Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke

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.

Elective carotid stenting fulfills quality standards defined in guidelines

PURPOSE

 According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke.

MATERIALS AND METHODS

 Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay.

RESULTS

 The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006).

CONCLUSION

 Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance.

KEY POINTS

· Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared..

CITATION FORMAT

· Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2175-4029.

Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions

BACKGROUND

We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment.

METHODS

This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality.

RESULTS

Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups.

CONCLUSIONS

Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days.

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.

Acute ischaemic stroke: recent advances in reperfusion treatment

During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.

Emergency Cervical Carotid Artery Stenting After Intravenous Thrombolysis in Patients With Hyperacute Ischemic Stroke

BACKGROUND

Intravenous recombinant tissue plasminogen activator (IV rtPA) is the mainstay of treatment for acute ischemic stroke to recanalize thrombosed intracranial vessels within 4.5 hours. Emergency carotid artery stenting for the treatment of acute stroke due to steno-occlusion of the proximal internal carotid artery (ICA) can improve symptoms, prevent neurological deterioration, and reduce recurrent stroke risk. The feasibility and safety of the combination therapy of IV rtPA and urgent carotid artery stenting have not been established.

METHODS

From November 2005 to October 2020, we retrospectively assessed patients who had undergone emergent carotid artery stenting after IV rtPA for hyperacute ischemic stroke due to steno-occlusive proximal ICA lesion. Hemorrhagic transformation, successful recanalization, modified Rankin Scale (mRS) score at 90 days, and stent patency at 3 and 12 months or longer were evaluated. Favorable outcome was defined as a 90-days mRS score of ≤ 2.

RESULTS

Nineteen patients with hyperacute stroke had undergone emergent carotid artery stenting after IV rtPA therapy. Their median age was 70 (67.5-73.5) years (94.7% men). Among 15 patients with an additional intracranial occlusion after flow restoration in the proximal ICA, a modified TICI grade ≥ 2b was achieved in 11 patients (73.3%). Hemorrhagic transformation occurred in five patients (26.3%); mortality rate was 5.7%. Eleven patients (57.9%) had favorable outcomes at 90 days. Stent patients (94.1%) maintained stent patency for ≥ 12 months.

CONCLUSION

We showed that emergent carotid artery stenting after IV rtPA therapy for hyperacute stroke caused by atherosclerotic proximal ICA steno-occlusion was feasible and safe.

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.

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.

[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.

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).

Endovascular Treatment of Stroke Caused by Carotid Artery Dissection

Ischemic stroke due to large vessel occlusion (LVO) is a devastating condition. Most LVOs are embolic in nature. Arterial dissection is responsible for only a small proportion of LVOs, is specific in nature and poses some challenges in treatment. We describe 3 cases where patients with stroke caused by carotid artery dissection were treated with mechanical thrombectomy and extensive stenting with good outcome. We believe that mechanical thrombectomy and stenting is a treatment of choice in these cases.

Utility of Hounsfield unit in the diagnosis of tandem occlusion in acute ischemic stroke

Background

Tandem occlusions can complicate medical and endovascular stroke treatment. To identify these occlusions, computed tomography angiography (CTA) represents the best imaging modality. However, CTA is still not initially performed in some patients not admitted directly to stroke centers. Early identification of an additional occlusion of the proximal extracranial internal carotid artery may improve the best suitable treatment strategy. The purpose of this study was to find a valuable threshold of thrombus attenuation in a non-contrast head CT (NCCT) scan to facilitate a safe diagnosis of tandem occlusions.

Materials and methods

Consecutive patients with acute middle cerebral artery (MCA) occlusions who underwent endovascular treatment were identified from our registry of neuroendovascular interventions. Thrombus attenuations of the affected MCA and contralateral vessel were measured by NCCT. To compare individual baseline blood attenuations, the difference between the thrombus attenuation and the contralateral MCA attenuation (referred to as ΔTM) was calculated.

Results

Three hundred and twenty-five patients were included. There was a highly significant difference between mean thrombus attenuation with isolated MCA occlusion and additional extracranial internal carotid artery (ICA) occlusion (49.9 ± 8 vs. 56.2 ± 10 Hounsfield units (HU); P < 0.001). The area under the receiver operating characteristic curve of ΔTM was 0.72. The optimal threshold value was 13.5 HU, with a sensitivity of 67.5% and a specificity of 68.6%.

Conclusion

Despite a significant difference in thrombus attenuation in MCA occlusions with an additional extracranial ICA occlusion compared with isolated MCA occlusions, a relevant threshold of thrombus attenuation was not found.

The Dilator-Dotter Technique: A Modified Method of Rapid Internal Carotid Artery Revascularization in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Acute ischemic stroke due to tandem occlusive lesions involves high-grade ICA stenosis or occlusion with a distal intracranial occlusion. Several approaches and devices exist in the treatment of tandem occlusions; however, a consensus on the optimal technique does not exist. The Dotter technique is a method of catheter-based angioplasty to recanalize cervical ICA occlusions. We present a modified dilator-Dotter technique, which involves a polyethylene, tapered inner dilator to initially cross the occlusion, followed by guide catheterization and subsequent intracranial thrombectomy. The purpose of this study was to examine the safety and efficacy of this dilator-Dotter technique.

MATERIALS AND METHODS

We performed a retrospective review of patients with acute stroke due to tandem ICA intracranial occlusions, treated with our dilator-Dotter technique and thrombectomy between June 2018 and December 2019. We examined clinical, radiographic, and procedural data, as well as complications and outcomes.

