[Endovascular treatment of acute ischemic stroke under conscious sedation compared to general anesthesia - safety, feasibility and clinical and radiological outcome]

Delayed neurological improvement after endovascular treatment for acute large vessel occlusion: data from ANGEL-ACT registry

BACKGROUND

A subgroup of patients with acute large vessel occlusion (ALVO) may experience delayed neurological improvement (DNI) after endovascular treatment (EVT). Our study aimed to investigate the incidence and independent predictors of DNI in patients with ALVO after EVT.

METHODS

We selected subjects from ANGEL-ACT Registry. The definition of DNI is patients with ALVO who did not experience early neurological improvement (ENI) despite complete recanalization after EVT. These patients achieved a 90-day favorable outcome assessed by a modified Rankin Scale (mRS) score. We defined ENI as a ≥ 4-point decrease in the National Institutes of Health Stroke Scale (NIHSS) between baseline and 24 h or NIHSS of 0 or 1 at 24 h, with complete recanalization after EVT. We performed logistic regression analyses to determine the independent predictors of DNI.

RESULTS

Among the 1056 enrolled patients, 406 (38.4%) did not experience ENI. 106 (26.1%) patients without ENI achieved DNI. On Multivariate analysis, lower admission NIHSS score (odds ratio [OR] = 1.17,95% confidence interval [CI]: 1.11-1.23, P < 0.001), underlying ICAD (OR = 2.03, 95% CI: 1.07-3.85, P = 0.029) and absence of general anesthesia (OR = 2.13, 95% CI: 1.24-3.64, P = 0.006) were independent predictors of DNI.

CONCLUSION

DNI occurred in 26.1% of patients with ALVO who did not experience ENI after EVT. Our study identified several independent predictors of DNI that should be highly considered in daily clinical practice to improve ALVO management.

Sedation Mode During Endovascular Stroke Treatment in the Posterior Circulation-Is Conscious Sedation for Eligible Patients Feasible?

Background and Purpose: To compare safety and efficacy of conscious sedation (CS) vs. general anesthesia (GA) in endovascular stroke treatment (EST) of the posterior circulation (PC).

Methods: Retrospective single-center analysis of patients receiving EST for large-vessel occlusion (LVO) in PC between January 2015 and November 2020. Exclusion criteria were severe stroke syndromes (NIHSS > 20), decreased level of consciousness, intubation for transport, and second stroke within 3 months of follow-up. The primary endpoint was a favorable clinical outcome 90 days after stroke onset (mRS 0–2 or 3 if pre-stroke mRS 3). Secondary endpoints were the rate of EST failure and procedural complications.

Results: Of 111 included patients, 45/111 patients (40.5%) were treated under CS and 60/111 (54.0%) under GA. In 6/111 cases (5.4%), sedation mode was changed from CS to GA during EST. Patients treated under CS showed a lower mRS 90 days after stroke onset [mRS, median (IQR): 2.5 (1–4) CS vs. 3 (2–6) GA, p = 0.036] and a comparable rate of good outcome [good outcome, n (%): 19 (42.2) CS vs. 15 (32.6) GA, p = 0.311]. There was no difference in complication rates during EST (6.7% CS vs. 8.3% GA) or intracranial bleeding in follow-up imaging [n (%): 4 (8.9) CS vs. 7 (11.7) GA), p = 0.705]. The rate of successful target vessel recanalization did not differ (84.4% CS vs. 85.0 % GA).

Conclusions: In this retrospective study, EST of the posterior circulation under conscious sedation was for eligible patients comparably safe and effective to patients treated under general anesthesia.

Conscious sedation compared to general anesthesia for intracranial mechanical thrombectomy: A meta-analysis

INTRODUCTION

Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large-vessel occlusion in the anterior circulation, but there is a debate on the optimal anesthetic approach during this therapy. Meta-analyses of observational studies suggest that general anesthesia increases disability and death compared with conscious sedation However, their results are conflicting. This meta-analysis study was performed to assess the relationship between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke.

METHODS

Through a systematic literature search up to August 2020, 18 studies included 4,802 subjects at baseline with endovascular therapy for acute ischemic stroke and reported a total of 1,711 subjects using general anesthesia and 1,961 subjects using conscious sedation were found. They recorded relationships between the effects of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke. Odds ratio (OR) or Mean differences (MD) with 95% confidence intervals (CIs) were calculated between the effect of general anesthesia compared to conscious sedation during endovascular therapy for acute ischemic stroke using the dichotomous or contentious methods with a random or fixed-effect model.

