospective study, aggressive periprocedural antiplatelet strategy led to improved stent patency and clinical outcomes, without increased HT. Further prospective randomized research is warranted to identify the optimal combination of antiplatelet agents for emergent carotid stenting in the setting of acute stroke.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

BACKGROUND

Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear.

OBJECTIVE

To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion.

METHODS

Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling.

RESULTS

Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors.

CONCLUSIONS

In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke

BACKGROUND

Double-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion.

METHODS

We retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months.

RESULTS

In 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0-2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%.

CONCLUSION

The CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.

Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke

BACKGROUND

Among tandem occlusions, atherosclerotic cervical internal carotid artery occlusion (ACICAO) can be technically challenging and associated with its unique complications. We evaluated our experience with endovascular treatment (EVT) of ACICAO in the setting of acute ischemic stroke.

METHODS

In total, 154 consecutive patients who underwent EVT for acute anterior circulation stroke at our institute were retrospectively reviewed. Patients with tandem ACICAO were analyzed in this study. Procedures, recanalization rates, complications, and prognoses were evaluated.

RESULTS

Ten patients (6%) of all 154 patients had ACICAO. In nine (90%) of the 10 patients, cervical lesions were successfully crossed and intervened upon. Four patients underwent stenting and five underwent angioplasty alone, followed by intracranial procedure. Eight patients (80%) achieved successful recanalization following mechanical thrombectomy for intracranial occlusion. However, one patient had massive subarachnoid hemorrhage during the procedure and another patient developed massive intracranial hemorrhage after EVT, both after stenting. Four of the five patients who initially underwent angioplasty alone subsequently underwent staged endarterectomy or stenting for residual stenosis on or after the next day. The single patient in whom the cervical lesion could not be crossed and another with reocclusion after EVT underwent a rescue bypass procedure due to persistent ischemic symptoms. After 90 days, four patients (40%) were functionally independent (modified Rankin scale score 0-2).

CONCLUSIONS

Our experience suggests that EVT for ACICAO is technically feasible; however, it involves the potential risk of several significant complications. To avoid serious hemorrhagic complications, cervical lesions may be better treated with angioplasty alone first.

Emergent carotid endarterectomy and mechanical thrombectomy in tandem occlusion

Background:

Acute tandem occlusions, or occlusions of the extracranial portion of the internal carotid artery (ICA) with concurrent thromboembolism of the intracranial ICA or middle cerebral artery, poses a major clinical challenge, with patients suffering worse outcomes compared to those with single occlusions. Management of these lesions generally includes a combination of mechanical thrombectomy (MT) of the intracranial occlusion and stenting of the extracranial carotid lesion. In this manuscript, we describe a successful surgical method for achieving revascularization of tandem occlusions in the rare circumstance that the proximal lesion cannot be crossed endovascularly to gain intracranial access.

Methods:

Despite using our institution’s standard protocol for achieving revascularization of such lesions, the extracranial occlusion could not be crossed endovascularly, and the case was converted to an emergent carotid endarterectomy (CEA) in the operating room. Once the endarterectomy was complete, intraoperative MT was performed before cervical incision closure to revascularization.

Results:

The patient recovered well postoperatively and was discharged with NIHSS of 2 due to minor facial palsy and minor dysarthria. Thirty-day follow-up revealed resolution of the prior neurologic deficits and an mRS of 1.

Conclusion:

Emergent CEA should be considered in the rare circumstance of being unable to cross the cervical occlusion during management of acute ischemic stroke with tandem occlusion.

Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I ² statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis

Background Despite thrombectomy having become the standard of care for large-vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes' associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta-analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3-month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random-effects model was used for analysis. Thirty-four studies were included in our systematic review and 9 in the meta-analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24-3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26-2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05-2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.

Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke

PURPOSE

Endovascular treatment of atherosclerotic tandem occlusions in acute ischemic stroke (AIS) is a matter of debate. This article reports a single-center experience using an intermediate catheter with microballoon for treatment of tandem occlusions.