RESULTS

Thirty-two patients were included. In 100% of cases, the dilator-Dotter technique resulted in ICA recanalization allowing successful thrombectomy. TICI 2b-3 revascularization was obtained in 31 patients (96%), within an average time of 25 minutes. The average preprocedural ICA stenosis was 98%, including 23 patients (72%) with complete occlusion. Following the dilator-Dotter technique, average ICA stenosis improved to 59%. There were no instances of death, iatrogenic dissection, emboli to new territory, or symptomatic intracranial hemorrhage.

CONCLUSIONS

The dilator-Dotter technique may be a safe and effective modification of the traditional Dotter technique in allowing rapid ICA recanalization in cases of acute ischemic stroke due to tandem occlusions.

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.

Two Patients Who Underwent Emergency Stenting for Iatrogenic Cervical Internal Carotid Artery Dissection during Thrombectomy

Objective

Iatrogenic artery dissection during reperfusion therapy is one of the complications causing a poor prognosis. We report two cases of emergent stent placement for iatrogenic cervical carotid artery dissection during reperfusion therapy for acute ischemic stroke.

Case Presentation

Two patients, a 77-year-old woman and a 77-year-old man, were diagnosed with acute major cerebral artery occlusion, and underwent reperfusion therapy. The iatrogenic internal carotid artery dissection was caused by derivation of a 6-Fr catheter and 0.014-inch wire in the tortuous cervical internal carotid artery, and emergent stent placement was performed. Recanalization was confirmed and no deterioration caused by the iatrogenic dissection was found.

Conclusion

In patients in whom cerebral infarction is localized on MRI, additional stent placement may be effective for preventing adverse events caused by iatrogenic cervical internal carotid artery dissection during reperfusion therapy for intracranial cerebral artery occlusion related to atherosclerotic change.

Utility of Coaxial Angioplasty-thrombectomy for Acute Tandem Occlusion of Intracranial and Extracranial Arteries

OBJECTIVE

We report a novel technique for acute occlusion of both intracranial and extracranial arteries (tandem lesions [TL]).

CASE PRESENTATION

A 67-year-old male was transferred to our hospital because of right hemiparesis and aphasia. MRA revealed occlusion of the left cervical internal carotid artery (ICA) and middle cerebral artery (MCA). A balloon guide catheter (BGC) was advanced into the left common carotid artery (CCA). A microcatheter was advanced over a microwire through the intracranial thrombus. A stent retriever (SR) was deployed from the MCA to the ICA through the microcatheter. Next, with the SR anchored to the thrombus, the microcatheter was withdrawn. The extracranial percutaneous transluminal angioplasty (PTA) balloon was coaxially advanced over the SR's delivery wire and angioplasty was performed. Then, an aspiration catheter was coaxially advanced to the proximal aspect of the intracranial thrombus over the delivery wire by pump aspiration. We removed the SR and the aspiration catheter as a single unit into the BGC, resulting in sufficient recanalization. The puncture to recanalization time was 29 minutes.

CONCLUSION

This technique can lead to faster recanalization in cases of TL.

Complication Rates Using CASPER Dual-Layer Stents for Carotid Artery Stenting in Acute Stroke : A 3-Year Single Center Experience

BACKGROUND AND PURPOSE

The number of acute and early stent occlusions after emergency stenting of the internal carotid artery (ICA) in patients with tandem lesions is unclear and only mentioned in a small number of publications, ranging from 0-20%. A recent article by Yilmaz et al. reported a high rate of acute in-stent occlusions of 45% within 72 h after deployment of CASPER dual layer stents.

METHODS

All patients with acute ischemic stroke treated with a CASPER stent between August 2014 and April 2018 were retrospectively evaluated for occlusion rates, periinterventional medication and early complications. A total of 66 patients, 45 with tandem pathologies and 21 with proximal ICA stenosis only were enrolled.

RESULTS

Thrombotic complications occurred in 16 out of 66 patients (24%) and hemorrhagic complications in 8/66 (12%) and 15 of the 16 thrombotic complications and 7/8 symptomatic intracranial hemorrhages (sICH) occurred in patients with tandem lesions and accessory intracranial thrombectomy. Of the patients with sICH five were treated in a prolonged or unknown time window. In patients with intraprocedural thrombotic complications ultrasound imaging showed patent stents in 13 of the 14 patients CONCLUSIONS: The CASPER stent system showed a high technical success rate in patients with acute stroke. The number of patients with sICH was not higher than the numbers reported in the published literature despite the early use of Gp IIb/IIIA inhibitors, whereas the number of thrombotic complications was smaller than that reported in recent studies. The majority of sICH occurred in patients treated because of tandem lesions in an unknown or prolonged time window.

Dual energy CT in the management of antiplatelet therapy in patients with acute ischemic stroke for carotid obstruction

BACKGROUND AND PURPOSE

Acute tandem occlusions often require carotid stenting. Combination of mechanical and pharmacologic therapies in addition to antiplatelet drugs administered to prevent acute stent thrombosis might increase the risk of intracerebral hemorrhage. We present a protocol of antiplatelet regimen based on early post-procedural dual-energy CT (DE-CT).

MATERIAL AND METHODS

Fifty consecutive stroke patients with tandem occlusions treated with acute carotid stenting after intracranial thrombectomy and TICI 2b/3 were reviewed. All patients received intravenous lysine acetylsalicylate during the procedure. Dual (aspirin+clopidogrel with or without clopidogrel load, groups A and B, respectively) or mono (aspirin) antiplatelet regimen (group C) was administered 12-24 h later according to brain DE-CT findings. Carotid ultrasonography was performed at 24 h and before discharge. We evaluated the rate of subsequent symptomatic intracranial hemorrhage (SICH) and acute stent thrombosis in each group.

RESULTS

Between June 2014 and December 2016, 50 patients were included (mean age 66 years, 76% men, baseline NIHSS 16, median time from symptom onset to recanalization 266 min). According to DE-CT, 24 patients were assigned to group A, 19 to group B and 7 to group C (4 of them had SICH at that time). One patient suffered a subsequent SICH (belonging to group B). There was only one stent thrombosis without clinical repercussions in group B.

CONCLUSIONS

DE-CT may contribute to select antiplatelet regimen after acute carotid stenting in tandem occlusions.

Carotid Artery Stenting and Intracranial Thrombectomy for Tandem Cervical and Intracranial Artery Occlusions

BACKGROUND

It remains controversial whether carotid artery stenting (CAS) is needed in cases of tandem cervical internal carotid artery occlusion (cICAO) and intracranial large vessel occlusion (LVO).

OBJECTIVE

To investigate the efficacy and safety of CAS in combination with endovascular thrombectomy (CAS-EVT) in cICAO-LVO patients and to compare its outcomes with those of EVT without CAS (EVT-alone).

METHODS

We identified all patients who underwent EVT for tandem cICAO-LVO from the prospectively maintained registries of 17 stroke centers. Patients were classified into 2 groups: CAS-EVT and EVT-alone. Clinical characteristics and procedural and clinical outcomes were compared between 2 groups. We tested whether CAS-EVT strategy was independently associated with recanalization success.

RESULTS

Of the 955 patients who underwent EVT, 75 patients (7.9%) had cICAO-LVO. Fifty-six patients underwent CAS-EVT (74.6%), and the remaining 19 patients underwent EVT-alone (25.4%). The recanalization (94.6% vs 63.2%, P = .002) and good outcome rates (64.3% vs 26.3%, P = .007) were significantly higher in the CAS-EVT than in the EVT-alone. Mortality was significantly lower in the CAS-EVT (7.1% vs 21.6%, P = .014). There was no significant difference in the rate of symptomatic intracranial hemorrhage between 2 groups (10.7 vs 15.8%; P = .684) and according to the use of glycoprotein IIb/IIIa inhibitor (10.0% vs 12.3%; P = .999) or antiplatelet medications (10.2% vs 18.8%; P = .392). CAS-EVT strategy remained independently associated with recanalization success (odds ratio: 24.844; 95% confidence interval: 1.445-427.187).

CONCLUSION

CAS-EVT strategy seemed to be effective and safe in cases of tandem cICAO-LVO. CAS-EVT strategy was associated with recanalization success, resulting in better clinical outcome.

Effect of extracranial lesion severity on outcome of endovascular thrombectomy in patients with anterior circulation tandem occlusion: analysis of the TITAN registry

Introduction

Endovascular treatment (EVT) for tandem occlusion (TO) of the anterior circulation is complex but effective. The effect of extracranial internal carotid artery (EICA) lesion severity on the outcomes of EVT is unknown. In this study we investigated the effect of EICA lesion severity on the outcomes of tandem occlusion EVT.

Methods

A multicenter retrospective TITAN (Thrombectomy In TANdem lesions) study that included 18 international endovascular capable centers was performed. Patients who received EVT for atherosclerotic TO with or without EICA lesion intervention were included. Patients were divided into two groups based on the EICA lesion severity (high-grade stenosis (≥90% North American Symptomatic Carotid Endarterectomy Trial) vs complete occlusion). Outcome measures included the 90-day clinical outcome (modified Rankin Scale score (mRS)), angiographic reperfusion (modified Thrombolysis In Cerebral Ischemia (mTICI) at the end of the procedure), procedural complications, and intracranial hemorrhage at 24 hours follow-up.

Results

A total of 305 patients were included in the study, of whom 135 had complete EICA occlusion and 170 had severe EICA stenosis. The EICA occlusion group had shorter mean onset-to-groin time (259±120 min vs 305±202 min; p=0.037), more patients with diabetes, and fewer with hyperlipidemia. With respect to the outcome, mTICI 2b–3 reperfusion was lower in the EICA occlusion group (70% vs 81%; p=0.03). The favorable outcome (90-day mRS 0–2), intracerebral hemorrhage and procedural complications were similar in both groups.

Conclusion

Atherosclerotic occlusion of the EICA in acute tandem strokes was associated with a lower rate of mTICI 2b–3 reperfusion but similar functional and safety outcomes when compared with high-grade EICA stenosis.

Predictors and Clinical Impact of Delayed Stent Thrombosis after Thrombectomy for Acute Stroke with Tandem Lesions

BACKGROUND AND PURPOSE

There are very few published data on the patency of carotid stents implanted during thrombectomies for tandem lesions in the anterior circulation. We aimed to communicate our experience of stenting in the acute setting with systematic follow-up of stent patency and discuss predictors and clinical repercussions of delayed stent thrombosis.

MATERIALS AND METHODS

We performed a retrospective study of stroke thrombectomies in a single center between January 2009 and April 2018. Patient files were reviewed to extract patient characteristics, procedural details, imaging studies, and clinical information. Predictors of delayed stent thrombosis and clinical outcome at discharge were analyzed using univariate and multivariate analyses.

RESULTS

We identified 81 patients treated for tandem lesions: 63 (77.7%) atheromas, 17 (20.9%) dissections, and 1 (1.2%) carotid web. TICI 2b-3 recanalization was achieved in 70 (86.4%) cases. Thirty-five patients (43.2%) were independent (mRS score ≤ 2) at discharge. Among 73 patients with intracranial recanalization and patent stents at the end of the procedure, delayed stent thrombosis was observed in 14 (19.1%). Among 59 patients with patent stents, 44 had further imaging controls (median, 105 days; range, 2-2407 days) and 1 (1.6%) had 50% in-stent stenosis with no retreatment. Stent occlusion rates were 11/39 (28.2%) for periprocedural aspirin treatment versus 3/34 (8.8%) for aspirin and clopidogrel (P = .04). Delayed stent thrombosis was independently associated with higher admission NIHSS scores (OR, 1.1; 95% CI, 1.01-1.28), diabetes (OR, 6.07; 95% CI, 1.2-30.6), and the presence of in-stent thrombus on the final angiographic run (OR, 6.2; 95% CI, 1.4-27.97). Delayed stent thrombosis (OR, 19.78; 95% CI, 2.78-296.83), higher admission NIHSS scores (OR, 1.27, 95% CI, 1.12-1.51), and symptomatic hemorrhagic transformation (OR, 23.65; 95% CI, 1.85-3478.94) were independent predictors of unfavorable clinical outcome at discharge.

CONCLUSIONS

We observed a non-negligible rate of delayed stent thrombosis with significant negative impact on clinical outcome. Future studies should systematically measure and report stent patency rates.

Treatment Methods and Early Neurologic Improvement After Endovascular Treatment of Tandem Occlusions in Acute Ischemic Stroke

Background and Purpose: A tandem occlusion of the intracranial circulation and the extracranial carotid artery (ICA) occurs in 10–20% of all strokes based on large vessel occlusion (LVO). The optimal treatment strategy for those patients is unknown. We report our management strategy and the outcome in these patients in a large single-center cohort.

Materials and Methods: We retrospectively identified and analyzed all patients treated by Mechanical Thrombectomy (MT) for an intracranial LVO associated with an occlusion of the extracranial ICA between April 2009 and May 2016 (163/1,645, 9.9%). The following data was collected: Recanalization rate, occurrence of symptomatic intracranial hemorrhage (sICH), clinical result according to the early neurological improvement (ENI, NIHSS score improvement of ≥8 points after 24 h or NIHSS score of 0 or 1 after 3 days) and functional outcome and mortality during long term follow up. Secondary endpoints were the patency of the internal carotid artery at 24 h. Patient demographics and anti-aggregation regimen were recorded as co-variables.

Results: 163/1,645 (9.9%) MT patients had a tandem occlusion. All thrombectomy procedures were performed with stent retrievers. PTA with or without additional placement of a stent was performed in 149 vs. 14 patients. The overall rate of TICI IIB/III recanalization was 91.4%. An early neurological improvement was found in 79 of 163 patients (48.4%), 51% (76/149) in the stent group and 21% (3/14) in the non stent group. 120/163 patients (73.6%) had a long term favorable outcome (mRS 0–2). The ICA re-occlusion rate at 24 h was 5.4% (8/149) in the stent group and 42% (6/14) in the non stent group. The rate of symptomatic hemorrhage was 4.9%.

The regression analysis showed that only younger age (p = 0.002) and shorter recanalization times (p = 0.017) were associated with good outcome.

Conclusion: Stent-PTA of the ICA in addition to MT with a stent retriever was safe and effective in tandem occlusion of the anterior brain circulation. PTA and MT without stenting in tandem lesions showed a higher early re-occlusion rate and lower rate of early neurological improvement. The technical approach should aim for the fastest possible recanalization of the intracranial vessels, either with stenting first or last.

Endovascular Therapy for Tandem Occlusion in Acute Ischemic Stroke: Intravenous Thrombolysis Improves Outcomes

Ischemic stroke related to tandem internal carotid and middle cerebral artery (TIM) occlusion is a challenging condition where endovascular treatment (EVT) is an emerging revascularization option. The identification of factors influencing clinical outcomes can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to evaluate prognostic factors in the context of EVT for TIM occlusion. We performed a retrospective study of consecutive patients with TIM occlusion admitted within 6 h from symptom onset to two tertiary stroke centers. We recorded the etiology of stroke, clinical deficits at stroke onset and discharge, details of EVT, final infarct volume (FIV), in-hospital mortality, and outcome at three months. Among 73 patients with TIM occlusion, 53 were treated with EVT. The median age was 75.9 years (interquartile range (IQR) 64.6–82.6), with the most common etiology of cardioembolism (51.9%). Intravenous thrombolysis with tissue-plasminogen activator (t-PA) was performed in the majority (69.8%) of cases. EVT achieved successful recanalization with a thrombolysis in cerebral infarction (TICI) grade of 2b or 3 in 67.9%. A good outcome (modified Rankin score of 0–2 at three months) was observed in 37.7%. After adjustment for age, the National Institutes of Health Stroke Scale (NIHSS) at admission, and success of recanalization, smaller final infarct volume (odds ratio (OR) 0.021 for FIV above 25th percentile (95% CI 0.001–0.332, p = 0.005)) and administration of intravenous t-PA (OR 12.04 (95% CI 1.004–144.392, p = 0.049)) were associated with a good outcome at three months. Our study demonstrates that bridging with t-PA is associated with improved outcomes in the setting of tandem ICA and MCA occlusions treated with EVT and should therefore not be withheld in eligible patients.

Endovascular Treatment of Atherosclerotic Tandem Occlusions in Anterior Circulation Stroke: Technical Aspects and Complications Compared to Isolated Intracranial Occlusions

Background and Purpose: Endovascular treatment of tandem occlusions is an emerging option. We describe our multicenter experience with endovascular management of atherosclerotic tandem occlusions in the anterior circulation, particularly the technical aspects and complications in comparison to isolated intracranial occlusions.

Materials and Methods: Consecutive patients with tandem occlusions due to atherosclerotic causes who underwent mechanical thrombectomy at two major stroke centers between January 2010 and September 2015 were reviewed. Clinical data, procedural aspects, recanalization rates, complication rates, and clinical outcome were analyzed and compared to findings in patients with isolated intracranial occlusions.