RESULTS

No significant difference were found between general anesthesia and conscious sedation during the endovascular therapy for acute ischemic stroke in functional independence at 90 days (OR, 0.78; 95% CI, 0.44-1.40, p = 40); successful recanalization at 24 hr (OR, 1.23; 95% CI, 0.62-2.41, p = 55); mortality at 90 days (OR, 1.36; 95% CI, 0.83-2.24, p = .22); interventional complication (OR, 1.24; 95% CI, 0.76-2.02, p = .40); symptomatic intracranial hemorrhage (OR, 0.64; 95% CI, 0.41-0.99, p = .05); aspiration pneumonia (OR, 0.96; 95% CI, 0.58-1.58, p = .87); and National Institute of Health Stroke Scale score after 24 hr (MD, 0.38; 95% CI, -1.15-1.91, p = .62); with relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage.

CONCLUSIONS

General anesthesia has no independent relationship compared to conscious sedation during the endovascular therapy for acute ischemic stroke with a relative relationship favoring general anesthesia only in decreasing the symptomatic intracranial hemorrhage. This relationship encouraged us to recommend either anesthetic strategy during the endovascular therapy for acute ischemic stroke with no possible fear of higher complication.

Impact of Anesthetic Variation in Endovascular Treatment of Acute Ischemic Stroke

Background

Given recent technological advancements leading to better outcomes in endovascular therapy for acute ischemic stroke (AIS), updated guidelines recommend thrombectomy as the standard of care in acute large vessel occlusions. However, use of general anesthesia versus conscious sedation continues to be discussed. Two previous randomized trials have shown no significant difference between the use of conscious sedation compared with general anesthesia.

Methods

The authors performed a retrospective analysis of all consecutive patients with acute ischemia who underwent intra-arterial thrombectomy between September 2014 and May 2020 at a Level 1 stroke center. Patient characteristics along with clinical and operative data were extracted. Frequency distributions of selected characteristics were obtained and statistical significance of any differences according to the mode of anesthesia was assessed.

Results

A total of 480 patients were included in this study, 257 underwent general anesthesia and 223 underwent conscious sedation. Length of stay (LOS) in the ICU nor length of hospital stay was significantly different between groups. Change in National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge, procedure times, and discharge disposition were not found to be significantly associated with either group although there was a trend towards longer door to puncture time with general anesthesia. Discharge disposition was found to be significantly associated with admission NIHSS (p=0.04). There was a trend towards longer hospital stay in patients with worse admission NIHSS (p=0.09). Success of thrombectomy was not significantly different between both anesthesia groups (p=0.37).

Conclusions

This large, single-center retrospective cohort study echoes the results of two previous randomized controlled trials in demonstrating non-inferiority of general anesthesia versus conscious sedation in cases of intra-arterial thrombectomy for AIS. These results contrast those of previously published retrospective studies.

Choice of ANaesthesia for EndoVAScular treatment of acute ischaemic stroke at posterior circulation (CANVAS II): protocol for an exploratory randomised controlled study

INTRODUCTION

Observational and interventional studies indicate that the type of anaesthesia may be associated with the postprocedural neurological function in patients with anterior circulation acute ischaemic stroke undergoing endovascular treatment. Patients with acute posterior circulation ischaemic stroke may experience different physiological changes and result in severe neurological outcome. However, the effect of the type of anaesthesia on postprocedure neurological function remained unclear in this population.

METHODS AND ANALYSIS

This is an exploratory randomised controlled trial that will be carried out at Beijing Tiantan Hospital, Capital Medical University. Patients with acute posterior circulation ischaemic stroke and deemed suitable for emergency endovascular recanalisation will be recruited in this trial. Eighty-four patients will be randomised to receive either general anaesthesia or conscious sedation with 1:1 allocation ratio. The primary endpoint is the 90-day modified Rankin Scale.

ETHICS AND DISSEMINATION

The study has been reviewed by and approved by Ethics Committee of Beijing Tiantan Hospital of Capital Medical University (KY2017-074-02). If the results are positive, the study will indicate whether the type of anaesthesia affects neurological outcome after endovascular treatment of posterior stroke. The findings of the study will be published in peer-reviewed journals and presented at national or international conferences.

TRIAL REGISTRATION NUMBER

NCT03317535.

