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Huber C, Berberat J, Sassenburg R, Pflugi S, Anon J, Diepers M, Andereggen L, Kahles T, Luft AR, Nedeltchev K, Remonda L, Gruber P. Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions. J Clin Med 2024; 13:2315. [PMID: 38673587 PMCID: PMC11050763 DOI: 10.3390/jcm13082315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.
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Affiliation(s)
- Cyrill Huber
- Department of Neuroradiology, Kantonsspital Aarau, University of Zurich, Tellstrasse 21, 5001 Aarau, Switzerland;
| | - Jatta Berberat
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Renske Sassenburg
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Stefanie Pflugi
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Javier Anon
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Michael Diepers
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, University of Bern, 3012 Bern, Switzerland;
| | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, University of Basel, 4001 Basel, Switzerland;
| | - Andreas R. Luft
- Department of Neurology, University Hospital Zurich, University of Zurich, 8952 Zurich, Switzerland;
- Cereneo, Center for Neurology and Rehabilitation, 6354 Vitznau, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Kantonsspital Aarau, University of Bern, 3012 Bern, Switzerland;
| | - Luca Remonda
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Philipp Gruber
- Department of Neuroradiology, Kantonsspital Aarau, University of Zurich, Tellstrasse 21, 5001 Aarau, Switzerland;
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2
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Simon SR, Knapen RRMM, Truijman MTB, van Oostenbrugge RJ, Wagemans BAJM, van Zwam WH, van der Leij C. Timing of acute carotid artery stenting for tandem lesions in patients with acute ischemic stroke: A Maastricht Stroke Quality Registry (MaSQ-Registry) study. Interv Neuroradiol 2024:15910199241245166. [PMID: 38592266 DOI: 10.1177/15910199241245166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND To better understand the influence of treatment strategies on outcomes for patients with tandem lesions undergoing acute internal carotid artery (ICA) stenting during endovascular treatment (EVT), this study compared clinical, technical, and safety outcomes in patients with acute ischemic stroke due to a large vessel occlusion (LVO) who underwent ICA stenting before versus after intracranial thrombectomy. METHODS This single-center retrospective cohort study included patients who underwent EVT due to a LVO and periprocedural ICA stenting for significant ICA stenosis or occlusion between September 2020 and January 2023. Data were extracted from the Maastricht Stroke Quality Registry (MaSQ-Registry). Primary outcome was the modified Rankin Scale (mRS) at 3 months. Secondary outcomes included procedure times, number of total thrombectomy attempts, first-attempt excellent recanalization rates (extended Thrombolysis In Cerebral Infarction (eTICI) ≥ 2C after one thrombectomy attempt), and safety outcomes. RESULTS This study included 50 patients. Thirty-one patients (62%) underwent ICA stenting before intracranial thrombectomy. No significant differences between both groups were found regarding mRS, total procedure time, number of total thrombectomy attempts, first-attempt excellent recanalization, or complications. Time between groin puncture and recanalization (reperfusion time) was significantly longer in patients who had ICA stenting before intracranial thrombectomy versus after intracranial thrombectomy (45 min versus 28 min, P = 0.004). CONCLUSION ICA stenting after intracranial thrombectomy in patients with tandem lesions undergoing EVT did not lead to better patient outcomes compared to stenting before intracranial thrombectomy, despite shorter reperfusion times.
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Affiliation(s)
- Sorina R Simon
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Martine T B Truijman
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart A J M Wagemans
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Christiaan van der Leij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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3
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Klail T, Piechowiak EI, Krug N, Maegerlein C, Maus V, Fischer S, Lobsien D, Pielenz D, Styczen H, Deuschl C, Thormann M, Diamandis E, Heldner MR, Kaesmacher J, Mordasini P. Endovascular revascularization of vertebrobasilar tandem occlusions in comparison to isolated basilar artery occlusions: A multi-center experience. Interv Neuroradiol 2024:15910199241240045. [PMID: 38576395 DOI: 10.1177/15910199241240045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Acute basilar artery occlusion (BAO) is a severe disease that is associated with an 85% mortality rate if untreated. Several studies have analyzed the use of mechanical thrombectomy (MT) in the different scenarios of BAO. However, the results remain conflicting and the role of MT as standard of care for vertebrobasilar tandem occlusions (VBTO) has not been confirmed. Our goal was to assess technical feasibility, safety, and functional outcome of endovascular treatment of VBTO in comparison to isolated BAO (IBAO). METHODS We retrospectively reviewed all prospectively collected patients with acute BAO from six tertiary centers between September 2016 and November 2021. Patients were subsequently divided into two groups: VBTO and IBAO. Baseline data, procedural details, and outcomes were compared between groups. RESULTS A total of 190 patients were included, 55 presenting with a VBTO and 135 with IBAO. Successful recanalization was equally common in both groups (89.1% and 86.0%). Rates of favorable functional outcome (modified Rankin Scale: 0-2) were higher in patients with VBTO compared to IBAO (36.4% vs. 25.2%, p = 0.048) and mortality was lower (29.1% vs. 33.3%). However, these associations faded after adjustment for confounders (adjusted odds ratio [aOR] 0.86, 95% CI 0.35-2.05; aOR 0.93, 95% CI 0.35-2.45). Rates of symptomatic intracranial hemorrhage did not differ between the groups (VBTO: 7.3% vs. IBAO: 4.2%; p = 0.496). CONCLUSION Endovascular treatment of VBTO is technically feasible and safe with similar rates of successful recanalization, favorable functional outcome, and mortality to those in patients with IBAO.
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Affiliation(s)
- Tomas Klail
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nadja Krug
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Christian Maegerlein
- Department of Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Volker Maus
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
- Klinik für Radiologie und Neuroradiologie, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Sebastian Fischer
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Donald Lobsien
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Daniel Pielenz
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Helios General Hospital Erfurt, Erfurt, Germany
| | - Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Cornelius Deuschl
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Maximilian Thormann
- University Clinic for Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Elie Diamandis
- University Clinic for Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
- Department of Radiology and Nuclear Medicine, Cantonal Hospital of St Gallen, St Gallen, Switzerland
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4
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Sui Y, Shi Y, Yang Y, Xiao J, Zhou Y, Zhang S, Qiu Y, Xie Y, Lv Z. Bridging techniques compared with direct endovascular therapy for stroke due to tandem occlusion: A systematic review and meta-analysis. Asian J Surg 2024; 47:1339-1343. [PMID: 38042661 DOI: 10.1016/j.asjsur.2023.11.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023] Open
Abstract
The superiority of the bridging strategy of intravenous thrombolysis (IVT) plus endovascular therapy (EVT) to EVT alone for the anterior circulation with tandem vascular occlusion (TO) has not been specifically addressed by a single randomized trial. Analysis of 15 studies (n = 1857 patients) revealed that 90 Day good functional outcomes (MRS≤2) were better for bridging therapy (IVT + EVT) than for dEVT (OR:1.39, 95%CI: 1.09-1.79, p = 0.008); 90-day mortality was lower for IVT + EVT than for dEVT (OR: 0.57; 95%CI: 0.40-0.81, p = 0.002) and rates of successful recanalization were higher for IVT + EVT than for dEVT (OR: 1.79, 95%CI: 1.36-2.36, p<0.0001). However, there was no significant difference in the incidence of symptomatic. intracranial hemorrhage (sICH) between groups (OR 0.91, 95%CI 0.64-1.31, p = 0.62).In conclusion, Patients receiving IVT + EVT have a better functional outcome, lower death rate and a higher rate of successful recanalization than those receiving dEVT but there was no difference in sICH risk between the two treatments.
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Affiliation(s)
- Yihang Sui
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yu Shi
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yanmei Yang
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Jin Xiao
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Yanru Zhou
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Siyuan Zhang
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China.
| | - Yue Qiu
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Yang Xie
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China
| | - Zhiyu Lv
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Luzhou, 646000, Sichuan, China; Laboratory of Neurological Diseases and Brain Function, Luzhou, Sichuan, 646000, China.
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5
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Diana F, Abdalkader M, Behme D, Li W, Maurer CJ, Pop R, Hwang YH, Bartolini B, Da Ros V, Bracco S, Cirillo L, Marnat G, Katsanos AH, Kaesmacher J, Fischer U, Aguiar de Sousa D, Peschillo S, Zini A, Tomasello A, Ribo M, Nguyen TN, Romoli M. Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data. J Neurointerv Surg 2024; 16:243-247. [PMID: 37185107 DOI: 10.1136/jnis-2023-020204] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
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.