METHODS

A total of 151 AIS patients with large vessel occlusion received endovascular therapy and a consecutive series of patients (n = 26) who suffered from tandem cervical intracranial occlusions were treated using the Passing Extracranial Artery Occlusion by Intermediate Catheter with Expanding Microballoon (PEACE) technique. Intracranial recanalization was achieved by aspiration or stent retriever and then emergency stenting was performed for extracranial internal carotid artery (ICA) lesion. Demographic, clinical characteristics, procedural details of endovascular therapy, and prognosis outcome were assessed. The outcomes of tandem occlusion group were compared with isolated intracranial occlusion group (n = 122) and previous studies.

RESULTS

As compared to isolated intracranial occlusion groups, only a few patients suffered from atrial fibrillation (7.7% vs 38.5%, p<0.01) in tandem occlusions group. A larger proportion of patients (61.5% vs 29.5%) had tandem occlusions in which extracranial ICA occlusion was combined with intracranial terminus occlusion in ICA (p<0.01). 46.2% of tandem occlusions patients achieved intracranial recanalization by aspiration alone versus 15.6% in patients with isolated intracranial occlusion (p<0.01). In tandem occlusion patients treated with PEACE, 92.3% achieved successful reperfusion (thrombolysis in cerebral infarct [TICI] ≥2b). The median time from puncture to recanalization was 51 minutes (interquartile range [IQR], 41-66). 67.6% favorable functional prognosis (modified Rankin score [mRS], 0-2) was seen, with 11.5% mortality and 3.8% of symptomatic intracerebral hemorrhage (sICH) at 90 days. These outcomes are all consistent or better than previously reported studies performed for tandem occlusion.

CONCLUSIONS

Endovascular therapy using the PEACE technique with intermediate catheter and lined expanding microballoon is safe, efficient, and fast in the treatment of atherosclerotic tandem occlusion patients.

Carotid Artery Stenting: Applications and Technical Considerations

PURPOSE OF THE REVIEW

To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches.

RECENT FINDINGS

Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia.

SUMMARY

Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.

Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices

Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.

Ostial common carotid artery occlusion and balloon-mounted stenting: Implication of embolic protection device in tandem lesion

Ostial common carotid artery (CCA) stenosis is rare, compared to extracranial internal carotid artery bifurcation lesions. In cases of a tandem lesion, the proximal lesion usually involves the extracranial internal carotid artery, and the ostial CCA is rarely implicated. A 69-year-old woman who underwent 3 months of antiplatelet therapy for asymptomatic, right ostial, severely calcified CCA stenosis presented with sudden onset left hemiparesis. Radiographic examination revealed an ostial CCA-intracranial artery tandem lesion. After intracranial revascularization using a clot retrieval stent, we performed the endovascular treatment with a balloon-mounted stent using an embolic protection device. This procedure may be superior to others because it is possible to achieve early intracranial revascularization and prevent distal embolism during the complete treatment of proximal lesions.

Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study

BACKGROUND

Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs.

METHODS

This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis.

RESULTS

There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003).

CONCLUSIONS

Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.

Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1

BACKGROUND AND PURPOSE

Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1.

MATERIALS AND METHODS

Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy.

RESULTS

Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment.

CONCLUSIONS

Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.

Tandem Lesions in Anterior Circulation Stroke: Analysis of the German Stroke Registry-Endovascular Treatment

[Figure: see text].

Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions

OBJECTIVES

Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs.

MATERIALS AND METHODS

Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed.

RESULTS

From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency.

CONCLUSIONS

Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.

[Results of endovascular treatment of acute tandem occlusion of internal carotid and middle cerebral arteries]

OBJECTIVE

To evaluate the results of endovascular treatment of patients with ischemic stroke caused by acute tandem occlusion of the internal carotid and middle cerebral arteries (ICA and MCA).

MATERIAL AND METHODS

Endovascular intervention was performed in 8 patients with tandem occlusion of ICA and MCA. The neurological deficit on admission was 17.4±5.6 NIHSS points and the average ASPECTS score was 9.5±0.8. The time from the onset of neurological symptoms to reperfusion was 224±68 min. Thrombolytic therapy was initiated before brain revascularization and continued intraoperatively in 4 out of 8 patients. ICA stenting after aspiration thrombectomy was required in 6 patients. Both antegrade (n=4) and retrograde (n=2) methods of brain revascularization were used.

