Abstract
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.
Highlights
In stroke patients with large vessel occlusion (LVO), mechanical thrombectomy (MT) has become the standard of care since randomized trials have proven superiority over intravenous thrombolysis alone [1,2,3,4,5]
We identified 163/1645 (9.9%) patients with a tandem occlusion that were treated by MT in our department between April 2009 and May 2016
Our analysis of a large cohort of 163 patients with tandem lesions is relevant, as there is no other study in this patient subgroup with all patients being treated in the same center. This type of study guarantees relatively consistent interventional experience and standardized endovascular approaches as well as low variability after care regimens. This retrospective analysis showed a high level of recanalization (91.4% Thrombolysis in Cerebral infarction (TICI) IIb and III) and a high rate of favorable early neurologic outcome with 51% of early neurological improvement in tandem occlusions treated by the combination of Stent-PTA, MT with a stent retriever and monoantiaggregation with aspirin
Summary
In stroke patients with large vessel occlusion (LVO), mechanical thrombectomy (MT) has become the standard of care since randomized trials have proven superiority over intravenous thrombolysis alone [1,2,3,4,5]. A review of 32 studies showed that acute stenting of EICA in patients with tandem occlusion resulted in a significantly better outcome [15]. Behme et al [16] published a retrospective multicenter series including 170 patients supporting the combination of carotid stenting and intracranial mechanical thrombectomy even though there were variations among the centers in the periprocedural management of antiplatelet regimen. 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). We report our management strategy and the outcome in these patients in a large single-center cohort
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