Endovascular treatment of acute tandem occlusion strokes and stenting first experience

Acute carotid stenting versus non-stenting treatment of acute ischemic stroke due to tandem lesions: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness and safety of acute carotid stenting (ACS) in comparison to non-stenting interventions for patients experiencing acute ischemic stroke (AIS) caused by tandem lesions (TL).

METHODS

A systematic review of literature from PubMed, Embase, and Cochrane databases was conducted to identify relevant studies published up to October 10, 2023. The comparison between ACS and no stenting in patients with TL undergoing endovascular therapy (EVT) focused on outcomes, such as 90-day modified Rankin Scale (mRS) score, successful recanalization, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

RESULTS

The final analysis encompassed a total of 3,187 patients from 21 studies, with 1,786 patients classified as ACS patients and 1,401 as non-stent patients. The overall treatment effect favored the ACS group, as evidenced by their association with improved functional independence at 90 days (mRS 0-2) [relative risk (RR) = 1.18; 95% confidence interval (CI) 1.05-1.34; P < 0.05; I2 = 44%] and a higher rate of successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b/3] (RR = 1.16; 95% CI 1.09-1.25; P < 0.05; I2 = 40%). The risk of sICH was not significantly different between the two groups (RR = 1.28; 95% CI 0.98-1.68; P > 0.05; I2 = 0%). Additionally, there was no significant difference in 90-day mortality between the two groups (RR = 0.78; 95% CI 0.58-1.07; P > 0.05; I2 = 45%).

CONCLUSION

Among TL patients undergoing EVT, ACS may be associated with better functional outcomes at 90 days compared with no stenting.

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.

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/.

Delayed reperfusion therapy for ischemic stroke tandem occlusion with subsequent secondary prophylaxis of cerebral ischemic events: A case report and literature review

Mechanical thrombectomy is currently the gold standard treatment of large vessel occlusions, especially in anterior circulation acute ischemic stroke. At the same time, the problem of tandem occlusions seems especially important since most of the major clinical mechanical thrombectomy studies did not specifically evaluate patients with concomitant extracranial occlusions or critical stenoses.

To date, there is no universally accepted optimal treatment strategy for such tandem lesions in acute ischemic stroke: it remains unclear which lesion – intracranial or extracranial – should be treated first. The selected reperfusion method should be based on the patients’ individual characteristics, data from non-invasive radiologic studies, and the stroke team experience.

We present a case of successful reperfusion therapy of acute tandem occlusion of the right internal carotid artery, followed by contralateral carotid artery stenting in a patient with stenosing extracranial atherosclerosis.

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

[Figure: see text].

Acute carotid stenting in patients undergoing thrombectomy: a systematic review and meta-analysis

BACKGROUND

The benefit of acute carotid stenting compared with no acute stenting on clinical outcomes among patients with tandem lesions (TL) undergoing endovascular thrombectomy (EVT) remains unknown.

METHODS

We conducted a a systematic review and meta-analysis of studies comparing acute carotid stenting versus no stenting among TL patients undergoing EVT with regards to 90 day modified Rankin Scale (mRS) score, symptomatic intracerebral hemorrhage (sICH), and mortality. Four reviewers screened citations for eligibility and two assessed retained studies for risk of bias and data extraction. A random effects model was used for the synthesis of aggregated data.

RESULTS

21 studies (n=1635 patients) were identified for the systematic review; 19 were cohort studies, 1 was a post-hoc analysis of an EVT trial, and 1 was a pilot randomized controlled trial. 16 studies were included in the meta-analysis. Acute stenting was associated with a favorable 90 day mRS score: OR 1.43 (95% CI 1.07, 1.91). No significant heterogeneity between studies was found for this outcome (I²=17.0%; χ²=18.07, p=0.26). There were no statistically significant differences for 3 month mortality (OR 0.80 (95% CI 0.50, 1.28)) or sICH (OR 1.41 (95% CI 0.91, 2.19)).

CONCLUSIONS

This meta-analysis suggests that among TL patients undergoing EVT, acute carotid stenting is associated with a greater likelihood of favorable outcome at 90 days compared with no stenting.

Functional Outcome and Safety of Intracranial Thrombectomy After Emergent Extracranial Stenting in Acute Ischemic Stroke Due to Tandem Occlusions

Background and Purpose: Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate.

Methods: From our ongoing prospective stroke registry we retrospectively analyzed 1,071 patients with anterior circulation stroke getting endovascular treatment within 6 h of symptom onset. ECS prior to intracranial MT for TO (n = 222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; n = 849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: n = 83; ticagrelor [TIC]: n = 137; in combination with Aspirin) and intravenous thrombolysis (IVT).

Results: Functional outcome was superior in TO (mRS 0–2: 44.6%) when compared with controls (36.0%; OR [95% CI]: 3.49 [1.59–7.67]; p = 0.002). There was no difference in all-cause mortality at 3 months (TO: 21.6%; C: 27.7%; 0.78 [0.47–1.29]; p = 0.324), in-hospital mortality (0.76 [0.45–1.30]; p = 0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30–1.59]; p = 0.389), and TICI 2b/3 (TO: 89.1%; C: 88.3%; p = 0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51–2.09]; p = 0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27–2.13]; p = 0.594). sICH was more frequent in TIC (n = 7 [5.1%]) vs. CLO (n = 0; p = 0.048).

Conclusion: In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.