RESULTS

The rate of detection of tandem lesion in patients with ischemic stroke who underwent endovascular treatment was 5.4%. Technical success in restoring blood flow in the ICA basin at extra-and intra-cranial levels (mTICI 2b/3) was achieved in 7 (87.5%) patients. Intracranial hemorrhagic complications that affected the outcome of the disease were clinically significant in 25% of patients (n=2). The mortality rate was 37.5% (n=3). A satisfactory clinical result (a deficit of 0-2 mRS scores) was achieved at discharge in one of 5 surviving patients.

CONCLUSION

Further studies of choosing the optimal surgical tactics for tandem occlusion of ICA and MCA, taking into account its effectiveness and safety, are need.

Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey

BACKGROUND

While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT.

METHODS

We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups.

RESULTS

We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial.

CONCLUSIONS

The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.

Management and prognosis of acute extracranial internal carotid artery occlusion

Acute occlusion of the internal carotid artery is the underlying etiology in 4 to 15% of all ischemic strokes. The clinical presentation varies considerably ranging from asymptomatic occlusion to severe ischemic strokes. Substantial differences in the acute management of acute symptomatic internal carotid artery occlusions (ICAO) exists between centers. Thusly, we comprised a narrative review of the natural course of acute ICAO and of available treatment options [i.v. thrombolysis, endovascular thrombectomy and stenting, bypass between the superficial temporal and the middle cerebral arteries (MCA) and carotid endarterectomy (CEA)]. We found that very few randomized treatment trials have been performed in patients acute symptomatic ICAO. Most evidence stems from case series and observational studies. Especially in older studies the intracranial vessel status has rarely been considered. After revision of these studies we concluded that the mainstay of the acute management of acute symptomatic ICAO is i.v. thrombolysis when applied within the label and in combination with mechanical thrombectomy in case of intracranial large vessel occlusion. In cases without intracranial large vessel occlusion mechanical thrombectomy of acute ICAO is associated with a risk of distal embolization. More research on prognostic parameters is needed to better characterize the risk of decompensation of collateral flow and to better define the time-window of intervention. When mechanical thrombectomy fails or is not available, surgical approaches are an alternative in selected patients.

Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

Endovascular treatment (EVT) is the standard treatment for patients with an acute ischemic stroke due to occlusion of large vessel occlusion (LVO). In 20% of patients, concomitant extracranial internal carotid artery (EICA) lesion is present. These tandem lesions (TL) offer a technical challenge. The treatment strategy for the treatment of the ipsilateral EICA is unclear. The aim of this review is to compare two treatment strategies for TL during EVT: balloon angioplasty (BA) only and immediate carotid artery stenting (iCAS). A systematic review and meta-analysis was performed. Data for each included study was extracted. For comparative studies a meta-analysis was performed. Functional outcome was expressed with the modified Rankin scale and safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). A total of 72 full text articles evaluating treatment of TL during EVT were screened. Sixteen iCAS and five comparative studies were included for meta-analysis. 53% of patients undergoing iCAS during EVT had good functional outcome in comparison to 45% of patients who underwent only BA. Mortality was comparable at 16% for both groups. The incidences of sICH were 8% and 4% for iCAS and BA respectively. In the meta-analysis, iCAS was associated with good functional outcome, with no significant differences in mortality and sICH with compared to BA. This study shows that treatment with iCAS of a simultaneously ipsilateral EICA lesion during EVT is associated with a favorable functional outcome compared to BA only with no significant difference in mortality or sICH. No conclusion could be drawn about the intracranial or extracranial first approach due to scarce of data. More studies are needed to determine long-term neurological outcomes, the necessity of re-interventions and optimal technical approach (intracranial or extracranial first).

Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance

BACKGROUND AND AIMS

Emergent stent placement may be required during neurothrombectomy. Our aim was to investigate the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following neurothrombectomy.

METHODS

We retrospectively analyzed a cohort of 761 consecutive neurothrombectomies performed at our center between May 2010 and August 2018, from whom a total of 106 patients had acute internal carotid artery occlusions. Early stent occlusion was defined as complete vessel occlusion within 24 h of neurothrombectomy. Clinical outcome was evaluated at day 90 with the modified Rankin Score scale (mRS). Pretreatment, procedural and outcome variables were recorded and analyzed using logistic regression.