Results: One hundred and twenty-one patients with tandem occlusions and 456 patients with isolated intracranial occlusions (carotid-T/M1) were included. Mean intervention time was faster (33 min vs. 57 min, p < 0.001) and recanalization success was higher (TICI 2b/3 83.6 vs. 70.2%, p = 0.002) in patients with isolated occlusions. No difference was seen in clinical outcome and complications, except for a higher rate of asymptomatic hemorrhage in the tandem group (29.8 vs. 17.1%, p = 0.003). Choice of recanalization approach (antegrade vs. retrograde) in the tandem group made no difference, except for a trend toward less distal emboli using the retrograde approach (4.0 vs. 13.0%, p = 0.082). Stenting of the extracranial internal carotid artery (ICA) was performed in 81%, PTA alone in 7.4%, and deferred stenting in 11.6%. Rate of stent/ICA occlusion within 7 days was 10.3% after stenting and 33.3% after PTA (p = 0.127). In the tandem group, age (p = 0.034), National Institutes of Health Stroke Scale score (NIHSS) at admission (p = 0.002), recanalization rate (p < 0.001), complications (p = 0.016), and symptomatic intracranial hemorrhage (sICH) (p = 0.001) were associated with poor outcome, whereas extracranial treatment modality and stent/ICA occlusion within 7 days did not affect outcome.

Conclusion: Endovascular treatment of tandem occlusions is technically feasible, achieves recanalization rates and rates of good clinical outcome comparable to those in patients with isolated intracranial occlusions. Following acute ICA stenting, the risk of stent occlusion and sICH appeared to be low, but was associated with an increased rate of asymptomatic ICH.

Endovascular therapy of acute ischemic stroke related to tandem occlusion: comparison of occlusion and severe stenosis of the proximal cervical internal carotid artery

METHODS

We retrospectively reviewed 42 patients with acute ischemic stroke who underwent endovascular treatment for tandem lesions between January 2011 and April 2017. After dividing the patients into two groups according to lesion type of the proximal cervical ICA (complete occlusion and severe stenosis), we analyzed demographic data, angiographic findings and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome.

RESULTS

Of 42 patients, 27 patients (64.3%) had complete occlusion of the cervical ICA, and the remaining 15 had high-grade stenosis. Successful stenting was performed in all patients with favorable clinical outcomes (27/42, 64.3%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2b) was 78.6%; occlusion group (18/27, 66.7%) vs stenosis group (15/15, 100%) of cases. Mean modified Rankin Scale score at 90 days was 2.36 ± 1.83. The rate of favorable clinical outcome was higher in stenosis group (11/15, 73.3%) than that of occlusion group (16/27, 59.3%) with no statistically significant difference (p = 0.506).

CONCLUSION

Acute endovascular treatment of carotid artery tandem lesions is a technically feasible and clinically effective intervention regardless of the lesion type in proximal cervical ICA.

ADVANCES IN KNOWLEDGE

Our study supports the results of previous studies in which endovascular therapy has a favorable clinical outcome in carotid artery tandem occlusion.

Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting

Background

Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium.

Summary

To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions.

Key Message

In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.

Acute administration of tirofiban versus aspirin in emergent carotid artery stenting

BACKGROUND

Carotid artery stenting requires antiplatelet therapy for prevention of in-stent thrombosis. Patients suffering from acute ischemic stroke undergoing intravenous thrombolysis and emergent carotid artery stenting (eCAS) are at high risk for intracranial bleeding. We assessed efficacy and safety of acute administration of intravenous tirofiban versus aspirin in these patients.

METHODS

A retrospective, single center, cohort study was carried out of 32 patients who underwent eCAS (18 received tirofiban, 14 received aspirin) at our comprehensive stroke center (2008-2016).

RESULTS

Of our 32 consecutive eCAS patients, favorable clinical outcomes (modified Rankin scale ≤ 2) were achieved in eight (47%) tirofiban patients and six (46%) aspirin patients ( p = 0.96). Overall rates were similar for symptomatic intracranial bleeding (tirofiban 22%, aspirin 29%, p = 0.68) and mortality (tirofiban 18%, aspirin 23%, p = 0.71).

CONCLUSIONS

Tirofiban and aspirin demonstrated similar efficacy and safety in thrombolyzed stroke patients who underwent eCAS in our cohort. Intravenous tirofiban with its short half-life might represent an alternative to aspirin in select patients.

Endovascular retrograde approach may be a better option for acute tandem occlusions stroke

OBJECTIVE

The endovascular treatment strategy for acute tandem occlusion stroke is challenging, and controversy exists regarding which lesion should be treated first. This study addresses the uncertainty regarding the priority choice for thrombectomy in acute anterior circulation tandem occlusion stroke.

METHODS

We analysed the clinical and angiographic data of tandem stroke patients who underwent interventional therapy from the endovAsCular Treatment of acUte Anterior circuLation ischaemic stroke (ACTUAL) registry. Recanalisation was assessed according to the modified thrombolysis in cerebral infarction score. Clinical outcome was evaluated at 90 days using the modified Rankin scale score.

RESULTS

Sixty tandem occlusion stroke patients were enrolled. Thirty-one (51.7%) patients received anterograde therapy, while 29 (48.3%) patients underwent the retrograde approach. Successful recanalisation (modified thrombolysis in cerebral infarction score 2b-3) occurred in 78.3% (47/60) of patients, and 50.0% (30/60) of patients achieved a modified Rankin scale score of 0-2 at 90 days. Patients undergoing the retrograde approach spent less time in distal occlusion recanalisation (125 (86-167) vs. 95 (74-122) minutes; P = 0.04) and achieved better functional outcomes at 90 days (69.0% (20/29) vs. 32.3% (10/31); P = 0.004) than patients who received anterograde therapy. The retrograde approach was associated with favourable clinical outcomes (odds ratio 0.21; 95% confidence interval 0.07-0.64; P = 0.006).

CONCLUSION

For acute tandem occlusion stroke, favourable outcomes were better in patients undergoing retrograde therapy than in patients who received the anterograde approach. Future randomised trials are warranted to determine the optimal treatment.

Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions

PURPOSE OF REVIEW

Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy.

RECENT FINDINGS

Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but "late-window" trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of "time is brain" remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes. Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.

Endovascular management for tandem occlusions of anterior cerebral circulation

Objectives:

To compare the endovascular approaches and techniques used to treat tandem occlusions of anterior cerebral circulation.

Methods:

A literature review was carried out using PubMed to review the studies that described endovascular therapies for patients with tandem cerebral occlusions.

Results:

A total of 106 patients (median age: 64 years; range: 18-90 years) were identified. The median National Institutes of Health Stroke scale score at the time of admission for 104 patients was 16.5 (standard deviation [SD] ±5.7). The mean times and ranges from symptom onset to recanalization were 396.85 minutes (range: 120-1,574 minutes) and from groin puncture to recanalization were 80.3 minutes (range: 14-180 minutes). The mean outcome modified Rankin scale (mRS) score was 2.31 (SD ±2.2), and 61.3% of patients had an outcome mRS score ≤2. Moreover, 80% of patients with a groin puncture-to-recanalization time of ≤60 minutes had a mRS score ≤2 compared to 51.5% of patients with longer times (p=0.02). Despite that only 11.3% of patients underwent a retrograde approach, 81.8% of them had an outcome mRS score ≤2 compared to 60.8% of patients with an anterograde approach (p=0.023).

Conclusion:

A groin puncture-to-recanalization time of <60 minutes and a retrograde approach were shown to be favorable prognostic factors in terms of mRS score. The use of intravenous tissue plasminogen activator was associated with higher Thrombolysis In Cerebral Infarction scores, but not superior prognosis based on mRS.

Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection

BACKGROUND AND PURPOSE

Internal carotid dissection is a frequent cause of ischemic stroke in young adults. It may cause tandem occlusions in which cervical carotid obstruction is associated with intracranial proximal vessel occlusion. To date, no consensus has emerged concerning endovascular treatment strategy. Our aim was to evaluate our endovascular "distal-to-proximal" strategy in the treatment of this stroke subtype in the first large multicentric cohort.

MATERIALS AND METHODS

Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. Atheromatous tandem occlusions were excluded. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded.

RESULTS

Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17.29 ± 6.23, and the mean delay between onset and groin puncture was 3.58 ± 1.1 hours. Recanalization TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. Twenty-one patients (67.65%) had a favorable clinical outcome after 3 months.

CONCLUSIONS

Endovascular treatment of internal carotid dissection-related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.

Management of acute tandem occlusions: Stent-retriever thrombectomy with emergency stenting or angioplasty

Objective

To compare outcomes following intracranial stent retriever-based intracranial thrombectomy (SRT) with emergency extracranial internal carotid artery (EICA) stenting or angioplasty alone in patients presenting with acute stroke due to tandem occlusions of the ICA.

Methods

Consecutive patients with acute anterior tandem occlusion who received an endovascular intervention within 6h of symptom onset between January 2013 and June 2016 were included in this prospective study. Demographic, radiological, procedural and clinical outcome data were compared between the stenting and the angioplasty alone groups.

Results

Of the 37 patients eligible for the study, 18 had angioplasty alone and 19 underwent stent placement. Successful recanalization rate was statistically significantly higher in the stenting group than in angioplasty alone group (74% vs. 39%) and although not statistically significant, more patients in the stenting group than in the angioplasty alone group had favourable outcomes (63% vs. 50%). There was no significant difference between groups in rates of symptomatic intracranial haemorrhage (SICH), cerebral herniation or mortality.

Conclusion

This study in a small sample size suggests that among patients with acute anterior tandem occlusion, SRT with EICA stenting tended to achieve higher recanalization and improved clinical outcomes at three months compared with SRT and angioplasty alone with a similar rate of SICH and mortality.

Periprocedural Antithrombotic Treatment During Acute Mechanical Thrombectomy for Ischemic Stroke: A Systematic Review

BACKGROUND

More than one-third of the patients with ischemic stroke caused by an intracranial large vessel occlusion do not recover to functional independence despite fast and successful recanalization by acute mechanical thrombectomy (MT). This may partially be explained by incomplete microvascular reperfusion. Some antithrombotics, e.g., antiplatelet agents and heparin, may be able to restore microvascular reperfusion. However, antithrombotics may also increase the risk of symptomatic intracranial hemorrhage (sICH). The aim of this review was to assess the potential safety and functional outcome of periprocedural antiplatelet or heparin use during acute MT for ischemic stroke.

METHODS

We systematically searched PubMed, Embase, Medline, Web of Science, and Cochrane for studies investigating the safety and functional outcome of periprocedural antiplatelet or heparin treatment during acute MT for ischemic stroke. The primary outcome was the risk for sICH. Secondary outcomes were functional independence after 3-6 months (modified Rankin Scale 0-2) and mortality within 6 months.

RESULTS

837 studies were identified through the search, of which 19 studies were included. The sICH risks of the periprocedural use of antiplatelets ranged from 6 to 17%, and for heparin from 5 to 12%. Two of four studies reporting relative effects of the use of antithrombotics are pointing toward an increased risk of sICH. Among patients treated with antiplatelet agents, functional independence varied from 23 to 60% and mortality from 18 to 33%. For heparin, this was, respectively, 19-54% and 19-33%. The three studies presenting relative effects of antiplatelets on functional independence showed neutral effects. Both studies reporting relative effects of heparin on functional independence found it to increase this chance.

CONCLUSION

Randomized controlled trials investigating the effect of periprocedural antithrombotic treatment in MT are lacking. Some observational studies report a slight increase in sICH risk, which may be acceptable because they also suggest a beneficial effect on functional outcome. Therefore, randomized controlled trials are warranted to address the question whether the potentially higher risk of sICH could be outweighed by improved functional outcome.

Management of tandem occlusions in acute ischemic stroke – intracranial versus extracranial first and extracranial stenting versus angioplasty alone: a systematic review and meta-analysis

Background

Optimal technical approaches of large-vessel anterior circulation acute ischemic strokes with concomitant extracranial internal carotid artery tandem occlusions is controversial.

Purpose

This systematic review and meta-analysis evaluates: the overall outcomes of patients with tandem occlusions treated with second-generation mechanical thrombectomy devices; differences in outcomes of extracranial versus intracranial first approaches; and differences in outcomes of extracranial stenting at time of procedure versus angioplasty alone.

Methods

MEDLINE, EMBASE, and the Web of Science was searched through September 2017 for studies evaluating patients presenting with acute tandem occlusions of the extracranial ICA and intracranial ICA, and/or proximal MCA treated with second-generation mechanical thrombectomy devices. Outcomes were pooled across studies using the random-effects model and expressed as cumulative incidence (event rate) and 95% CI.

Results

Thirty-three studies were included in analysis. Overall mRS≤0–2 at 90 days was 47% (95% CI 42% to 51%). No statistical difference was seen in 90-day mRS≤0–2 for patients treated with extracranial versus intracranial first approaches, 53% (95% CI 44% to 61%) vs 49% (95% CI 44% to 57%) (P=0.58). No statistical difference was seen in 90-day mRS≤0–2 for patients treated with extracranial stenting versus angioplasty alone, 49% (95% CI 42% to 56%) vs 49% (95% CI 33% to 65%) (P=0.39). No other statistical differences in outcome or safety were identified.

Conclusions

Nearly half of all tandem occlusion patients treated with mechanical thrombectomy have good neurological outcomes. No statistical differences in outcome are identified between extracranial first versus intracranial first approaches, nor extracranial stenting versus angioplasty alone.

Efficacy of carotid thrombus penetration with a balloon guiding catheter to fast recanalization of acute extra- and intra-cranial carotid artery tandem occlusion - a preliminary report

Acute ischemic stroke with ipsilateral Internal carotid artery (ICA) stenosis presents a great management dilemma. We present our preliminary report of retrograde retrieval of clot from middle cerebral artery (MCA) followed by delayed carotid artery stenting (CAS) with dual anti platelet therapy (DAPT).

Overview of evidence on emergency carotid stenting in patients with acute ischemic stroke due to tandem occlusions: a systematic review and meta-analysis

INTRODUCTION

Endovascular intracranial thrombectomy (IT) has established itself as the standard of care in treating large-vessel anterior circulation acute ischemic stroke (AIS). However, internal carotid artery (ICA) stenosis/occlusion hampers distal access and controversy about simultaneous emergency ICA stenting ensues. The purpose of this review was to evaluate the safety of emergency ICA stenting in combination with IT for AIS with tandem occlusions. To our knowledge this is the first meta-analysis to evaluate emergency ICA stenting in tandem occlusions, combining results from studies with a control group.

EVIDENCE ACQUISITION

A meta-analysis was conducted according to the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement.

EVIDENCE SYNTHESIS

A total of 649 potentially relevant articles were initially selected. After reviewing at title or abstract level, 87 articles were read in full and 23 were included. These studies recruited 1000 patients, 220 submitted to IT with no emergency ICA stenting and 780 to IT and emergency ICA stenting. Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2b) was achieved in 48.6-100%. Good outcome (modified Rankin scale [mRS] ≤2) ranged from 18.2-100%. Symptomatic intracranial hemorrhage (sICH) ranged from 0-45.7% (overall N.=168; 17.2%). Mortality at 90 days ranged from 0-45.4% (overall N.=114; 11.7%). Time to recanalization was significantly longer in the stenting group with an overall mean difference of 1.76 (95% CI: 1.59-1.93).

CONCLUSIONS

In this meta-analysis time to recanalization was significantly longer in the emergency ICA stenting group. There was no benefit from emergency stenting in parameters such as successful revascularization (TICI≥2b), clinical outcome (mRS≤2) or 90-day mortality. Data on sICH were scarce. Emergency ICA stenting appears to increase time to revascularization and increase the risk of complications with no demonstrated clinical benefit. Furthermore, no prospective, randomized controlled trials demonstrating relative efficacy and safety of concomitant ICA stenting have been published to date. Additional studies must be undertaken to define the role of angioplasty and stenting of the extracranial carotid arteries in the early management of acute stroke in tandem occlusions. Until then, we recommend that ICA stenting concomitant to thrombectomy in acute stroke patients should be avoided.

Mechanical Thrombectomy of Acute Middle Cerebral Artery Occlusion Using Trans-Anterior Communicating Artery Approach

BACKGROUND

A cross-circulation technique involves gaining access to a cerebral vessel through a patent anterior or posterior communicating artery. This technique may be used in patients with emergent large-vessel occlusions and an unfavorable direct route to the occlusion. While few previous reports have demonstrated a successful cross-circulation technique for treatment of emergent large-vessel occlusions, we present the first 2 cases of transanterior communicating artery stent retriever thrombectomy.

CASE DESCRIPTION

Case #1: A 64-year-old female presented with acute right middle cerebral artery (MCA) occlusion. She demonstrated a "triple-tandem" brachiocephalic-internal carotid artery-middle cerebral artery occlusion, thus precluding direct access to the right MCA. Successful stent retriever mechanical thrombectomy was performed across the anterior communicating artery, using a left internal carotid artery approach. Case #2: A 70-year old female presented with acute occlusion of the left MCA and tandem occlusion of the cervical left internal carotid artery. Multiple attempts to catheterize the left common carotid artery were unsuccessful. She underwent successful stent retriever mechanical thrombectomy across a patent anterior communicating artery, using a right internal carotid artery approach.

CONCLUSIONS

Timely recanalization of an occluded artery plays a critical role in the prognosis of patients with acute ischemic stroke. Successful stent retriever mechanical thrombectomy of an occluded MCA is possible using a transanterior communicating artery approach in patients without a direct access route to the occluded intracranial vessel. We review the pathophysiology of tandem lesions, access routes to intracranial occlusions, and the literature on cross-circulation techniques to treat emergent large-vessel occlusions.

Safety of bridging antiplatelet therapy with the gpIIb-IIIa inhibitor tirofiban after emergency stenting in stroke

BACKGROUND

In a proportion of stroke patients with acute large vessel occlusion permanent stent implantation is mandatory to achieve successful recanalization. The optimum platelet inhibition strategy after such emergency stenting is unknown. We therefore analyzed the outcome of early glycoprotein (gp) IIb/IIIa inhibitor treatment after emergency stenting in acute stroke.

METHODS

Sixty patients with emergency stenting were identified in our stroke unit registry from 12/2010-06/2014 and analyzed retrospectively. All patients were bridged intravenously with the gpIIb/IIIa antagonist tirofiban immediately after the acute procedure until switching to oral aspirin and clopidogrel was performed. For comparison we studied 135 patients with M1 occlusion undergoing thrombectomy without stent implantation or tirofiban treatment in a propensity score-adjusted analysis.

RESULTS

In the acute stenting group receiving tirofiban complications with 6 deaths during the hospital stay (10%), 2 reinfarctions (3%), 12 intracerebral hemorrhages (ICH; 20%) and 5 symptomatic ICH (8%) occurred. Thirty-seven patients (62%) reached a moderate outcome of mRS 0-3 after 90 days. In the thrombectomy group without tirofiban administration the rate of deaths within hospital stay, the rate of ICH and outcome at day 90 were not different.

CONCLUSION

In our retrospective study acute stenting with subsequent gpIIb/IIIa inhibition was not associated with an increased risk of ICH or in-hospital death.

Carotid Artery Stenosis Contralateral to Acute Tandem Occlusion: An Independent Predictor of Poor Clinical Outcome after Mechanical Thrombectomy with Concomitant Carotid Artery Stenting

BACKGROUND AND PURPOSE

Cerebral ischemic strokes due to extra-/intracranial tandem occlusions (TO) of the anterior circulation are responsible for causing mechanical thrombectomy (MT). The impact of concomitant contralateral carotid stenosis (CCS) upon outcome remains unclear in this stroke subtype.

METHODS

Retrospective analysis of prospectively collected data of 4 international stroke centers between 2011 and 2017. One hundred ninety-seven consecutive patients with anterior TO were treated with MT and acute carotid artery stenting (CAS). Clinical (including demographics and National Institutes of Health Stroke Scale [NIHSS]), imaging (including angiographic evaluation of CCS) and procedural data were evaluated. Favorable clinical outcome was defined as modified Rankin Scale (mRS) ≤2 at 90 days.

RESULTS

In 186 out of 197 TO patients preinterventional CT angiography was available for analysis, thereof 49 patients (26%) presented with CCS. Median admission NIHSS and procedural timings did not differ between groups. Reperfusion was successful in 38 out of 49 patients (78%) vs. 113 out of 148 patients (76%) without CCS. In stark contrast, rate of favorable outcome at 90 days differed significantly between groups (22 vs. 44%; p < 0.05). The presence of CCS in TO was associated with an unfavorable clinical outcome independent of age and NIHSS in multivariate logistic regression (p < 0.05). Final infarct volume was significantly larger in CCS patients (100 ± 127 vs. 63 ± 77 cm3; p < 0.05). Neither all-cause mortality rates (25 vs. 17%) nor frequency of peri-interventional symptomatic intracranial hemorrhage differed between groups (7 vs. 6%).

CONCLUSION

For patients with anterior TO undergoing MT with concomitant CAS the presence of CCS >50% is an independent predictor of poor clinical outcome. This most likely cause is due to poorer collateral flow to the affected tissue.

Combined interventional and surgical treatment of tandem middle cerebral artery embolus and internal carotid artery occlusion: case report

Tandem internal carotid artery (ICA) origin occlusion and middle cerebral artery (MCA) thromboembolism is a life-threatening condition with poor neurological outcome. The authors report on a patient presenting with acute ischemic stroke from a tandem ICA and MCA occlusion with penumbra. Emergency MCA mechanical thrombectomy was performed through percutaneous cervical ICA access due to the inability to cross the cervical carotid occlusion. Emergency carotid endarterectomy to reperfuse the poorly collateralized hemisphere and repair the ICA access site was performed 2 hours after completion of tissue plasminogen activator (tPA) infusion. This case illustrates the shortest reported interval between tPA infusion and open surgical intervention for carotid revascularization, as well as the role of direct carotid artery access for mechanical thrombectomy. The authors also describe the use of a temporizing femoral artery-to-ICA shunt to maintain cerebral perfusion in the setting of ICA occlusion.