Extracranial carotid artery stenting followed by intracranial stent-based thrombectomy for acute tandem occlusive disease

Acute carotid stenting versus non-stenting treatment of acute ischemic stroke due to tandem lesions: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness and safety of acute carotid stenting (ACS) in comparison to non-stenting interventions for patients experiencing acute ischemic stroke (AIS) caused by tandem lesions (TL).

METHODS

A systematic review of literature from PubMed, Embase, and Cochrane databases was conducted to identify relevant studies published up to October 10, 2023. The comparison between ACS and no stenting in patients with TL undergoing endovascular therapy (EVT) focused on outcomes, such as 90-day modified Rankin Scale (mRS) score, successful recanalization, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality.

RESULTS

The final analysis encompassed a total of 3,187 patients from 21 studies, with 1,786 patients classified as ACS patients and 1,401 as non-stent patients. The overall treatment effect favored the ACS group, as evidenced by their association with improved functional independence at 90 days (mRS 0-2) [relative risk (RR) = 1.18; 95% confidence interval (CI) 1.05-1.34; P < 0.05; I2 = 44%] and a higher rate of successful recanalization [modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b/3] (RR = 1.16; 95% CI 1.09-1.25; P < 0.05; I2 = 40%). The risk of sICH was not significantly different between the two groups (RR = 1.28; 95% CI 0.98-1.68; P > 0.05; I2 = 0%). Additionally, there was no significant difference in 90-day mortality between the two groups (RR = 0.78; 95% CI 0.58-1.07; P > 0.05; I2 = 45%).

CONCLUSION

Among TL patients undergoing EVT, ACS may be associated with better functional outcomes at 90 days compared with no stenting.

Antithrombotic regimen in emergent carotid stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis of aggregate data

BACKGROUND

The periprocedural antithrombotic regimen might affect the risk-benefit profile of emergent carotid artery stenting (eCAS) in patients with acute ischemic stroke (AIS) due to tandem lesions, especially after intravenous thrombolysis. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of antithrombotics following eCAS.

METHODS

We followed PRISMA guidelines and searched MEDLINE, Embase, and Scopus from January 1, 2004 to November 30, 2022 for studies evaluating eCAS in tandem occlusion. The primary endpoint was 90-day good functional outcome. Secondary outcomes were symptomatic intracerebral hemorrhage, in-stent thrombosis, delayed stent thrombosis, and successful recanalization. Meta-analysis of proportions and meta-analysis of odds ratios were implemented.

RESULTS

34 studies with 1658 patients were included. We found that the use of no antiplatelets (noAPT), single antiplatelet (SAPT), dual antiplatelets (DAPT), or glycoprotein IIb/IIIa inhibitors (GPI) yielded similar rates of good functional outcomes, with a marginal benefit of GPI over SAPT (OR 1.88, 95% CI 1.05 to 3.35, Pheterogeneity=0.31). Sensitivity analysis and meta-regression excluded a significant impact of intravenous thrombolysis and Alberta Stroke Program Early CT Score (ASPECTS). We observed no increase in symptomatic intracerebral hemorrhage (sICH) with DAPT or GPI compared with noAPT or SAPT. We also found similar rates of delayed stent thrombosis across groups, with acute in-stent thrombosis showing marginal, non-significant benefits from GPI and DAPT over SAPT and noAPT.

CONCLUSIONS

In AIS due to tandem occlusion, the periprocedural antithrombotic regimen of eCAS seems to have a marginal effect on good functional outcome. Overall, high intensity antithrombotic therapy may provide a marginal benefit on good functional outcome and carotid stent patency without a significant increase in risk of sICH.

Efficacy and safety of bridging therapy versus direct thrombectomy for tandem lesions in acute stroke: A systematic review and meta-analysis

BACKGROUND

Current studies have concluded that MT (Mechanical Thrombectomy) is safe and effective for tandem lesions (TL). However, The benefit of bridging therapy for TL is controversial.