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Affiliation(s)
- Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | | | - Daniel Behme
- Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Wei Li
- Neurology, Hainan Medical University, Haikou, Hainan, China
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Yang-Ha Hwang
- Neurology and Radiology, Kyungpook National University Hospital, Daegu, Korea (the Republic of)
| | - Bruno Bartolini
- Diagnostic and Interventional Radiology, Interventional Neuroradiology Unit, CHUV - Lausanne University Hospital, Lausanne, Switzerland
| | - Valerio Da Ros
- Biomedicine and Prevention, Diagnostic Imaging Unit, Fondazione PTV Policlinico Tor Vergata, Roma, Italy
| | - Sandra Bracco
- Neurology and Human Movement Sciences, Interventional Neuroradiology Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Luigi Cirillo
- Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Aristeidis H Katsanos
- Neurology Division, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Johannes Kaesmacher
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/ CHULN, University of Lisbon, Lisboa, Portugal
| | - Simone Peschillo
- Endovascular Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
- UniCamillus International Medical University, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Emilia-Romagna, Italy
| | - Alejandro Tomasello
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
| | - Marc Ribo
- Stroke Research Group, Vall d'Hebron Research Institute, Barcelona, Catalunya, Spain
- Stroke Unit, Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston, Massachusetts, USA
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Emilia-Romagna, Italy
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6
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Gohla G, Schwarz R, Bier G, Estler A, Bongers MN, Ditt H, Fritz J, Kemmling A, Ernemann U, Horger M. A novel fully automated method for measuring ASPECTS to improve stroke diagnosis: Comparison to traditional ASPECTS. J Neuroimaging 2024; 34:145-151. [PMID: 37807097 DOI: 10.1111/jon.13159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/20/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND AND PURPOSE To compare the accuracy of subjective Alberta Stroke Program Early CT Score (sASPECTS) evaluation and that of an automated prototype software (aASPECTS) on nonenhanced CT (NECT) in patients with early anterior territory stroke and controls using side-to-side quantification of hypoattenuated brain areas. METHODS We retrospectively analyzed the NECT scans of 42 consecutive patients with ischemic stroke before reperfusion and 42 controls using first sASPECTS and subsequently aASPECTS. We assessed the differences in Alberta Stroke Program Early CT Score (ASPECTS) and calculated the sensitivity and specificity of NECT with CT perfusion, whereas cerebral blood volume (CBV) served as the reference standard for brain infarction. RESULTS The clot was located in the middle cerebral artery (MCA) in 47.6% of cases and the internal carotid artery (ICA) in 28.6% of cases. Ten cases presented combined ICA and MCA occlusions. The stroke was right sided in 52.4% of cases and left sided in 47.6%. Reader-based NECT analysis yielded a median sASPECTS of 10. The median CBV-based ASPECTS was 7. Compared to the area of decreased CBV, sASPECTS yielded a sensitivity of 12.5% and specificity of 86.8%. The software prototype (aASPECTS) yielded an overall sensitivity of 65.5% and a specificity of 92.2%. The interreader agreement for ASPECTS evaluation of admission NECT and follow-up CT was almost perfect (κ = .93). The interreader agreement of the CBV color map evaluation was substantial (κ = .77). CONCLUSIONS aASPECTS of NECT can outperform sASPECTS for stroke detection.
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Affiliation(s)
- Georg Gohla
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Ricarda Schwarz
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Georg Bier
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
- Radiology Salzstraße, Muenster, Germany
| | - Arne Estler
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Malte N Bongers
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Hendrik Ditt
- Siemens AG Healthcare; Imaging & Therapy Systems Computed Tomography & Radiation Oncology, Forchheim, Germany
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - André Kemmling
- Institute of Neuroradiology, Philipps University of Marburg, Marburg, Germany
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
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7
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Pop R, Burel J, Finitsis SN, Papagiannaki C, Severac F, Mangin PH, Mihoc D, Leonard-Lorant I, Gheoca R, Wolff V, Chibbaro S, Sibon I, Richard S, Beaujeux R, Marnat G, Gory B. Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter study. J Neurointerv Surg 2023; 15:e388-e395. [PMID: 36759180 DOI: 10.1136/jnis-2022-019875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment. METHODS Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups. RESULTS Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency. CONCLUSIONS Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
- Interventional Radiology, Institut de Chirurgie Guidée par l'Image, Strasbourg, France
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Julien Burel
- Radiology, University Hospital Centre Rouen, Rouen, France
| | | | | | - Francois Severac
- Public Healthcare Department, University Hospitals Strasbourg, Strasbourg, France
| | - Pierre H Mangin
- INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, F-67065, University of Strasbourg, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Ian Leonard-Lorant
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Roxana Gheoca
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | - Valerie Wolff
- Neurology, University Hospitals Strasbourg, Strasbourg, France
| | | | - Igor Sibon
- Neurology, University Hospital Center Bordeaux, Bordeaux, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Remy Beaujeux
- Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, Centre hospitalier regional universitaire de Nancy, Nancy, France
- Université de Lorraine, Nancy, France
- IADI, INSERM U1254, Nancy, France
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8
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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9
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Siddiq F, Bhagavan S, Ishfaq MF, Jaura A, Bhatti IA, Gomez CR, Qureshi AI. Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke. Oper Neurosurg (Hagerstown) 2023; 25:190-198. [PMID: 37133290 DOI: 10.1227/ons.0000000000000723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/08/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists. OBJECTIVE To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion. METHODS A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed. RESULTS Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection. CONCLUSION The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Sachin Bhagavan
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - M Fawad Ishfaq
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Attiya Jaura
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | | | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
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10
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Collette SL, Rodgers MP, van Walderveen MAA, Compagne KCJ, Nederkoorn PJ, Hofmeijer J, Martens JM, de Borst GJ, Luijckx GJR, Majoie CBLM, van der Lugt A, Bokkers RPH, Uyttenboogaart M. Management of extracranial carotid artery stenosis during endovascular treatment for acute ischaemic stroke: results from the MR CLEAN Registry. Stroke Vasc Neurol 2023; 8:229-237. [PMID: 36572506 PMCID: PMC10359798 DOI: 10.1136/svn-2022-001891] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/02/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The optimal management of ipsilateral extracranial internal carotid artery (ICA) stenosis during endovascular treatment (EVT) is unclear. We compared the outcomes of two different strategies: EVT with vs without carotid artery stenting (CAS). METHODS In this observational study, we included patients who had an acute ischaemic stroke undergoing EVT and a concomitant ipsilateral extracranial ICA stenosis of ≥50% or occlusion of presumed atherosclerotic origin, from the Dutch Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry (2014-2017). The primary endpoint was a good functional outcome at 90 days, defined as a modified Rankin Scale score ≤2. Secondary endpoints were successful intracranial reperfusion, new clot in a different vascular territory, symptomatic intracranial haemorrhage, recurrent ischaemic stroke and any serious adverse event. RESULTS Of the 433 included patients, 169 (39%) underwent EVT with CAS. In 123/168 (73%) patients, CAS was performed before intracranial thrombectomy. In 42/224 (19%) patients who underwent EVT without CAS, a deferred carotid endarterectomy or CAS was performed. EVT with and without CAS were associated with similar proportions of good functional outcome (47% vs 42%, respectively; adjusted OR (aOR), 0.90; 95% CI, 0.50 to 1.62). There were no major differences between the groups in any of the secondary endpoints, except for the increased odds of a new clot in a different vascular territory in the EVT with CAS group (aOR, 2.96; 95% CI, 1.07 to 8.21). CONCLUSIONS Functional outcomes were comparable after EVT with and without CAS. CAS during EVT might be a feasible option to treat the extracranial ICA stenosis but randomised studies are warranted to prove non-inferiority or superiority.