RESULTS

Carotid stenting was performed in 99 (13%) patients. Of those, 22 (22%) had early stent occlusion at follow-up. Stent occlusion was associated with a lower use of post-stenting angioplasty [adjusted OR (aOR) = 11.2, 95%CI = 2.49-50.78, p = 0.002)], increased residual intrastent stenosis (aOR = 2.1, 95%CI = 1.38-3.06, p < 0.001) and unsuccesful intracranial recanalization (modified TICI score 0-2a) (aOR = 13.5, 95%CI = 1.97-92.24, p = 0.008). Stent occlusion was associated with poor clinical outcome at day 90 (poorer mRS shift, aOR = 3.9, 95%CI = 1.3-11.3, p = 0.014; mRS>2, aOR = 6.3, 95%CI = 1.8-22.7, p = 0.005), and with an increased rate of symptomatic intracranial hemorrhage at 24 h (14% versus 1%, p = 0.033).

CONCLUSIONS

Early carotid stent occlusion occurred in one out of five neurothrombectomies and was associated with periprocedural factors that included increased residual intrastent stenosis, a lower use of post-stenting angioplasty and unsuccessful intracranial recanalization. Further investigation is warranted for the evaluation of strategies aimed to prevent carotid stent occlusion.

Endovascular Treatment for Vertebrobasilar Artery Tandem Occlusion Beyond 24 Hours From Onset of Stroke-Case Report

We report a case in which endovascular treatment (EVT) was performed for vertebral and basilar artery (VA and BA) tandem occlusion beyond 24 hours from onset of stroke. A 78-year-old man was admitted to our institution with dysarthria and disturbance of gait. MRI revealed occlusion of the BA with acute ischemic change in bilateral cerebellum and brain stem. At 36 hours after onset and 30 hours after administration, EVT was performed because of deteriorating neurological symptom. Successful revascularization was achieved with percutaneous transluminal angioplasty for VA and thrombectomy for BA occlusion. The neurological symptoms were improved in postoperative course.

Posterior circulation tandem occlusions: Classification and techniques

BACKGROUND

Posterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited.

METHODS

We conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019.

RESULTS

Of 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%.

CONCLUSION

Endovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions.

Carotid Artery Stenting Using a Double-layer Micromesh Stent

Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy (CEA) in Japan. However, one of its disadvantages is the higher incidence of ischemic complications than CEA, such as distal embolism during or after the procedure. Plaque protrusion (PP) through the stent strut after deployment of the stent has been suggested as one of the major causes of distal embolism, especially in patients with unstable plaques. The need for increased plaque coverage to reduce the risk of PP through the stent struts has led to the development of a double-layer micromesh stent (micromesh stent) system. This stent system has already been used clinically in European countries with good short- to medium-term follow-up results. Also clinical trials evaluating micromesh stents have been completed in Japan. Hence, usefulness of the micromesh stent for CAS is expected. According to the results of several clinical studies, CAS with the double-layer micromesh stent has the potential to minimize distal embolism during or after the procedure even in patients with unstable plaques. However, it may not be suitable for emergency CAS at this point. Also, since results of only short- to medium-term follow-up have been reported, longer-term follow-up will be required in the near future.

Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions

Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.

Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke

There is no consensus for the treatment of a tandem occlusion (TO) in a patient presenting with an acute ischemic stroke. In this review article, we will focus on the controversial treatment strategies for TOs. First, we will discuss treatment options including retrograde, antegrade, and delayed approaches. Second, the role of carotid stent placement versus balloon angioplasty for the extracranial occlusion will be presented. Third, anticoagulation and antiplatelet regimens for the treatment TOs published in the literature will be reviewed. Finally, we will discuss whether there is a role for coil occlusion of the cervical carotid artery or whether staged carotid revascularization days after mechanical thrombectomy of the intracranial occlusion maybe appropriate. The optimal treatment strategy of TO has not been established and further larger trials need to be performed to answer the question.

Carotid Revascularization: Current Practice and Future Directions

Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.

Outcome and effect of endovascular treatment in stroke associated with acute extracranial internal carotid artery occlusion: Single-center experience in Japan

BACKGROUND

Positive data from several randomized controlled trials (RCTs) of endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (ACLVO) have emerged. However, little evidence exists on EVT for acute extracranial internal carotid artery (EC-ICA) occlusion. We therefore analysed the outcome and effect of EVT on AIS due to ACLVO caused by EC-ICA occlusion, including tandem occlusion compared with that caused by pure intracranial artery occlusion.