General Anesthesia Versus Conscious Sedation for Intracranial Mechanical Thrombectomy: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Background

Endovascular therapy is the standard of care for severe acute ischemic stroke caused by large‐vessel occlusion in the anterior circulation, but there is uncertainty regarding the optimal anesthetic approach during this therapy. Meta‐analyses of observational studies suggest that general anesthesia increases morbidity and mortality compared with conscious sedation. We performed a systematic review and meta‐analysis of randomized clinical trials to examine the effect of anesthetic strategy during endovascular treatment for acute ischemic stroke.

Methods and Results

Systematic review and meta‐analysis according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) guidelines has been registered with the PROSPERO (International Prospective Register of Ongoing Systematic Reviews) (CRD42018103684). Medline, EMBASE, and CENTRAL databases were searched through August 1, 2018. Meta‐analyses were conducted using a random‐effects model to pool odds ratio with corresponding 95% CI. The primary outcome was 90‐day functional independence (modified Rankin Scale 0–2). In the results, 3 trials with a total of 368 patients were selected. Among patients with ischemic stroke undergoing endovascular therapy, general anesthesia was significantly associated with higher odds of functional independence (odds ratio 1.87, 95% CI 1.15–3.03, I²=17%) and successful recanalization (odds ratio 1.94, 95% CI 1.13–3.3) compared with conscious sedation. However, general anesthesia was associated with a higher risk of 20% mean arterial pressure decrease (odds ratio 10.76, 95% CI 5.25–22.07). There were no significant differences in death, symptomatic intracranial hemorrhage, anesthesiologic complication, intensive care unit length of stay, pneumonia, and interventional complication.

Conclusions

Moderate‐quality evidence suggests that general anesthesia results in significantly higher rates of functional independence than conscious sedation in patients with ischemic stroke undergoing endovascular therapy. Large randomized clinical trials are required to confirm the benefit.

Outcomes of general anesthesia versus conscious sedation for Stroke undergoing endovascular treatment: a meta-analysis

Background

The impact of anesthesia strategy on the outcomes of acute ischemic stroke (AIS) patients undergoing endovascular treatment is currently controversy. Thus, we performed this meta-analysis to compare the differences of clinical and angiographic outcomes between general anesthesia (GA) and conscious sedation (CS).

Methods

A literature search in PubMed, Embase, and Web of Knowledge databases through February 2019 was conducted for related records on GA and CS of AIS undergoing endovascular treatment. The results of the studies were pooled and meta-analyzed with fixed- or random-effect model based on heterogeneity test in total and subgroup analyses.

Results

Twenty-three studies including 6703 patients were analyzed in this meta-analysis. We found that patients in the GA group have lower odds of favorable functional outcome (mRS scores ≤2) compared with the CS group (odds ratio [OR] = 0.62, 95% confidence interval [CI]: 0.49–0.77), and higher risk of mortality (OR = 1.68, 95% CI: 1.49–1.90), pneumonia (OR = 1.78, 95% CI: 1.40–2.26), symptomatic intracranial hemorrhage (OR = 1.64, 95% CI: 1.13–2.37). However, no significant differences were seen between the groups in the rate of recanalization (OR = 1.07, 95% CI: 0.89–1.28), vessel dissection or perforation (OR = 1.00, 95% CI: 0.98–1.03) and asymptomatic intracranial hemorrhage (OR = 1.19, 95% CI: 0.96–1.47). While in the RCT subgroup analysis, we found patients in the GA group does not show lower rate of favorable functional outcome compared with the CS group (OR = 1.84, 95% CI: 1.17–2.89). And there was no significant difference in the rate of mortality between GA and CS groups during RCT subgroup analysis (OR = 0.74, 95% CI: 0.43–1.27).

Conclusions

AIS patients performed endovascular treatment under GA compared with CS was associated with worse functional outcome and increased rate of mortality, but differences in worsened outcomes do not exist when one looks into the GA vs. CS RCTs. Moreover, these findings are mainly based on the retrospective studies and additional multi-center randomized controlled trials to definitively address these issues is warranted.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0741-7) contains supplementary material, which is available to authorized users.

Influence of Anesthesia Type on Outcomes after Endovascular Treatment in Acute Ischemic Stroke: Meta-Analysis

PURPOSE

To assess clinical and angiographic outcomes after endovascular treatment (EVT) in ischemic stroke patients according to anesthesia types (general anesthesia vs. conscious sedation).

MATERIALS AND METHODS

A systematic literature review through an online data base between January 1990 and September 2017 was performed. A fixed effect model was used in cases of <50% heterogeneity. The primary outcomes were good clinical outcome at the 3-month follow-up and successful recanalization. A meta-regression analysis was done to estimate primary outcomes of log odds ratio (OR) on onset-to-puncture time (OTP) differences. Publication bias was determined using Begg's funnel plot and additional the Trim and Fill method.