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Affiliation(s)
- Sabine L Collette
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Michael P Rodgers
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Paul J Nederkoorn
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Gert J de Borst
- University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Gert Jan R Luijckx
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Charles B L M Majoie
- Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Aad van der Lugt
- Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Reinoud P H Bokkers
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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11
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Pop R, Severac F, Hasiu A, Mihoc D, Mangin PH, Chibbaro S, Simu M, Tudor R, Gheoca R, Quenardelle V, Wolff V, Beaujeux R. Conservative versus aggressive antiplatelet strategy for emergent carotid stenting during stroke thrombectomy. Interv Neuroradiol 2023; 29:268-276. [PMID: 35253529 PMCID: PMC10369108 DOI: 10.1177/15910199221083112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is no consensus regarding optimal antiplatelet regimen for emergent carotid stenting during stroke thrombectomy. We aimed to assess the safety and efficacy of an aggressive periprocedural antiplatelet strategy focused on preserving stent patency, in comparison with conservative antiplatelet strategy consisting of aspirin monotherapy. MATERIALS AND METHODS Retrospective review of a prospectively collected database in a comprehensive stroke center, including all cases of emergent carotid stenting for tandem lesions stroke between 01.03.2012-01.06.2021. Aggressive antiplatelet strategy consisted of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel loading doses, with added intravenous (IV) tirofiban if in-stent thrombosis was observed during thrombectomy. Clinical and radiological outcomes were compared between conservative and aggressive antiplatelet treatment groups using inverse probability of treatment weighting (IPTW) analysis based on propensity scores. RESULTS We included 132 cases (76.5% atheroma, 22.7% dissection, 0.7% carotid web). Forty-five patients (34%) cases received conservative antiplatelet therapy. The remaining 87 (65.9%) received aggressive antiplatelet therapy: 66 (75.8%) treated with DAPT, 21 (24.1%) with DAPT and tirofiban. Periprocedural heparin was avoided in all cases. In adjusted analysis of the weighted samples, aggressive antiplatelet strategy was associated with improved carotid stent patency (aOR 0.23, 95% CI 0.07-0.80, p = 0.021), higher proportion of moderate clinical outcome (mRS ≤ 3, aOR 2.72, 95% CI 1.01-7.30, p = 0.04), with no significant differences in mortality and hemorrhagic transformation (HT) rates. CONCLUSIONS In this retrospective study, aggressive periprocedural antiplatelet strategy led to improved stent patency and clinical outcomes, without increased HT. Further prospective randomized research is warranted to identify the optimal combination of antiplatelet agents for emergent carotid stenting in the setting of acute stroke.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - François Severac
- Public Healthcare Department, Strasbourg University Hospitals, Strasbourg, France
| | - Anca Hasiu
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Dan Mihoc
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
| | - Pierre H Mangin
- University of Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S1255, FMTS, Strasbourg, France
| | - Salvatore Chibbaro
- Neurosurgery Department, Strasbourg University Hospitals, Strasbourg, France
| | - Mihaela Simu
- Neurology Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Raluca Tudor
- Neurology Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - Roxana Gheoca
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | | | - Valérie Wolff
- Stroke Unit, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l’Image, Strasbourg, France
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12
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Diana F, Romoli M, Toccaceli G, Rouchaud A, Mounayer C, Romano DG, Di Salle F, Missori P, Zini A, Aguiar de Sousa D, Peschillo S. Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:428-432. [PMID: 35428740 DOI: 10.1136/neurintsurg-2022-018683] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Francesco Diana
- Neuroradiology, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Giada Toccaceli
- Emergency Neurosurgery, Ospedale Civile 'Santo Spirito', Pescara, Italy
| | - Aymeric Rouchaud
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | - Charbel Mounayer
- Interventional Neuroradiology, University Hospital Centre of Limoges, Limoges, France
- BioEMXLim, University of Limoges Medical Faculty, Limoges, France
| | | | - Francesco Di Salle
- Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Fisciano, Italy
| | - Paolo Missori
- Human Neurosciences, Neurosurgery, University of Rome La Sapienza, Rome, Italy
| | - Andrea Zini
- Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Diana Aguiar de Sousa
- Neurosciences and Mental Health, Neurology Service, Hospital de Santa Maria/CHULN, University of Lisbon, Santa Maria, Portugal
| | - Simone Peschillo
- Surgical Medical Sciences and Advanced Technologies "G.F. Ingrassia" - Endovascular Neurosurgery, University of Catania, Catania, Italy
- Neurosurgery, Pia Fondazione Cardinale G Panico Hospital, Tricase, Italy
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13
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Safety and Efficacy of Carotid Artery Stenting with the CGuard Double-layer Stent in Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:237-244. [PMID: 36070140 PMCID: PMC9449946 DOI: 10.1007/s00062-022-01209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 07/30/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Double-layer stents show promising results in preventing periinterventional and postinterventional embolic events in elective settings of carotid artery stenting (CAS). We report a single-center experience with the CGuard stent in the treatment of acute ischemic stroke (AIS) due to symptomatic internal carotid artery (ICA) stenosis or occlusion with or without intracranial occlusion. METHODS We retrospectively analyzed all patients who received a CGuard stent in the setting of AIS at our institution. Neuroimaging and clinical data were analyzed with the following primary endpoints: technical feasibility, acute and delayed stent occlusion or thrombosis, distal embolism, symptomatic intracranial hemorrhage (sICH) and functional outcome at 3 months. RESULTS In 33 patients, stenting with the CGuard was performed. Stent deployment was successful in all patients (28 with tandem occlusions, 5 with isolated ICA occlusion). Transient acute in-stent thrombus formation occurred in three patients (9%) without early stent occlusion. Delayed, asymptomatic stent occlusion was seen in 1 patient (3%) after 49 days. Asymptomatic periinterventional distal emboli occurred in 2 patients (6%), 1 patient experienced a transient ischemic attack 79 days after the procedure and 1 patient (3%) developed sICH. Favorable clinical outcome (mRS 0-2) at 3 months was achieved in 12 patients (36%) and the mortality rate was 24%. CONCLUSION The CGuard use in emergencies was technically feasible, the safety has to be confirmed by further multicentric studies.
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14
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Yamashita S, Imahori T, Koyama J, Tanaka K, Okamura Y, Arai A, Iwahashi H, Mori T, Onobuchi K, Sasayama T. Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke. Vasc Endovascular Surg 2023; 57:137-148. [PMID: 36189731 DOI: 10.1177/15385744221130865] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Among tandem occlusions, atherosclerotic cervical internal carotid artery occlusion (ACICAO) can be technically challenging and associated with its unique complications. We evaluated our experience with endovascular treatment (EVT) of ACICAO in the setting of acute ischemic stroke. METHODS In total, 154 consecutive patients who underwent EVT for acute anterior circulation stroke at our institute were retrospectively reviewed. Patients with tandem ACICAO were analyzed in this study. Procedures, recanalization rates, complications, and prognoses were evaluated. RESULTS Ten patients (6%) of all 154 patients had ACICAO. In nine (90%) of the 10 patients, cervical lesions were successfully crossed and intervened upon. Four patients underwent stenting and five underwent angioplasty alone, followed by intracranial procedure. Eight patients (80%) achieved successful recanalization following mechanical thrombectomy for intracranial occlusion. However, one patient had massive subarachnoid hemorrhage during the procedure and another patient developed massive intracranial hemorrhage after EVT, both after stenting. Four of the five patients who initially underwent angioplasty alone subsequently underwent staged endarterectomy or stenting for residual stenosis on or after the next day. The single patient in whom the cervical lesion could not be crossed and another with reocclusion after EVT underwent a rescue bypass procedure due to persistent ischemic symptoms. After 90 days, four patients (40%) were functionally independent (modified Rankin scale score 0-2). CONCLUSIONS Our experience suggests that EVT for ACICAO is technically feasible; however, it involves the potential risk of several significant complications. To avoid serious hemorrhagic complications, cervical lesions may be better treated with angioplasty alone first.
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Affiliation(s)
- Shunsuke Yamashita
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Taichiro Imahori
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Junji Koyama
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Yusuke Okamura
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Atsushi Arai
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | | | - Tatsuya Mori
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kana Onobuchi
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan
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15
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Hebert D, Elder TA, Adel JG. Emergent carotid endarterectomy and mechanical thrombectomy in tandem occlusion. Surg Neurol Int 2022; 13:521. [DOI: 10.25259/sni_740_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Acute tandem occlusions, or occlusions of the extracranial portion of the internal carotid artery (ICA) with concurrent thromboembolism of the intracranial ICA or middle cerebral artery, poses a major clinical challenge, with patients suffering worse outcomes compared to those with single occlusions. Management of these lesions generally includes a combination of mechanical thrombectomy (MT) of the intracranial occlusion and stenting of the extracranial carotid lesion. In this manuscript, we describe a successful surgical method for achieving revascularization of tandem occlusions in the rare circumstance that the proximal lesion cannot be crossed endovascularly to gain intracranial access.
Methods:
Despite using our institution’s standard protocol for achieving revascularization of such lesions, the extracranial occlusion could not be crossed endovascularly, and the case was converted to an emergent carotid endarterectomy (CEA) in the operating room. Once the endarterectomy was complete, intraoperative MT was performed before cervical incision closure to revascularization.
Results:
The patient recovered well postoperatively and was discharged with NIHSS of 2 due to minor facial palsy and minor dysarthria. Thirty-day follow-up revealed resolution of the prior neurologic deficits and an mRS of 1.
Conclusion:
Emergent CEA should be considered in the rare circumstance of being unable to cross the cervical occlusion during management of acute ischemic stroke with tandem occlusion.
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Affiliation(s)
- Danielle Hebert
- Department of General Surgery, Central Michigan University College of Medicine, Michigan, United States
| | - Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Joseph G. Adel
- Department of Neuroscience, Ascension St. Mary’s Hospital, Saginaw, Michigan, United States
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16
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Min X, Du J, Bai X, Wei T, Dmytriw AA, Patel AB, Zhang X, Xu X, Feng Y, Wang T, Wang X, Yang K, Hu W, Yi T, Chen W, Jiao L. Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:757665. [PMID: 35095720 PMCID: PMC8790816 DOI: 10.3389/fneur.2021.757665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I 2 statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.
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Affiliation(s)
- Xiaoli Min
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital, Kunming Medical University, Kunming, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianhua Du
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wei
- Library, Kunming Medical University, Kunming, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiwu Hu
- Department of Neurology, The First Traditional Chinese Medicine Hospital of Chengde, Chengde, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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17
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Dajles A, Garg A, Galecio-Castillo M, Patterson M, Zaidat O, Ortega-Gutierrez S. Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e022335. [PMID: 35023353 PMCID: PMC9238531 DOI: 10.1161/jaha.121.022335] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite thrombectomy having become the standard of care for large-vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes' associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta-analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3-month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random-effects model was used for analysis. Thirty-four studies were included in our systematic review and 9 in the meta-analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24-3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26-2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05-2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.
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Affiliation(s)
- Cynthia B Zevallos
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Mudassir Farooqui
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Darko Quispe-Orozco
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Alan Mendez-Ruiz
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Andres Dajles
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | - Aayushi Garg
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA
| | | | - Mary Patterson
- Department of Neurology Mercy HealthSt. Vincent Hospital Toledo OH
| | - Osama Zaidat
- Department of Neurology Mercy HealthSt. Vincent Hospital Toledo OH
| | - Santiago Ortega-Gutierrez
- Department of Neurology University of Iowa Hospitals and Clinics Iowa City IA.,Department of Neurosurgery University of Iowa Hospitals and Clinics Iowa City IA.,Department of Radiology University of Iowa Hospitals and Clinics Iowa City IA
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18
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Lee CW, Chen KW, Lin YH, Hsu CH, Lu CJ, Tang SC, Chiang PY. Balloon Angioplasty Followed by Aspiration of Large-Vessel Occlusion (BAFALO): An efficient and protective treatment of tandem occlusion. FORMOSAN JOURNAL OF SURGERY 2022. [DOI: 10.4103/fjs.fjs_34_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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19
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Cheng Z, Rajah GB, Gao J, Geng X, Ding Y. Passing Extracranial Artery Occlusion by Intermediate Catheter With Expanding Microballoon (PEACE): A Novel Endovascular Therapy in Acute Tandem Occlusion Stroke. J Endovasc Ther 2021; 29:790-797. [PMID: 34894849 DOI: 10.1177/15266028211064818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Endovascular treatment of atherosclerotic tandem occlusions in acute ischemic stroke (AIS) is a matter of debate. This article reports a single-center experience using an intermediate catheter with microballoon for treatment of tandem occlusions. METHODS A total of 151 AIS patients with large vessel occlusion received endovascular therapy and a consecutive series of patients (n = 26) who suffered from tandem cervical intracranial occlusions were treated using the Passing Extracranial Artery Occlusion by Intermediate Catheter with Expanding Microballoon (PEACE) technique. Intracranial recanalization was achieved by aspiration or stent retriever and then emergency stenting was performed for extracranial internal carotid artery (ICA) lesion. Demographic, clinical characteristics, procedural details of endovascular therapy, and prognosis outcome were assessed. The outcomes of tandem occlusion group were compared with isolated intracranial occlusion group (n = 122) and previous studies. RESULTS As compared to isolated intracranial occlusion groups, only a few patients suffered from atrial fibrillation (7.7% vs 38.5%, p<0.01) in tandem occlusions group. A larger proportion of patients (61.5% vs 29.5%) had tandem occlusions in which extracranial ICA occlusion was combined with intracranial terminus occlusion in ICA (p<0.01). 46.2% of tandem occlusions patients achieved intracranial recanalization by aspiration alone versus 15.6% in patients with isolated intracranial occlusion (p<0.01). In tandem occlusion patients treated with PEACE, 92.3% achieved successful reperfusion (thrombolysis in cerebral infarct [TICI] ≥2b). The median time from puncture to recanalization was 51 minutes (interquartile range [IQR], 41-66). 67.6% favorable functional prognosis (modified Rankin score [mRS], 0-2) was seen, with 11.5% mortality and 3.8% of symptomatic intracerebral hemorrhage (sICH) at 90 days. These outcomes are all consistent or better than previously reported studies performed for tandem occlusion. CONCLUSIONS Endovascular therapy using the PEACE technique with intermediate catheter and lined expanding microballoon is safe, efficient, and fast in the treatment of atherosclerotic tandem occlusion patients.
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Affiliation(s)
- Zhe Cheng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Gary B Rajah
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.,Department of Neurosurgery, Munson Healthcare, Traverse City, MI, USA
| | - Jie Gao
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, School of Medicine, Wayne State University, Detroit, MI, USA
| | - Yuchuan Ding
- China-America Institute of Neuroscience, Beijing Luhe Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, School of Medicine, Wayne State University, Detroit, MI, USA
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20
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Al-Bayati AR, Nogueira RG, Haussen DC. Carotid Artery Stenting: Applications and Technical Considerations. Neurology 2021; 97:S137-S144. [PMID: 34785612 DOI: 10.1212/wnl.0000000000012802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/03/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW To examine current understanding of diverse etiologies of extracranial carotid disease, including clinical and imaging manifestations as well as treatment approaches. RECENT FINDINGS Increasing availability of advanced cerebrovascular imaging modalities continues to elucidate atherosclerotic and nonatherosclerotic carotid steno-occlusive disease as a common culprit of cerebral ischemia. Individualized treatment strategies targeting each etiologic subset would optimize preventive measures and minimize recurrence of cerebral ischemia. SUMMARY Ischemic stroke is a prominent cause of mortality and long-term disability worldwide. The magnified effect of carotid disease warrants constant and close inspection.
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Affiliation(s)
- Alhamza R Al-Bayati
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
| | - Raul G Nogueira
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Diogo C Haussen
- From the Department of Neurology and Radiology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
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21
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Turowski B, Caspers J. Radiologische Interventionen bei Schlaganfall. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00907-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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22
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Yeo LLL, Jing M, Bhogal P, Tu T, Gopinathan A, Yang C, Tan BYQ, Arnberg F, Sia CH, Holmin S, Andersson T. Evidence-Based Updates to Thrombectomy: Targets, New Techniques, and Devices. Front Neurol 2021; 12:712527. [PMID: 34566856 PMCID: PMC8459011 DOI: 10.3389/fneur.2021.712527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/30/2021] [Indexed: 01/23/2023] Open
Abstract
Endovascular thrombectomy (EVT) has been validated in several randomized controlled trials in recent years for its efficacy in the treatment of acute ischemic strokes (AIS) and is now the standard of care according to international guidelines. However, in about 20% of EVT procedures, recanalization is not achieved, and over 50% of patients who undergo EVT still do not have good functional outcome. In this article, we provide an extensive review of the latest evidence and developments in the field of EVT, with particular focus on the factors that improve patient outcomes. These factors include new and adjunctive techniques such as combination of direct aspiration and stent retriever, intra-arterial urokinase or 2b/3a inhibitors, rescue stenting, as well as novel devices including balloon guide catheters and the newer generations of aspiration catheters and stent retrievers. We also examined the latest notion of using first-pass effect (FPE) as the target to achieve during EVT, which has been associated with an improved functional outcome. While the field of EVT has been rapidly evolving, further research is required in specific AIS patient populations such as those with large ischemic core, late presentation beyond 24 h, posterior circulation strokes, and with distal medium vessel occlusion or tandem lesions to better assess its efficacy and safety.
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Affiliation(s)
- Leonard L L Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mingxue Jing
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Pervinder Bhogal
- Department of Neuroradiology, St. Bartholomew's and the Royal London Hospital, London, United Kingdom
| | - Tianming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Benjamin Y Q Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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23
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Mizowaki T, Fujita A, Imura J, Nakahara M, Tanaka H, Takaishi Y, Kondoh T. Ostial common carotid artery occlusion and balloon-mounted stenting: Implication of embolic protection device in tandem lesion. Radiol Case Rep 2021; 16:2783-2786. [PMID: 34367395 PMCID: PMC8326589 DOI: 10.1016/j.radcr.2021.06.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 11/18/2022] Open
Abstract
Ostial common carotid artery (CCA) stenosis is rare, compared to extracranial internal carotid artery bifurcation lesions. In cases of a tandem lesion, the proximal lesion usually involves the extracranial internal carotid artery, and the ostial CCA is rarely implicated. A 69-year-old woman who underwent 3 months of antiplatelet therapy for asymptomatic, right ostial, severely calcified CCA stenosis presented with sudden onset left hemiparesis. Radiographic examination revealed an ostial CCA-intracranial artery tandem lesion. After intracranial revascularization using a clot retrieval stent, we performed the endovascular treatment with a balloon-mounted stent using an embolic protection device. This procedure may be superior to others because it is possible to achieve early intracranial revascularization and prevent distal embolism during the complete treatment of proximal lesions.
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Affiliation(s)
- Takashi Mizowaki
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, Kobe, Hyogo, 654-0048, Japan
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Jun Imura
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, Kobe, Hyogo, 654-0048, Japan
| | - Masahiro Nakahara
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, Kobe, Hyogo, 654-0048, Japan
| | - Hirotomo Tanaka
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, Kobe, Hyogo, 654-0048, Japan
| | - Yoshiyuki Takaishi
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, Kobe, Hyogo, 654-0048, Japan
| | - Takeshi Kondoh
- Department of Neurosurgery, Shinsuma General Hospital, 3-1-14 Kinugake-cho, Suma-ku, Kobe, Hyogo, 654-0048, Japan
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24
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Gigliotti MJ, Sweid A, El Naamani K, Patel N, Cockroft KM, Park C, Kanekar S, Church EW, Tjoumakaris SI, Simon SD. Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study. World Neurosurg 2021; 153:e237-e243. [PMID: 34175489 DOI: 10.1016/j.wneu.2021.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neel Patel
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christian Park
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Sangam Kanekar
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ephraim W Church
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Scott D Simon
- Department of Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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25
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Pop R, Hasiu A, Mangin PH, Severac F, Mihoc D, Nistoran D, Manisor M, Simu M, Chibbaro S, Gheoca R, Quenardelle V, Rouyer O, Wolff V, Beaujeux R. Postprocedural Antiplatelet Treatment after Emergent Carotid Stenting in Tandem Lesions Stroke: Impact on Stent Patency beyond Day 1. AJNR Am J Neuroradiol 2021; 42:921-925. [PMID: 33602749 DOI: 10.3174/ajnr.a6993] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 11/10/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Postprocedural dual-antiplatelet therapy is frequently withheld after emergent carotid stent placement during stroke thrombectomy. We aimed to assess whether antiplatelet regimen variations increase the risk of stent thrombosis beyond postprocedural day 1. MATERIALS AND METHODS Retrospective review was undertaken of all consecutive thrombectomies for acute stroke with tandem lesions in the anterior circulation performed in a single comprehensive stroke center between January 9, 2011 and March 30, 2020. Patients were included if carotid stent patency was confirmed at day 1 postprocedure. The group of patients with continuous dual-antiplatelet therapy from day 1 was compared with the group of patients with absent/discontinued dual-antiplatelet therapy. RESULTS Of a total of 109 tandem lesion thrombectomies, 96 patients had patent carotid stents at the end of the procedure. The early postprocedural stent thrombosis rate during the first 24 hours was 14/96 (14.5%). Of 82 patients with patent stents at day 1, in 28 (34.1%), dual-antiplatelet therapy was either not initiated at day 1 or was discontinued thereafter. After exclusion of cases without further controls of stent patency, there was no significant difference in the rate of subacute/late stent thrombosis between the 2 groups: 1/50 (2%) in patients with continuous dual-antiplatelet therapy versus 0/22 (0%) in patients with absent/discontinued dual-antiplatelet therapy (P = 1.000). In total, we observed 88 patient days without any antiplatelet treatment and 471 patient days with single antiplatelet treatment. CONCLUSIONS Discontinuation of dual-antiplatelet therapy was not associated with an increased risk of stent thrombosis beyond postprocedural day 1. Further studies are warranted to better assess the additional benefit and optimal duration of dual-antiplatelet therapy after tandem lesion stroke thrombectomy.
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Affiliation(s)
- R Pop
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
| | - A Hasiu
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - P H Mangin
- Institut National de la Santé et de la Recherche Médicale (P.H.M.), University of Strasbourg, l'Établissement français du sang Grand-Est, BPPS UMR-S1255, Fédération de Médecine Translationnelle de Strasbourg, Strasbourg, France
| | - F Severac
- Public Healthcare Department (F.S.), Strasbourg University Hospitals, Strasbourg, France
| | - D Mihoc
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - D Nistoran
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Manisor
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
| | - M Simu
- Neurology Department (M.S.), Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - S Chibbaro
- Neurosurgery Department (S.C.), Strasbourg University Hospitals, Strasbourg, France
| | - R Gheoca
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Quenardelle
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - O Rouyer
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - V Wolff
- Stroke Unit (R.G., V.Q., O.R., V.W.), Strasbourg University Hospitals, Strasbourg, France
| | - R Beaujeux
- From the Interventional Neuroradiology Department (R.P., A.H., D.M., D.N., M.M., R.B.), Strasbourg University Hospitals, Strasbourg, France
- Institut de Chirurgie Minime Invasive Guidée par l'Image (R.P., R.B.), Strasbourg, France
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26
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Feil K, Herzberg M, Dorn F, Tiedt S, Küpper C, Thunstedt DC, Papanagiotou P, Meyer L, Kastrup A, Dimitriadis K, Liebig T, Dieterich M, Kellert L. Tandem Lesions in Anterior Circulation Stroke: Analysis of the German Stroke Registry-Endovascular Treatment. Stroke 2021; 52:1265-1275. [PMID: 33588589 DOI: 10.1161/strokeaha.120.031797] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Katharina Feil
- Department of Neurology (K.F., C.K., D.C.T., M.D., L.K.), Ludwig Maximilians Universität, Munich, Germany
- Department of Neurology and Stroke, Eberhard-Karls University, Tübingen, Germany (K.F.)
| | - Moriz Herzberg
- Institute of Neuroradiology (M.H., F.D., T.L.), Ludwig Maximilians Universität, Munich, Germany
- Department of Radiology, University Hospital, Würzburg, Germany (M.H.)
| | - Franziska Dorn
- Institute of Neuroradiology (M.H., F.D., T.L.), Ludwig Maximilians Universität, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), University Hospital (S.T., K.D.), Ludwig Maximilians Universität, Munich, Germany
| | - Clemens Küpper
- Department of Neurology (K.F., C.K., D.C.T., M.D., L.K.), Ludwig Maximilians Universität, Munich, Germany
| | - Dennis C Thunstedt
- Department of Neurology (K.F., C.K., D.C.T., M.D., L.K.), Ludwig Maximilians Universität, Munich, Germany
| | - Panagiotis Papanagiotou
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Greece (P.P.)
- Department of Neurology, Klinikum Bremen Mitte, Germany (P.P.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M.)
| | | | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research (ISD), University Hospital (S.T., K.D.), Ludwig Maximilians Universität, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology (M.H., F.D., T.L.), Ludwig Maximilians Universität, Munich, Germany
| | - Marianne Dieterich
- Department of Neurology (K.F., C.K., D.C.T., M.D., L.K.), Ludwig Maximilians Universität, Munich, Germany
- German Center for Vertigo and Balance Disorders (M.D.), Ludwig Maximilians Universität, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Germany (M.D.)
| | - Lars Kellert
- Department of Neurology (K.F., C.K., D.C.T., M.D., L.K.), Ludwig Maximilians Universität, Munich, Germany
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27
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Khripun AI, Salikov AV, Mironkov AB, Pryamikov AD, Asratyan SA, Suryakhin VS, Kamchatnov PR, Sazhina OA, Zakharov KA. [Results of endovascular treatment of acute tandem occlusion of internal carotid and middle cerebral arteries]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 120:5-10. [PMID: 33449526 DOI: 10.17116/jnevro20201201225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- A I Khripun
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A V Salikov
- Buyanov City Clinical Hospital, Moscow, Russia
| | - A B Mironkov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov City Clinical Hospital, Moscow, Russia
| | - A D Pryamikov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Buyanov City Clinical Hospital, Moscow, Russia
| | | | | | - P R Kamchatnov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O A Sazhina
- Buyanov City Clinical Hospital, Moscow, Russia
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28
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Zevallos CB, Farooqui M, Quispe-Orozco D, Mendez-Ruiz A, Patterson M, Below K, Martins SO, Mansour OY, Mont'Alverne F, Nguyen TN, Lemme L, Siddiqui AH, Fraser JF, Jadhav AP, Zaidat OO, Ortega-Gutierrez S. Proximal Internal Carotid artery Acute Stroke Secondary to tandem Occlusions (PICASSO) international survey. J Neurointerv Surg 2020; 13:1106-1110. [PMID: 33323501 DOI: 10.1136/neurintsurg-2020-017025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/19/2020] [Accepted: 11/24/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND While mechanical thrombectomy (MT) is the standard of care for large vessel occlusion strokes, the optimal management of tandem occlusions (TO) remains uncertain. We aimed to determine the current practice patterns among stroke physicians involved in the treatment of TO during MT. METHODS We distributed an online survey to neurovascular practitioners (stroke neurologists, neurointerventionalists, neurosurgeons, and radiologists), members of professional societies. After 2 months the site was closed and data were extracted and analyzed. We divided respondents into acute stenting and delayed treatment groups and responses were compared between the two groups. RESULTS We received 220 responses from North America (48%), Latin America (28%), Asia (15%), Europe (5%), and Africa (4%). Preferred timing for cervical revascularization varied among respondents; 51% preferred treatment in a subsequent procedure during the same hospitalization whereas 39% preferred to treat during MT. Angioplasty and stenting (41%) was the preferred technique, followed by balloon angioplasty and local aspiration (38%). The risk of intracerebral hemorrhage was the most compelling reason for not stenting acutely (68%). There were no significant differences among practice characteristics and timing groups. Most practitioners (70%) agreed that there is equipoise regarding the optimal endovascular treatment of cervical lesions in TO; hence, 77% would participate in a randomized controlled trial. CONCLUSIONS The PICASSO survey demonstrates multiple areas of uncertainty regarding the medical and endovascular management of TOs. Experts acknowledged the need for further evidence and their willingness to participate in a randomized controlled trial to evaluate the best treatment for the cervical TO lesion.
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Affiliation(s)
- Cynthia B Zevallos
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | - Alan Mendez-Ruiz
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mary Patterson
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Kristine Below
- Neurology, Mercy Health St Vincent Hospital, Toledo, Ohio, USA
| | - Sheila O Martins
- Neurology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ossama Y Mansour
- Neurology, Stroke and NeuroInterventional Unit, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | | | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Luis Lemme
- Interventional Neuroradiology, Centro Endovascular Neurologico Buenos Aires, Buenos Aires, Argentina
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | | | - Osama O Zaidat
- Neuroscience, St Vincent Mercy Hospital, Toledo, Indiana, USA
| | - Santiago Ortega-Gutierrez
- Division of Neurointerventional Surgery-Interventional Neuroradiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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29
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Nolan NM, Regenhardt RW, Koch MJ, Raymond SB, Stapleton CJ, Rabinov JD, Silverman SB, Leslie-Mazwi TM, Patel AB. Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions. J Stroke Cerebrovasc Dis 2020; 30:105478. [PMID: 33248344 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105478] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs. MATERIALS AND METHODS Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed. RESULTS From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency. CONCLUSIONS Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.
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Affiliation(s)
- Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Raymond
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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30
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Mayer L, Grams A, Freyschlag CF, Gummerer M, Knoflach M. Management and prognosis of acute extracranial internal carotid artery occlusion. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1268. [PMID: 33178800 PMCID: PMC7607089 DOI: 10.21037/atm-20-3169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute occlusion of the internal carotid artery is the underlying etiology in 4 to 15% of all ischemic strokes. The clinical presentation varies considerably ranging from asymptomatic occlusion to severe ischemic strokes. Substantial differences in the acute management of acute symptomatic internal carotid artery occlusions (ICAO) exists between centers. Thusly, we comprised a narrative review of the natural course of acute ICAO and of available treatment options [i.v. thrombolysis, endovascular thrombectomy and stenting, bypass between the superficial temporal and the middle cerebral arteries (MCA) and carotid endarterectomy (CEA)]. We found that very few randomized treatment trials have been performed in patients acute symptomatic ICAO. Most evidence stems from case series and observational studies. Especially in older studies the intracranial vessel status has rarely been considered. After revision of these studies we concluded that the mainstay of the acute management of acute symptomatic ICAO is i.v. thrombolysis when applied within the label and in combination with mechanical thrombectomy in case of intracranial large vessel occlusion. In cases without intracranial large vessel occlusion mechanical thrombectomy of acute ICAO is associated with a risk of distal embolization. More research on prognostic parameters is needed to better characterize the risk of decompensation of collateral flow and to better define the time-window of intervention. When mechanical thrombectomy fails or is not available, surgical approaches are an alternative in selected patients.
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Affiliation(s)
- Lukas Mayer
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Maria Gummerer
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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31
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Hellegering J, Uyttenboogaart M, Bokkers RPH, El Moumni M, Zeebregts CJ, van der Laan MJ. Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1278. [PMID: 33178810 PMCID: PMC7607118 DOI: 10.21037/atm-2020-cass-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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).
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Affiliation(s)
- Joyce Hellegering
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mostafa El Moumni
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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32
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Renú A, Blasco J, Laredo C, Llull L, Urra X, Obach V, López-Rueda A, Rudilosso S, Zarco F, González E, Guio JD, Amaro S, Chamorro A. Carotid stent occlusion after emergent stenting in acute ischemic stroke: Incidence, predictors and clinical relevance. Atherosclerosis 2020; 313:8-13. [PMID: 33002751 DOI: 10.1016/j.atherosclerosis.2020.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/02/2020] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Emergent stent placement may be required during neurothrombectomy. Our aim was to investigate the incidence, predictors and clinical relevance of early extracranial carotid stent occlusion following neurothrombectomy. METHODS We retrospectively analyzed a cohort of 761 consecutive neurothrombectomies performed at our center between May 2010 and August 2018, from whom a total of 106 patients had acute internal carotid artery occlusions. Early stent occlusion was defined as complete vessel occlusion within 24 h of neurothrombectomy. Clinical outcome was evaluated at day 90 with the modified Rankin Score scale (mRS). Pretreatment, procedural and outcome variables were recorded and analyzed using logistic regression. RESULTS Carotid stenting was performed in 99 (13%) patients. Of those, 22 (22%) had early stent occlusion at follow-up. Stent occlusion was associated with a lower use of post-stenting angioplasty [adjusted OR (aOR) = 11.2, 95%CI = 2.49-50.78, p = 0.002)], increased residual intrastent stenosis (aOR = 2.1, 95%CI = 1.38-3.06, p < 0.001) and unsuccesful intracranial recanalization (modified TICI score 0-2a) (aOR = 13.5, 95%CI = 1.97-92.24, p = 0.008). Stent occlusion was associated with poor clinical outcome at day 90 (poorer mRS shift, aOR = 3.9, 95%CI = 1.3-11.3, p = 0.014; mRS>2, aOR = 6.3, 95%CI = 1.8-22.7, p = 0.005), and with an increased rate of symptomatic intracranial hemorrhage at 24 h (14% versus 1%, p = 0.033). CONCLUSIONS Early carotid stent occlusion occurred in one out of five neurothrombectomies and was associated with periprocedural factors that included increased residual intrastent stenosis, a lower use of post-stenting angioplasty and unsuccessful intracranial recanalization. Further investigation is warranted for the evaluation of strategies aimed to prevent carotid stent occlusion.
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Affiliation(s)
- Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Jordi Blasco
- Radiology Department, Hospital Clinic, Barcelona, Spain
| | - Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Victor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Elisabet González
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - José David Guio
- Radiology Department, Hospital General Universitario, Ciudad Real, Spain
| | - Sergio Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
| | - Angel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
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33
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Park JS, Lee JM, Kwak HS, Chung GH. Endovascular treatment of acute carotid atherosclerotic tandem occlusions: Predictors of clinical outcomes as technical aspects and location of tandem occlusions. J Stroke Cerebrovasc Dis 2020; 29:105090. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/30/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022] Open
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34
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Mizowaki T, Fujita A, Inoue S, Kurihara E. Endovascular Treatment for Vertebrobasilar Artery Tandem Occlusion Beyond 24 Hours From Onset of Stroke-Case Report. Vasc Endovascular Surg 2020; 55:77-80. [PMID: 32869715 DOI: 10.1177/1538574420953953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report a case in which endovascular treatment (EVT) was performed for vertebral and basilar artery (VA and BA) tandem occlusion beyond 24 hours from onset of stroke. A 78-year-old man was admitted to our institution with dysarthria and disturbance of gait. MRI revealed occlusion of the BA with acute ischemic change in bilateral cerebellum and brain stem. At 36 hours after onset and 30 hours after administration, EVT was performed because of deteriorating neurological symptom. Successful revascularization was achieved with percutaneous transluminal angioplasty for VA and thrombectomy for BA occlusion. The neurological symptoms were improved in postoperative course.
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Affiliation(s)
- Takashi Mizowaki
- Department of Neurosurgery, Junshin Hospital, Kakogawa, Hyogo, Japan
| | - Atsushi Fujita
- Department of Neurosurgery, 12885Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Satoshi Inoue
- Department of Neurosurgery, Junshin Hospital, Kakogawa, Hyogo, Japan
| | - Eiji Kurihara
- Department of Neurosurgery, Junshin Hospital, Kakogawa, Hyogo, Japan
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35
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Weinberg JH, Sweid A, Sajja K, Abbas R, Asada A, Kozak O, Mackenzie L, Choe H, Gooch MR, Herial N, Tjoumakaris S, Zarzour H, Rosenwasser RH, Jabbour P. Posterior circulation tandem occlusions: Classification and techniques. Clin Neurol Neurosurg 2020; 198:106154. [PMID: 32829201 DOI: 10.1016/j.clineuro.2020.106154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Posterior circulation tandem occlusions are poorly characterized in current literature. Data regarding endovascular approaches and outcomes in this patient subgroup is extremely limited. METHODS We conducted a retrospective analysis of a prospectively maintained database and identified 17 patients with posterior circulation tandem occlusions who underwent mechanical thrombectomy between 2014 and 2019. RESULTS Of 17 patients with posterior circulation tandem occlusion, the mean age was 55.76 ± 11.8 with 35.3% female. The mean NIHSS score on presentation was 17.2 ± 9.2. Tissue plasminogen activator was administered in 7 (41.2%) patients, stent-retrievers alone were used in 2 (11.8%), aspiration catheters alone were used in 2 (11.8%), a combination was used 12 (70.6%), and a self-expandable stent in 5 (29.4%). The mean number of device passes was 2.24 ± 2.02, recanalization failure occurred in 4 (23.5%) patients, the mean time from stroke onset to puncture was 6.9 ± 2.4 h, and the mean time from puncture to recanalization was 59.3 ± 26.6 min. Postprocedural symptomatic ICH occurred in 1 (5.9 %) patient, periprocedural ICH/SAH occurred in 2 (11.8%), periprocedural distal emboli occurred in 0 (0%), periprocedural vessel dissection occurred in 1 (5.9%), and periprocedural vessel perforation occurred in 1 (5.9%) patient. TICI score>2b was achieved in 13 (76.5%) patients. An improvement in NIHSS>3 at discharge occurred in 10 (58.8%) patients, and good outcomes (mRS score < 2) occurred in 7 (41.2%). The mean length of stay was 11.6 ± 12.2 days, and the mortality rate was 41.2%. CONCLUSION Endovascular intervention with mechanical thrombectomy is safe and feasible in patients with posterior circulation tandem occlusions.
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Affiliation(s)
- Joshua H Weinberg
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Rawad Abbas
- Faculty of Medicine, American University of Beirut Medical Center, Beirut 00000, Lebanon.
| | - Ashlee Asada
- Drexel University, College of Medicine, Drexel University, Philadelphia, PA, USA.
| | - Osman Kozak
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Larami Mackenzie
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Hana Choe
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Nabeel Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut street 3rd Floor, Philadelphia 19107, PA USA.
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36
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Elective carotid stenting after urgent best medical treatment suppresses recurrent stroke in patients with symptomatic carotid artery severe stenosis. Clin Neurol Neurosurg 2020; 195:105855. [DOI: 10.1016/j.clineuro.2020.105855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 11/17/2022]
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37
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Yamada K, Yoshimura S, Yoshida K, Uchida K, Shirakawa M, Kawasaki M, Miura M, Ishii A, Kataoka H, Miyamoto S. Carotid Artery Stenting Using a Double-layer Micromesh Stent. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:407-412. [PMID: 37502654 PMCID: PMC10370536 DOI: 10.5797/jnet.ra.2020-0066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/10/2020] [Indexed: 07/29/2023]
Abstract
Carotid artery stenting (CAS) has recently emerged as a potential alternative to carotid endarterectomy (CEA) in Japan. However, one of its disadvantages is the higher incidence of ischemic complications than CEA, such as distal embolism during or after the procedure. Plaque protrusion (PP) through the stent strut after deployment of the stent has been suggested as one of the major causes of distal embolism, especially in patients with unstable plaques. The need for increased plaque coverage to reduce the risk of PP through the stent struts has led to the development of a double-layer micromesh stent (micromesh stent) system. This stent system has already been used clinically in European countries with good short- to medium-term follow-up results. Also clinical trials evaluating micromesh stents have been completed in Japan. Hence, usefulness of the micromesh stent for CAS is expected. According to the results of several clinical studies, CAS with the double-layer micromesh stent has the potential to minimize distal embolism during or after the procedure even in patients with unstable plaques. However, it may not be suitable for emergency CAS at this point. Also, since results of only short- to medium-term follow-up have been reported, longer-term follow-up will be required in the near future.
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Affiliation(s)
- Kiyofumi Yamada
- Department of Neurosurgery, Kyoto University, Kyoto, Kyoto, Japan
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Masatomo Miura
- Department of Neurology, Kumamoto Red Cross Hospital, Kumamoto, Kumamoto, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University, Kyoto, Kyoto, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, Kyoto University, Kyoto, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University, Kyoto, Kyoto, Japan
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38
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Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142-1148. [PMID: 32499251 DOI: 10.3174/ajnr.a6582] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/17/2020] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- A Y Poppe
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.) .,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - G Jacquin
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - D Roy
- Radiology (Neuroradiology) (D.R.), Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C Stapf
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - L Derex
- Stroke Center (L.D.), Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7425 HESPER (L.D.), Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
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Gemmete JJ, Wilseck Z, Pandey AS, Chaudhary N. Treatment Strategies for Tandem Occlusions in Acute Ischemic Stroke. Semin Intervent Radiol 2020; 37:207-213. [PMID: 32419734 DOI: 10.1055/s-0040-1709207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Joseph J Gemmete
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
| | - Zachary Wilseck
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Department of Radiology, Michigan Medicine, Ann Arbor, Michigan.,Department of Neurosurgery, Michigan Medicine, Ann Arbor, Michigan
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40
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Bagley JH, Priest R. Carotid Revascularization: Current Practice and Future Directions. Semin Intervent Radiol 2020; 37:132-139. [PMID: 32419725 DOI: 10.1055/s-0040-1709154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Carotid stenosis is responsible for approximately 15% of ischemic strokes. Carotid revascularization significantly decreases patients' stroke risk. Carotid endarterectomy has first-line therapy for moderate-to-severe carotid stenosis after a series of pivotal randomized controlled trials were published almost 30 years ago. Revascularization with carotid stenting has become a popular and effective alternative in a select subpopulation of patients. We review the current state of the literature regarding revascularization indications, patient selection, advantages of each revascularization approach, timing of intervention, and emerging interventional techniques, such as transcarotid artery revascularization.
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Affiliation(s)
- Jacob H Bagley
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - Ryan Priest
- Dotter Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon
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Mizowaki T, Fujita A, Inoue S, Kuroda R, Urui S, Kurihara E, Hosoda K, Kohmura E. Outcome and effect of endovascular treatment in stroke associated with acute extracranial internal carotid artery occlusion: Single-center experience in Japan. J Stroke Cerebrovasc Dis 2020; 29:104824. [PMID: 32376201 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Positive data from several randomized controlled trials (RCTs) of endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (ACLVO) have emerged. However, little evidence exists on EVT for acute extracranial internal carotid artery (EC-ICA) occlusion. We therefore analysed the outcome and effect of EVT on AIS due to ACLVO caused by EC-ICA occlusion, including tandem occlusion compared with that caused by pure intracranial artery occlusion. METHODS A total of 135 consecutive AIS patients with ACLVO between July 2014 and December 2017 were identified. We retrospectively analysed the efficacy of EVT for ACLVO after introducing a stent retriever (SR). We classified ACLVO into the following categories: group A, intracranial artery occlusion without EC-ICA occlusion (pure intracranial artery occlusion), and group B, ipsilateral EC-ICA occlusion with/without intracranial artery occlusion. RESULTS In total, 65 patients were enrolled. Group A comprised 71% (46/65) of all cases. No difference was observed in terms of age, National Institute of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early Computed Tomography Score-Diffusion Weighted imaging (ASPECTS-DWI), several clinical time intervals, rate of successful revascularization (74% versus 84%), and rate of functional independence (42% versus 39%) between groups A and B. In all patients, an ASPECTS-DWI ≥6 and an onset-to-door time ≤6 h were associated with good outcome, whereas intracranial artery occlusion without EC-ICA occlusion (pure intracranial artery occlusion) was not. CONCLUSIONS The outcomes support the efficacy of EVT in stroke associated with acute EC-ICA occlusion. In the EVT of AIS due to ACLVO, there was no significant difference in the results between ipsilateral EC-ICA occlusion with/without intracranial artery occlusion and intracranial artery occlusion without EC-ICA occlusion (pure intracranial artery occlusion).
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Affiliation(s)
- Takashi Mizowaki
- Department of Neurosurgery, Junshin Hospital, 865-1 Befu-cho, Kakogawa City, Hyogo 675-0122, Japan.
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe City, Hyogo, Japan.
| | - Satoshi Inoue
- Department of Neurosurgery, Junshin Hospital, 865-1 Befu-cho, Kakogawa City, Hyogo 675-0122, Japan.
| | - Ryuichi Kuroda
- Department of Neurosurgery, Junshin Hospital, 865-1 Befu-cho, Kakogawa City, Hyogo 675-0122, Japan.
| | - Seishirou Urui
- Department of Neurosurgery, Junshin Hospital, 865-1 Befu-cho, Kakogawa City, Hyogo 675-0122, Japan.
| | - Eiji Kurihara
- Department of Neurosurgery, Junshin Hospital, 865-1 Befu-cho, Kakogawa City, Hyogo 675-0122, Japan.
| | - Kohkichi Hosoda
- Department of Neurosurgery, Kobe City Nishi-Kobe Medical Center, Kobe City, Hyogo, Japan.
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe City, Hyogo, Japan.
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The "distal-to-proximal" strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience. Neuroradiology 2020; 62:867-876. [PMID: 32242265 DOI: 10.1007/s00234-020-02412-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Data on posterior circulation tandem occlusions in acute ischemic stroke are scarce: recognition may be challenging and little is known about optimal treatment strategy. We report our endovascular treatment strategy for posterior circulation tandem occlusion. METHODS Consecutive patients with posterior circulation tandem occlusions in our centre were enrolled retrospectively. The preferred strategy was "distal-to-proximal" strategy, which means opening the distal occlusion first followed by treatment of the proximal pathology. The imaging characteristics, treatment strategy, clinical outcomes, and complications of patients with posterior circulation tandem occlusions were analyzed. RESULTS In total, 21 patients with posterior circulation tandem occlusions were enrolled in the study, which accounted for 23.6% of patients with posterior circulation stroke in our centre. The mean age was 60 years (range 32 to 80), and median pre-procedure NIHSS score was 28 (interquartile range: 13-31). Eighteen patients (85.7%) had vertebrobasilar artery tandem occlusions and 3 (14.3%) had basilar artery to basilar artery tandem occlusions. All distal occlusions were successfully recanalized (modified TICI 2b/3). Two (9.5%) of the proximal lesions were not treated. A total of 57.1% of the patients had stents implanted on the proximal occlusions. The rate of mRS 0-3 at 3 months was 57.1% and the mortality rate was 19.0%. CONCLUSION In patients with acute ischaemic stroke caused by posterior circulation tandem occlusions, we favor "distal-to-proximal" strategy based on the positive results in this small series. Nevertheless, a more extensive study is required to explore the optimal treatment strategy further.
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Parthasarathy R, Gupta V. Mechanical Thrombectomy: Answering Unanswered. Ann Indian Acad Neurol 2020; 23:13-19. [PMID: 32055116 PMCID: PMC7001454 DOI: 10.4103/aian.aian_359_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The stroke physician community witnessed a major “breakthrough” in acute stroke therapeutics when the results of the first of the many positive trials, “MR CLEAN,” were published showing a significant absolute benefit in favor of mechanical thrombectomy in patients with large vessel occlusion (LVO). Thereafter, the investigators of ESCAPE, SWIFT PRIME, REVASCAT, THRACE, and PISTE concluded the same. Based on the initial studies, the American Stroke Association amended the 2013 guidelines in 2015 to include mechanical thrombectomy as the standard of care in patients with LVO presenting within six hours. In the past year, the horizon was further expanded when two major landmark trials, DAWN and DEFUSE 3, established the benefit of mechanical thrombectomy in the delayed window period in a select group of patients. It further led to the inclusion of the delayed window period treatment strategies in the 2018 guidelines. However, there are many unanswered questions in scenarios like small deficit with LVO, borderline large core, wake-up stroke (WUS), tandem occlusion, imaging of choice, conscious sedation (CS) versus general anesthesia (GA), and choice of technique. In our review, we aim to answer these questions along with a schematic representation of current techniques used in stroke thrombectomy.
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Affiliation(s)
- Rajsrinivas Parthasarathy
- Department of Stroke and Neurointerventional Surgery, Artemis Agrim Institute of Neuroscience, Gurgaon, India
| | - Vipul Gupta
- Department of Stroke and Neurointerventional Surgery, Artemis Agrim Institute of Neuroscience, Gurgaon, India
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Vu-Dang L, Nguyen QA, Nguyen-Thi-Thu T, Tran AT, Le-Chi C, Le-Hoang K, Nguyen-Tat T, Nguyen-Huu A, Pham-Minh T, Chu-Dinh T, Chu DT. Endovascular Treatment for Acute Tandem Occlusion Stroke: Results from Case Series of 17 Patients. Ann Indian Acad Neurol 2020; 23:78-83. [PMID: 32055126 PMCID: PMC7001425 DOI: 10.4103/aian.aian_464_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background and Purpose: Tandem occlusive lesion, a major challenge for thrombectomy in acute anterior circulation strokes, is poorly represented in randomized trials. This study demonstrates the findings of thrombectomy in tandem occlusion and comparative analysis of two treatment groups (extracranial versus intracranial first subgroup). Patients and Methods: We enrolled and divided 17 patients with acute tandem ischemic stroke who received endovascular treatment into two groups. Group 1 with completed (100%) internal carotid artery (ICA) occlusion was treated by an extracranial stent, whereas Group 2 with severe (70%–99%) ICA occlusion was prioritized with intracranial thrombectomy. Data of clinical parameters, imaging and angiographic results, periprocedural complications, and results after 3 months were collected and analyzed. Results: The mean age of patients was 70.2 ± 8.8 years, and males accounted for 94.1%. The National Institutes of Health Stroke Scale and Alberta Stroke Program Early CT Score (ASPECTS) baseline were 16.6 ± 4.2 and 7.6 ± 1.1, respectively, with occlusive side was 52.9% on the right. Group 1 including ten cases (58.8%) was treated extracranial lesion with carotid stent before intracranial thrombectomy, and Group 2 with seven cases (41.2%) was prioritized intracranial thrombectomy. In total 17 procedures, there were ten stent retrievers (58.8%), four aspirations (23.5%), and three Solumbra (17.7%). No re-occlusion of carotid stent postoperation was recorded. The good revascularization (thrombolysis in cerebral infarction 2b-3) was archived in 82.4% of patients, while symptomatic hemorrhage was seen in 2 cases (11.8%). Three months after treatment, patients with favorable clinical outcome (Modified Rankin Scale ≤2) accounted for 47.1%. Conclusion: Our study determined a promising outcome with reasonable good recanalization and clinical recovery for endovascular intervention in tandem ischemic. In the subgroup of treatment, “extracranial stent first” had more complex disease with completed ICA occlusion which required longer procedure time may lead to worse outcome.
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Affiliation(s)
- Luu Vu-Dang
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Quang-Anh Nguyen
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | | | - Anh-Tuan Tran
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Cong Le-Chi
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Kien Le-Hoang
- Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | | | - An Nguyen-Huu
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam
| | - Thong Pham-Minh
- Radiology Faculty, Hanoi Medical University, Danang, Vietnam.,Radiology Center, Bach Mai University Hospital, Danang, Vietnam
| | - Thien Chu-Dinh
- Institute for Research and Development, Duy Tan University, Danang, Vietnam
| | - Dinh-Toi Chu
- Faculty of Biology, Hanoi National University of Education, Hanoi, Vietnam
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Zhang M, Hao JH, Lin K, Cui QK, Zhang LY. Combined surgical and interventional treatment of tandem carotid artery and middle cerebral artery embolus: A case report. World J Clin Cases 2020; 8:630-637. [PMID: 32110676 PMCID: PMC7031835 DOI: 10.12998/wjcc.v8.i3.630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 11/19/2019] [Accepted: 12/06/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The 2018 American Heart Association/American Stroke Association guidelines for early management of acute ischemic stroke recommend the use of retrievable stents for mechanical thrombectomy in patients with acute internal carotid artery or middle cerebral artery M1 occlusion that can be treated within 6 h from onset. For cases of carotid artery with ipsilateral middle cerebral artery tandem embolization, the operation is more complicated and challenging. We here report a case of a tandem embolism, and the anatomy of the aortic arch was complex. Direct carotid artery incision and thrombectomy can not only prevent the escape of the carotid embolus but also save time during establishment of the thrombectomy access.
CASE SUMMARY The patient was a 70-year-old man. He was admitted to hospital due to sudden inability to speak and inability to move his right limb for 3 h. Imaging confirmed a diagnosis of a tandem embolism in the left carotid artery with left M1 occlusion. Carotid artery incision thrombectomy combined with stent thrombectomy was performed. The operation was successful, and 24 h later the patient was conscious and mentally competent but had motor aphasia. His bilateral limb muscle strength level was 5, and his neurologic severity scores score was 2.
CONCLUSION Carotid artery incision thrombectomy combined with stenting for carotid artery plus cerebral artery tandem embolization is clinically feasible. For patients with a complicated aortic arch and an extremely tortuous carotid artery, carotid artery incision can be chosen to establish the interventional path.
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Affiliation(s)
- Meng Zhang
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Ji-Heng Hao
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Kai Lin
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Qing-Ke Cui
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
| | - Li-Yong Zhang
- Department of Neurosurgery, Liaocheng Brain Hospital, Liaocheng 252000, Shandong Province, China
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Miyauchi Y, Kamiya Y, Kuriki A, Kato Y, Wada T, Fujii T, Fukuda S, Komuro H. Utility of Coaxial Angioplasty-thrombectomy for Acute Tandem Occlusion of Intracranial and Extracranial Arteries. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:76-80. [PMID: 37502459 PMCID: PMC10370799 DOI: 10.5797/jnet.tn.2019-0047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/18/2019] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Yoshifumi Miyauchi
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Ayako Kuriki
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuta Kato
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takahide Wada
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takashi Fujii
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Saori Fukuda
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hiroyasu Komuro
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Complication Rates Using CASPER Dual-Layer Stents for Carotid Artery Stenting in Acute Stroke : A 3-Year Single Center Experience. Clin Neuroradiol 2019; 31:173-179. [PMID: 31822934 DOI: 10.1007/s00062-019-00860-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
Abstract
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.
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de Vries EE, Vonken EJ, Kappelle LJ, Toorop RJ, de Borst GJ. Short-Term Double Layer Mesh Stent Patency for Emergent or Elective Carotid Artery Stenting. Stroke 2019; 50:1898-1901. [DOI: 10.1161/strokeaha.118.024586] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Novel double layer micromesh stents have recently been introduced for treatment of patients with significant carotid stenosis. Strict evaluation of safety and patency of such novel devices is required both in elective and in emergency interventions. We report a single center experience with double layer mesh stents for carotid artery revascularization.
Methods—
Consecutive patients who underwent carotid artery stenting with a double layer mesh stent between June 2015 and September 2018 in our tertiary vascular referral center were included. Treatment indications were emergent carotid artery stenting for intracranial or extracranial carotid stenosis in patients undergoing intraarterial thrombectomy for acute ischemic stroke in the anterior circulation, or elective carotid artery stenting for significant symptomatic or asymptomatic stenosis. End points were postprocedural thrombotic stent occlusion and procedural stroke or death.
Results—
Fifty-four patients were included; 27 were treated for acute stroke with intracranial and extracranial (tandem) lesions and 27 for elective stenting. Follow-up imaging was available for 9/27 (33%) patients with acute stroke, and 19/27 (70%) electively treated patients. Five stent occlusions occurred, of which 2 were symptomatic with clinical deterioration within one day. Another patient deteriorated on postprocedural day one, but imaging of the carotids was not performed, and the stent turned out occluded on the 30-day duplex. All stent occlusions occurred in patients treated for acute stroke.
Conclusions—
This study suggests that occlusion of novel double layer mesh stents occurs in a considerable proportion of carotid artery stenting procedures performed in the emergency setting for acute stroke, with occlusion-related symptoms in half the cases. Future prospective studies should clarify the role of double layer mesh stents in this high-risk patient population.
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Affiliation(s)
- Evelien E. de Vries
- From the Departments of Vascular Surgery (E.E.d.V., R.J.T., G.J.d.B.), University Medical Center Utrecht, the Netherlands
| | - Evert J. Vonken
- Radiology (E.J.V.), University Medical Center Utrecht, the Netherlands
| | - L. Jaap Kappelle
- Neurology (L.J.K.), University Medical Center Utrecht, the Netherlands
| | - Raechel J. Toorop
- From the Departments of Vascular Surgery (E.E.d.V., R.J.T., G.J.d.B.), University Medical Center Utrecht, the Netherlands
| | - Gert J. de Borst
- From the Departments of Vascular Surgery (E.E.d.V., R.J.T., G.J.d.B.), University Medical Center Utrecht, the Netherlands
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Endovascular Recanalization of Acute Tandem Cervical Carotid and Intracranial Occlusions: Efficacy of Cervical Balloon Angioplasty Alone Then Intracranial Target Recanalization Strategy. World Neurosurg 2019; 126:e1268-e1275. [DOI: 10.1016/j.wneu.2019.02.240] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/22/2022]
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50
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Piechowiak EI, Kaesmacher J, Zibold F, Dobrocky T, Mosimann PJ, Jung S, Fischer U, Arnold M, Bellwald S, Heldner MR, Gralla J, Mordasini P. Endovascular treatment of tandem occlusions in vertebrobasilar stroke: technical aspects and outcome compared with isolated basilar artery occlusion. J Neurointerv Surg 2019; 12:25-29. [DOI: 10.1136/neurintsurg-2019-014825] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 11/03/2022]
Abstract
Background and purposeAcute basilar artery occlusion (BAO) is a devastating disease with a high rate of mortality and morbidity, and early recanalization is crucial to achieve a good prognosis. The best treatment strategy for BAO combined with a proximal stenosis (tandem occlusion) is not yet clear. Our study aimed to evaluate whether and how vertebrobasilar tandem occlusions can be treated effectively and safely compared with isolated BAO.Materials and methodsFifty-two patients with acute vertebrobasilar occlusive stroke treated with mechanical thrombectomy were identified in a prospective database from March 2010 to September 2016. We retrospectively analysed the clinical, technical, and functional outcomes of the patients.ResultsOf the 52 patients, 15 presented with a tandem occlusion, 14 with a single intracranial occlusion due to an underlying stenosis, and 23 with a single embolic BAO. Successful recanalization was achieved in all of the patients with tandem occlusions (modified Thrombolysis in Cranial Infarction 2b/3) and in 35 of 37 patients with a single BAO (with and without stenosis). A favourable outcome was achieved (modified Rankin Scale ≤2) in 8 of the 15 patients with a tandem occlusion compared with 4 of the 14 patients with a single BAO with underlying stenosis and 5 of the 23 patients with isolated embolic BAO (p=0.18).ConclusionsWe suggest that endovascular treatment of vertebrobasilar tandem occlusions is safe and feasible, with a high rate of good outcome.
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