OBJECTIVE

To compare efficacy and safety between bridging therapy and direct thrombectomy of tandem lesions.

METHOD

We conducted a systematic review and meta-analysis of studies comparing bridging therapy versus direct thrombectomy among TL patients with regards to symptomatic intracerebral hemorrhage(sICH), Parenchymal hemorrhage (PH), 3-month mortality, modified Rankin Scale (mRS) score within 3 months, successful reperfusion, and excellent reperfusion. The meta-analysis of proportions was conducted with a common effects model.

RESULT

Five studies (n = 1198 patients) were identified for the systematic review. For safety outcomes, the bridging group had no significant difference in the rate of symptomatic intracranial hemorrhage (OR = 0.78, 95% CI = 0.49-1.25, P = 0.31) and the rate of PH (OR = 0.67, 95% CI = 0.39-1.13, P = 0.13) but significantly lower rate of 3-month mortality (OR = 0.53, 95% CI = 0.37-0.75, P = 0.0004) compared to the direct thrombectomy group. In terms of efficacy outcomes, the bridging therapy group had a significantly higher rate of 3- month good functional outcome (mRS 0-2) (OR = 1.76, 95% CI = 1.38-2.24, P < 0.00001) and successful recanalization (OR = 1.69, 95% CI = 1.27-2.25, P = 0.0003) but no significant difference in the rate of excellent recanalization(OR = 1.21, 95% CI = 0.91-1.59, P = 0.19) in patients with TL compared to direct thrombectomy group.

CONCLUSION

Bridging therapy is effective in improving the 3-month functional prognosis and increasing the rate of arterial recanalization without increasing the risk of intracranial hemorrhage in patients with TL compared to direct thrombectomy. A large multicentre clinical RCT is expected, as are advanced intravenous thrombolysis and endovascular thrombectomy techniques.

Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke

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.

Emergent carotid stenting versus no stenting for acute ischemic stroke due to tandem occlusion: a meta-analysis

BACKGROUND

Emergent carotid artery stenting (eCAS) is performed during mechanical thrombectomy for acute ischemic stroke due to tandem occlusion. However, the optimal management strategy in this setting is still unclear.

OBJECTIVE

To carry out a systematic review and meta-analysis to investigate the safety and efficacy of eCAS in patients with tandem occlusion.

METHODS

Systematic review followed the PRISMA guidelines. Medline, EMBASE, and Scopus were searched from January 1, 2004 to March 7, 2022 for studies evaluating eCAS and no-stenting approach in patients with stroke with tandem occlusion. Primary endpoint was the 90-day modified Rankin Scale score 0-2; secondary outcomes were (1) symptomatic intracerebral hemorrhage (sICH), (2) recurrent stroke, (3) successful recanalization (Thrombolysis in Cerebral Infarction score 2b-3), (4) embolization in new territories, and (5) restenosis rate. Meta-analysis was performed using the Mantel-Haenszel method and random-effects modeling.

RESULTS

Forty-six studies reached synthesis. eCAS was associated with higher good functional outcome compared with the no-stenting approach (OR=1.52, 95% CI 1.19 to 1.95), despite a significantly increased risk of sICH (OR=1.97, 95% CI 1.23 to 3.15), and higher successful recanalization rate (OR=1.91, 95% CI 1.29 to 2.85). Restenosis rate was lower in the eCAS group than in the no-stenting group (2% vs 9%, p=0.001). Recanalization rate was higher in retrograde than antegrade eCAS (OR=0.51, 95% CI 0.28 to 0.93). Intraprocedural antiplatelets during eCAS were associated with higher rate of good functional outcome (60% vs 46%, p=0.016) and lower rate of sICH (7% vs 11%; p=0.08) compared with glycoprotein IIb/IIIa inhibitors.

CONCLUSIONS

In observational studies, eCAS seems to be associated with higher good functional outcome than no-stenting in patients with acute ischemic stroke due to tandem occlusion, despite the higher risk of sICH. Dedicated trials are needed to confirm these results.