RESULTS

Sixteen articles including 2,662 patients (general anesthesia, n=1,275; conscious sedation, n=1,387) were included. General anesthesia significantly decreased good outcomes than conscious sedation (OR, 0.564; 95% confidence interval [CI], 0.354-0.899). However, outcomes did not differ significantly in randomized controlled trials (RCTs; OR, 1.101; 95% CI, 0.395-3.071). Anesthesia type was not associated with successful recanalization (OR, 0.985; 95% CI, 0.787-1.233). General anesthesia increased the risk of mortality (OR, 1.532; 95% CI, 1.187-1.976) and pneumonia (OR, 1.613; 95% CI, 1.172-2.221), but not symptomatic intracranial hemorrhage (OR, 1.125; 95% CI, 0.767-1.652). The meta-regression analysis showed no linear relationship between OTP differences and log OR of good outcome (coefficient, 0.0004; P=0.95) or successful recanalization (coefficient, 0.0005; P=0.94), respectively.

CONCLUSION

General anesthesia seemed to be associated with adverse clinical outcome after EVT. However, its efficacy was not demonstrated in RCTs. Successful recanalization did not differ according to anesthesia type. Studies using individual patient data based on further RCTs are necessary to elucidate anesthesia effect on procedural and clinical outcomes.

Current evidence for anesthesia management during endovascular stroke therapy: updated systematic review and meta-analysis

Introduction

Debate continues about the optimal anesthetic management for patients undergoing endovascular treatment (ET) of acute ischemic stroke due to emergent large vessel occlusion.

Objective

To compare, using current evidence, the clinical outcomes and procedural characteristics among patients undergoing general anesthesia (GA) and local or monitored anesthesia (non-GA).

Methods

We performed a systematic review and meta-analysis of all available studies that involved the use of stent retrievers for ET (stentriever group). Additionally, we included studies that were published in 2015 and later, and compared the clinical outcomes among the studies using stentrievers or no stentrievers (pre-stentriever group). Outcome variables included functional independence (FI; modified Rankin Scale scores of 0–2), symptomatic hemorrhage, mortality, procedure duration, and vascular and respiratory complications. We calculated pooled odds ratios and 95% CIs using random-effects models.

Results

Sixteen studies (three randomized controlled clinical trials (RCTs) and 13 non-randomized studies) were identified comprising 5836 patients. Although non-GA was associated with higher odds of 3-month FI (OR=1.57; 95% CI 1.17 to 2.10; P=0.003) and lower odds of 3-month mortality (OR=0.62; 95% CI 0.47 to 0.82; P=0.0006, substantial heterogeneity was noted across included trials. Sensitivity analyses of RCTs showed that non-GA was inversely associated with FI (OR=0.55; 95% CI 0.34 to 0.89; P=0.01; I2=15%), while no association was noted with mortality (OR=1.36; 95% CI 0.79 to 2.34; P=0.27; I2=0%).

Conclusion

Our updated meta-analysis demonstrates favorable results with non-GA, probably owing to inclusion of non-randomized studies. Recent single-center RCTs indicate that GA is associated with higher odds of FI at 3 months, while other outcomes are similar between the two groups.

Monitored Anesthesia Care vs Intubation for Vertebrobasilar Stroke Endovascular Therapy

Importance

No consensus regarding the ideal sedation treatment for stroke endovascular therapy has been reached, and practices remain largely based on local protocols and clinician preferences. Most studies have focused on anterior circulation strokes; therefore, little is known regarding the optimal anesthesia type for vertebrobasilar occlusion strokes.

Objective

To compare clinical and angiographic outcomes between monitored anesthesia care (MAC) and general anesthesia (GA) in patients presenting with vertebrobasilar occlusion strokes.

Design, Setting, and Participants

Retrospective, matched, case-control study of consecutive vertebrobasilar occlusion strokes treated with endovascular therapy at 2 academic institutions. The study took place between September 2005 and September 2015 at University of Pittsburgh Medical Center Stroke Institute, Pittsburgh, Pennsylvania, and between September 2010 and September 2015 at the Marcus Stroke and Neuroscience Center at Grady Memorial Hospital, Atlanta, Georgia. Patients requiring emergent intubation prior to endovascular therapy were excluded. The remaining patients were categorized into (1) MAC and (2) elective intubation for the procedure (elective GA). Patients who converted from MAC to GA during the procedure were included in the MAC group. The 2 groups were matched for age, baseline National Institutes of Health Stroke Scale score, and glucose levels. Baseline characteristics and outcomes were compared.

Main Outcomes and Measures

The primary outcome measure was the shift in the degree of disability among the 2 groups as measured by the modified Rankin scale at 90 days.

Results

A total of 215 patients underwent endovascular therapy for vertebrobasilar occlusion strokes during the study period. Thirty-nine patients were excluded owing to emergent pre-endovascular therapy intubation. Sixty-three patients had MAC (36%) and 113 patients had GA (64%). The conversion rate from MAC to GA was 13% (n = 8). After matching, 61 pairs of patients (n = 122) underwent primary analysis. The 2 groups were well balanced in terms of baseline characteristics. Median age was 69 years (interquartile range, 60-75 years) in the MAC group vs 67 years (interquartile range, 55.5-78.5 years) in the GA group (P = .83). Fifty-four percent of the patients in the MAC group were men vs 41% in the GA group (P = .44). When compared with the elective GA group, patients who underwent the procedure with MAC had similar rates of successful reperfusion, good clinical outcomes, hemorrhagic complications, and mortality. The modality of anesthesia was not associated with any significant changes in the modified Rankin scale score distribution (MAC: OR, 1.52; 95% CI, 0.80-2.90; P = .19).

Conclusions and Relevance

In endovascular therapy for acute posterior circulation stroke, MAC is feasible and appears to be as safe and effective as GA. Future clinical trials are warranted to confirm our findings.

Anesthesia Technique and Outcomes of Mechanical Thrombectomy in Patients With Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke.

METHODS

We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay.

RESULTS

Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models.

CONCLUSIONS

Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.

[Intubation and sedation in the endovascular treatment of acute cerebral infarction]

In the past complex intracranial treatments demanded intubation and general anesthesia of the patient. With increasing rate of endovascular local treatment of acute stroke more and more neurointerventionalists report that recanalisation techniques can be performed in sedation of the patient without the need of additional intubation. Although prospective studies are lacking retrospective studies have shown that the risk of iatrogeneous vessel injuries without global anesthesia is not increased but outcomes in case of conscious sedations are better compared with intubation and general anesthesia.

[News and perspectives in neurocritical care]

Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.

Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types.

MATERIALS AND METHODS

In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization.

RESULTS

Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36-3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score.

CONCLUSIONS

Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.

Two in One: Endovascular Treatment of Acute Tandem Occlusions in the Anterior Circulation. Clin Neuroradiol. 2015;25:397-402. [PMID: 24988990 DOI: 10.1007/s00062-014-0318-2]

PURPOSE

Acute major stroke with high-grade stenosis or occlusion of the extracranial internal carotid artery (ICA) and additional intracranial large artery occlusion is increasingly treated with a mechanical endovascular approach by extracranial stenting and intracranial thrombectomy due to poor response to systemic thrombolysis with recombinant tissue plasminogen activator (rtPA). This article presents a single centre cohort of this challenging subtype of stroke, describing the technical procedure and analysing the angiographic and clinical outcome.

METHODS

Clinical and imaging data of all consecutive patients between July 2008 and March 2013 with intracranial artery occlusion in the anterior circulation and additional occlusion or pseudo-occlusion of the cervical ICA were retrospectively analysed with respect to demographical and clinical characteristics. Technical approach, recanalization rate, recanalization time and short-term clinical outcome were determined.

RESULTS

A total of 43 patients with tandem occlusion in the anterior circulation met the inclusion criteria. Out of these, 32 (74.4%) occlusions and 11 (25.6%) pseudo-occlusions of the extracranial ICA with additional occlusion of the distal segment of the ICA in 7.0% (3/43), the M1-segment of the middle cerebral artery (MCA) in 81.4% (35/43) or the M2-segment of the MCA in 11.6% (5/43) of cases were treated with combined endovascular approach including extracranial stenting with angioplasty and intracranial mechanical thrombectomy. In 76.7% of cases, an angiographic recanalization result of 2b or 3 using the Thrombolysis in Cerebral Infarction (TICI) score was achieved. Mean time from first angiographic series to recanalization was 103 min. A modified Rankin Scale (mRS) score of ≤ 2 was achieved in 32.6% at the time of discharge.

CONCLUSION

Endovascular therapy of patients with tandem occlusion in the anterior circulation with emergency extracranial stenting and intracranial mechanical thrombectomy appears to be safe and may lead to a satisfactory angiographic result and clinical outcome.