METHODS

A total of 135 consecutive AIS patients with ACLVO between July 2014 and December 2017 were identified. We retrospectively analysed the efficacy of EVT for ACLVO after introducing a stent retriever (SR). We classified ACLVO into the following categories: group A, intracranial artery occlusion without EC-ICA occlusion (pure intracranial artery occlusion), and group B, ipsilateral EC-ICA occlusion with/without intracranial artery occlusion.

RESULTS

In total, 65 patients were enrolled. Group A comprised 71% (46/65) of all cases. No difference was observed in terms of age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomography Score-Diffusion Weighted imaging (ASPECTS-DWI), several clinical time intervals, rate of successful revascularization (74% versus 84%), and rate of functional independence (42% versus 39%) between groups A and B. In all patients, an ASPECTS-DWI ≥6 and an onset-to-door time ≤6 h were associated with good outcome, whereas intracranial artery occlusion without EC-ICA occlusion (pure intracranial artery occlusion) was not.

CONCLUSIONS

The outcomes support the efficacy of EVT in stroke associated with acute EC-ICA occlusion. In the EVT of AIS due to ACLVO, there was no significant difference in the results between ipsilateral EC-ICA occlusion with/without intracranial artery occlusion and intracranial artery occlusion without EC-ICA occlusion (pure intracranial artery occlusion).

The "distal-to-proximal" strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience

PURPOSE

Data on posterior circulation tandem occlusions in acute ischemic stroke are scarce: recognition may be challenging and little is known about optimal treatment strategy. We report our endovascular treatment strategy for posterior circulation tandem occlusion.

METHODS

Consecutive patients with posterior circulation tandem occlusions in our centre were enrolled retrospectively. The preferred strategy was "distal-to-proximal" strategy, which means opening the distal occlusion first followed by treatment of the proximal pathology. The imaging characteristics, treatment strategy, clinical outcomes, and complications of patients with posterior circulation tandem occlusions were analyzed.

RESULTS

In total, 21 patients with posterior circulation tandem occlusions were enrolled in the study, which accounted for 23.6% of patients with posterior circulation stroke in our centre. The mean age was 60 years (range 32 to 80), and median pre-procedure NIHSS score was 28 (interquartile range: 13-31). Eighteen patients (85.7%) had vertebrobasilar artery tandem occlusions and 3 (14.3%) had basilar artery to basilar artery tandem occlusions. All distal occlusions were successfully recanalized (modified TICI 2b/3). Two (9.5%) of the proximal lesions were not treated. A total of 57.1% of the patients had stents implanted on the proximal occlusions. The rate of mRS 0-3 at 3 months was 57.1% and the mortality rate was 19.0%.

CONCLUSION

In patients with acute ischaemic stroke caused by posterior circulation tandem occlusions, we favor "distal-to-proximal" strategy based on the positive results in this small series. Nevertheless, a more extensive study is required to explore the optimal treatment strategy further.

Mechanical Thrombectomy: Answering Unanswered

The stroke physician community witnessed a major “breakthrough” in acute stroke therapeutics when the results of the first of the many positive trials, “MR CLEAN,” were published showing a significant absolute benefit in favor of mechanical thrombectomy in patients with large vessel occlusion (LVO). Thereafter, the investigators of ESCAPE, SWIFT PRIME, REVASCAT, THRACE, and PISTE concluded the same. Based on the initial studies, the American Stroke Association amended the 2013 guidelines in 2015 to include mechanical thrombectomy as the standard of care in patients with LVO presenting within six hours. In the past year, the horizon was further expanded when two major landmark trials, DAWN and DEFUSE 3, established the benefit of mechanical thrombectomy in the delayed window period in a select group of patients. It further led to the inclusion of the delayed window period treatment strategies in the 2018 guidelines. However, there are many unanswered questions in scenarios like small deficit with LVO, borderline large core, wake-up stroke (WUS), tandem occlusion, imaging of choice, conscious sedation (CS) versus general anesthesia (GA), and choice of technique. In our review, we aim to answer these questions along with a schematic representation of current techniques used in stroke thrombectomy.