Tandem occlusions involving the internal carotid and anterior cerebral arteries-A rare form of stroke: Results from the multicenter EVATRISP collaboration study

Background

Patients with stroke secondary to isolated anterior cerebral artery (ACA) occlusions have poor outcomes. Whether tandem occlusions (TO) of the extracranial internal carotid (ICA) and the ACA carry even worse outcomes that remain unknown.

Methods

Patients with TO involving ICA and ACA occlusions were identified from 14 participating centers from the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) project which is a multicenter, observational, cohort study with prospective accrual of data followed by retrospective data analysis. Patients with isolated ACA stroke served as controls.

Results

Included were 92 patients with isolated ACA and 16 patients with ICA-ACA TO stroke. On univariate analyses, patients with TO had more severe strokes on admission [median NIHSS (IQR) 13.5 (9-21) vs. 8 (5-12), p = 0.003] and were more often treated with thrombectomy (81 vs. 40%, p = 0.002). Mortality rates were higher among TO patients (31 vs. 11%, p = 0.03). Rates of favorable functional outcomes were numerically lower among TO patients (38 vs. 60%) but the difference was not statistically significant (p = 0.09). On multivariate analyses, the presence of TO did not modify the chances for favorable outcomes.

Conclusion

TO stroke with ICA and isolated ACA involvement is rare and results in more severe initial neurological deficits and higher mortality compared to those seen in patients with isolated ACA stroke.

Acute Carotid Artery Stenting Versus Balloon Angioplasty for Tandem Occlusions: A Systematic Review and Meta-Analysis

Background Despite thrombectomy having become the standard of care for large-vessel occlusion strokes, acute endovascular management in tandem occlusions, especially of the cervical internal carotid artery lesion, remains uncertain. We aimed to compare efficacy and safety of acute carotid artery stenting to balloon angioplasty alone on treating the cervical lesion in tandem occlusions. Similarly, we aimed to explore those outcomes' associations with technique approaches and use of thrombolysis. Methods and Results We performed a systematic review and meta-analysis to compare functional outcomes (modified Rankin Scale), reperfusion, and symptomatic intracranial hemorrhage and 3-month mortality. We explored the association of first approach (anterograde/retrograde) and use of thrombolysis with those outcomes as well. Two independent reviewers performed the screening, data extraction, and quality assessment. A random-effects model was used for analysis. Thirty-four studies were included in our systematic review and 9 in the meta-analysis. Acute carotid artery stenting was associated with higher odds of modified Rankin Scale score ≤2 (odds ratio [OR], 1.95 [95% CI, 1.24-3.05]) and successful reperfusion (OR, 1.89 [95% CI, 1.26-2.83]), with no differences in mortality or symptomatic intracranial hemorrhage rates. Moreover, a retrograde approach was significantly associated with modified Rankin Scale score ≤2 (OR, 1.72 [95% CI, 1.05-2.83]), and no differences were found on thrombolysis status. Conclusions Carotid artery stenting and a retrograde approach had higher odds of successful reperfusion and good functional outcomes at 3 months than balloon angioplasty and an anterograde approach, respectively, in patients with tandem occlusions. A randomized controlled trial comparing these techniques with structured antithrombotic regimens and safety outcomes will offer definitive guidance in the optimal management of this complex disease.

Carotid artery angioplasty versus stenting for management of acute tandem occlusions

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Management of Internal Carotid Artery and Intracranial Anterior Circulation Tandem Occlusion with Stenting versus No Stenting: A Multicenter Study

BACKGROUND

Tandem occlusion (TO) describes not only occlusion of the middle cerebral artery but a contemporaneous occlusion of the cervical internal carotid artery. There is a paucity of data over whether mechanical thrombectomy (MT) alone, MT with angioplasty, or MT with carotid artery stent placement is superior. We aim to address a gap in the literature comparing carotid stenting with mechanical thrombectomy (CSMT) and carotid angioplasty with mechanical thrombectomy (CAMT) in patients presenting with acute anterior circulation TOs.

METHODS

This is a multicenter, retrospective study from 2012 to 2020 comparing CSMT and CAMT presenting with acute anterior circulation TOs. Primary outcomes of interest were functional status, perioperative stroke, mortality, and symptomatic intracranial hemorrhage (sICH). A total of 92 patients (66 vs. 26 in CSMT and CAMT, respectively) met inclusion criteria for analysis.

RESULTS

There was no statistically significant difference in functional outcomes at 90-day follow-up (adjusted odds ratio [aOR] 0.82; 95% confidence interval [CI] 0.20-3.5; P = 0.46). In addition, there was no statistically significant difference in 90-day mortality (aOR 0.361; 95% CI 0.016-2.92; P = 0.532) and perioperative stroke rate (aOR 1.76; 95% CI 0.160-15.6; P = 0.613). However, sICH risk was significantly greater in the stent-treated cohort (aOR 3.94; 95% CI 0.529-37.4; P = 0.003).

CONCLUSIONS

Functional outcomes, mortality, and perioperative stroke rates do not significantly differ in CSMT and CAMT procedures in the acute setting. However, CSMT-treated patients do appear to have an increased risk of sICH, potentially due to the use of additional antiplatelet agents following stent placement.

Increased Rates of Hemorrhages after Endovascular Stroke Treatment with Emergency Carotid Artery Stenting and Dual Antiplatelet Therapy

BACKGROUND

While endovascular stroke treatment (EST) of large vessel occlusions in acute ischemic stroke (AIS) is proven to be safe and effective, there are subgroups of patients with increased rates of hemorrhages. Our goal was to identify risk factors for intracerebral hemorrhage and to assess whether acute carotid artery stenting (CAS) was associated with increased bleeding rates.

METHODS

We performed a retrospective analysis of our monocentric prospective stroke registry in the period from May 2010 to May 2018 and compared AIS patients receiving EST with (n = 73) versus without acute CAS (n = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded.

RESULTS

Parenchymal hemorrhage rates (PH2 according to the ECASS classification) and symptomatic hemorrhage (sICH) rates were increased in EST patients receiving CAS with odds being 6.3 (PH2) and 6.5 (sICH) times higher (PH2 17.8 vs. 3.3%, p < 0.001 and sICH: 16.4 vs. 2.9%, p < 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (p = 0.213).

CONCLUSION

AIS patients receiving EST with acute CAS and consecutive tirofiban or dual antiplatelet therapy suffered from an increased risk of relevant secondary intracranial bleeding. After adjusting for confounders, tirofiban and dual antiplatelet therapy were associated with higher bleeding rates.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Achievable aspiration flow rates with large balloon guide catheters during carotid artery stenting

Background

Emergency carotid artery stenting (CAS) is a frequent endovascular procedure, especially in combination with intracranial thrombectomy. Balloon guide catheters are frequently used in these procedures. Our aim was to determine if mechanical aspiration through the working lumen of a balloon occlusion catheter during the steps of a carotid stenting procedure achieve flow rates that may lead to internal carotid artery (ICA) flow reversal which consecutively may prevent distal embolism.

Methods

Aspiration experiments were conducted using a commercially available aspiration pump. Aspiration flow rates/min with 6 different types of carotid stents inserted into a balloon guide catheter were measured. Measurements were repeated three times with increasing pressure in the phantom. To determine if the achieved aspiration flow rates were similar to physiologic values, flow rates in the ICA and external carotid artery (ECA) in 10 healthy volunteers were measured using 4D-flow MRI.

Results

Aspiration flow rates ranged from 25 to 82 mL/min depending on the stent model. The pressure in the phantom had a significant influence on the aspiration volume. Mean blood flow volumes in volunteers were 210 mL/min in the ICA and 101 mL/min in the ECA.

Conclusions

Based on the results of this study, flow reversal in the ICA during common carotid artery occlusion is most likely achieved with the smallest diameter stent sheath and the stent model with the shortest outer stent sheath maximum diameter. This implies that embolic protection during emergency CAS through aspiration is most effective with these models.

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Eptifibatide use following emergent carotid stenting in acute anterior circulation ischemic stroke with tandem occlusion

BACKGROUND

Early revascularization of the extracranial internal carotid artery in acute anterior circulation ischemic stroke (ACIS) is feasible and may improve clinical outcome. When a stent is deployed, antithrombotic agents should be administered peri-procedurally to ensure stent patency. Our institution implemented a protocol for the use of eptifibatide as a means of maintaining stent patency in the treatment of ACIS associated with cervical internal carotid artery occlusion.

METHODS

Our internal database was queried for patients who received emergent endovascular therapy (ET) for ACIS with stent placement and eptifibatide administration between July 2016 and 2019.

RESULTS

Twenty nine patients met the study criteria. The etiology was large artery atherosclerosis in 26 cases. Two patients had a dissection (7%), and one had a carotid occlusion related to a recent carotid endarterectomy. Mean NIHSS was 14. Sixteen patients received IVrtPA. Extracranial-intracranial tandem occlusion (TO) was present in 21 of cases. All patients received an eptifibatide bolus followed by an infusion for approximately 24 hours post stent deployment. Head CT was obtained prior to initiation of oral dual antiplatelet therapy with aspirin and clopidogrel. Successful recanalization was achieved in all patients with no evidence of downstream embolization. Symptomatic intracerebral hemorrhage occurred in one patient. Stent occlusion occurred in two patients, only one of which was symptomatic. Favorable clinical outcome with mRS ≤ 2 at 3 months was achieved in seventeen patients.

CONCLUSIONS

The use of eptifibatide post procedure was associated with low risk of symptomatic intracranial hemorrhage, including in patients treated with rtPA.

Outcome and effect of endovascular treatment in stroke associated with acute extracranial internal carotid artery occlusion: Single-center experience in Japan

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).

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

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.

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

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

BACKGROUND AND PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical Impact of Intracerebral Hemorrhage after Hyperacute Extracranial Stenting in Patients with Ischemic Stroke

PURPOSE

Emergent intracranial occlusions causing acute ischemic stroke are often related to extracranial atherosclerotic stenosis. This study aimed to investigate the association between post-procedure intracerebral hemorrhage (ICH) and emergent extracranial artery stenting and assess their effects on clinical outcomes in patients with acute ischemic stroke.

MATERIALS AND METHODS

We retrospectively analyzed patients undergoing hyperacute endovascular treatment for cervicocephalic vascular occlusion in three Korean hospitals between January 2011 and February 2016. Patients who had extracranial artery involvement and were treated from 24 hours of symptom onset to puncture were included in this study, and they were divided into the extracranial stenting (ES) and non-ES groups. Any type of petechial hemorrhages and parenchymal hematoma was defined as ICH for the current study.

RESULTS

In total, 76 patients were included in this study. Among them, 56 patients underwent ES, and 20 patients did not. Baseline characteristics, risk factors, laboratory data, treatment methods, successful reperfusion rates, and baseline stenotic degrees of extracranial internal carotid artery did not differ between these two groups. However, atrial fibrillation was more frequent in patients without than with ES (P=0.002), and post-procedure ICH was more frequent in patients with than without ES (P=0.035). Logistic regression models revealed that ES was independently associated with post-procedure ICH (odds ratio [OR], 7.807; 95% confidence interval [CI], 1.213-50.248; P=0.031), and ICH was independently associated with poor clinical outcomes (OR, 0.202; 95% CI, 0.054-0.759; P=0.018); however, ES itself was not associated with clinical outcomes (OR, 0.530; 95% CI, 0.117-2.395; P=0.409). