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.

Emergent Management of Tandem Occlusions in Anterior Circulation Stroke: A Single-Centre Experience

OBJECTIVE

For anterior circulation tandem occlusions, the optimal management strategy for extracranial carotid lesions is controversial. We aimed to compare the efficacy and safety of acute stenting (AS) with balloon angioplasty (BA) only.

METHODS

Clinical data were collected from 98 patients with anterior circulation tandem occlusion who underwent endovascular treatment at our center. Of these patients, 64 and 34 were assigned to the AS and BA groups, respectively. The clinical characteristics and outcome data of the 2 groups were analyzed and compared.

RESULTS

The proportion of patients with good outcomes was 59.2%. The AS group had a higher rate of successful recanalization (98.4% vs. 82.4%, P = 0.007) and a lower rate of occlusion of the responsible vessel at 90 days (14.1% vs. 32.4%, P = 0.039) than the BA group. The AS group was also significantly better than the BA group in terms of good outcomes (67.2% vs. 44.1%, P = 0.027), but there was no significant difference between the 2 groups in terms of 90-day mortality (6.3% vs. 8.8%, P = 0.691) and asymptomatic intracranial hemorrhage (6.3% vs. 5.9%, P = 1.000). Lower baseline National Institutes of Health Stroke Scale scores were associated with good outcomes (P < 0.001), and the presence of symptomatic intracranial hemorrhage was associated with 90-day mortality (P = 0.003).

CONCLUSIONS

Acute stent placement in patients with acute ischemic stroke due to anterior circulation tandem occlusion may have a better outcome than BA alone, and the safety of both approaches is comparable.

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.

Carotid artery angioplasty versus stenting for management of acute tandem occlusions

Background The optimal approach to treat the cervical carotid artery lesion during endovascular thrombectomy (EVT) for acute strokes with tandem occlusions is unclear. While carotid artery stenting (CAS) might be a more definitive recanalization method, the potential risk of intracranial hemorrhage (ICH) limits its routine usage. In this study, we aimed to evaluate the safety outcomes of CAS and carotid artery angioplasty (CAA) in patients with acute tandem occlusions. Methods In this retrospective cohort study, data were obtained from the Nationwide Readmissions Database 2016-2017. The primary safety outcome was a composite of ICH and all-cause in-hospital mortality. Logistic regression analysis was used to compare the in-hospital outcomes. Survival analysis was used to estimate the 30-day readmissions. Results We identified 2042 hospitalizations meeting the study inclusion criteria (median age: 66 years, female 31.3%). Of these, 1391 (68.1%) had undergone CAS and 651 (31.9%) CAA alone. Baseline characteristics between the two groups were similar, except patients with CAS were more likely to be on anti-thrombotic medications and were less likely to have received intravenous thrombolysis. There was no significant difference in the clinical outcomes including ICH, in-hospital mortality, gastrostomy tube placement, prolonged mechanical ventilation, length of stay, hospital charges, and 30-day readmissions between the two groups, however, patients with CAS were more likely to be discharged home after adjusting for the confounding variables [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.05-2.12, P 0.025]. Conclusion The emergent CAS-EVT approach appears to be safe with no adverse outcomes compared to CAA alone.

Angioplasty alone versus acute stenting for acute tandem occlusions due to internal carotid artery atherosclerotic

OBJECTIVE

The aim of the study is to compare the efficacy and safety of angioplasty alone with acute stenting for acute tandem occlusions (TO) due to internal carotid artery atherosclerotic.

METHODS

We identified 112 patients who underwent an endovascular treatment (EVT) for acute tandem internal carotid artery occlusions from the prospectively maintained registries 5 comprehensive stroke centers. The study cohort included 75 patients with underlying atherosclerotic lesion of the extracranial internal carotid artery, forty-five in the balloon angioplasty (BA) alone group and 30 in the acute stenting (AS) group. Using propensity score matching analysis, forty-four patients were matched. Clinical characteristics and outcome data were compared between two groups.

RESULTS

The successful reperfusion immediately post procedure [72.7% (16/22) vs. 77.3% (17/22), P = 1.0] and 90-days good functional outcome [54.5% (12/22) vs. 59.1% (13/22), P = 0.761] were not significantly different between the BA group and AS group. There was also no significant difference in the rate of symptomatic intracranial hemorrhage [13.6% (3/22) vs. 9.1% (2/22), P = 1.00] and restenosis of ICA (>50%)[27.3% (6/22) vs. 22.7% (5/22), P = 0.728] between 2 groups. Patients in the BA group appear to have a numerically lower rate of asymptomatic intracranial hemorrhage [40.9% (9/22) vs. 50% (11/22), P = 0.545] and mortality [0 vs. 9.1% (2/22), P = 0.488] than in the AS group, although there were not statistically significant.

CONCLUSION

Among TO patients with etiology of large vessel atherosclerosis, no statistical differences in outcome are identified between balloon angioplasty alone versus acute stenting. Future randomized controlled trials are warranted.

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.

Emergency Carotid Endarterectomy Instead of Carotid Artery Stenting Reduces Delayed Hemorrhage in Thrombectomy Stroke Patients

PURPOSE

Data in the literature suggest that thrombectomy with emergency carotid artery stenting (CAS) in acute stroke is associated with an increased hemorrhage rate. As we perform thrombectomy with the patient under general anesthesia, we avoid emergency CAS and perform emergency carotid endarterectomy (CEA) as an alternative to CAS in the same anesthesia session in our angiography suite whenever needed and possible.

METHODS

We compared 27 thrombectomy patients with emergency CEA and 62 thrombectomy patients with emergency CAS and glycoprotein (Gp) IIb/IIIa inhibitors and/or dual antiplatelet therapy (DAPT) in the same time span.

RESULTS

The symptomatic hemorrhage rate was 0% (0/27) in the CEA group and 8% (5/62) in the CAS group (p = 0.317). The parenchymal hemorrhage rate (PH2) was 7% (2/27) in the CEA group and 16% (10/62) in the CAS group (p = 0.333). Both cases of PH2 in the CEA group occurred during the intervention and were diagnosed on immediate postinterventional imaging, whereas in the CAS group only 2/10 cases of PH2 occurred during the intervention and the remaining 8 PH2 occurred within 3 days after the intervention (p = 0.048). Clinical outcome at 90 days was comparable with 39% of CEA and 51% of CAS patients achieving good clinical outcome (modified Rankin scale, mRS 0-2, p = 0.452).

CONCLUSION

The use of CEA is a feasible alternative to CAS in acute stroke and has the advantage that DAPT/GpIIb/IIIa inhibitors are not needed. All PH2 in CEA patients occurred during the intervention, implying that hemorrhage in this group is likely to be caused by reperfusion injury, whereas delayed hemorrhage is likely to be caused by DAPT/GpIIb/IIIa inhibitors.

Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort

Introduction

Acute ischemic strokes with tandem occlusions, which represent 10–20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management.

Objective

We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports.

Methods

From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points).

Results

A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH.

Conclusions

Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.

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.

A Case of Intravascular Treatment for Acute Ischemic Stroke with Internal Carotid Artery Stenosis That Developed While Driving

Objective

We report a case of acute cerebral infarction that may have been associated with high-energy trauma due to onset while driving.

Case Presentation

A 67-year-old man had a traffic accident. His neurological symptoms were left hemiplegia and contrast CT revealed right middle cerebral artery occlusion. Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) and intravascular treatment were performed. Right carotid artery angiography demonstrated internal carotid artery stenosis. Middle cerebral artery (MCA) revascularization was performed only by percutaneous transluminal angioplasty (PTA) of the internal carotid artery. Thoracic hemorrhage was observed a few hours after surgery, and hemostasis was performed by thoracotomy. Carotid artery stenting (CAS) was performed 8 days after onset. The patient was transferred to a convalescent rehabilitation hospital.

Conclusion

Rt-PA and acute CAS were not recommended for cerebral infarction due to traffic accident.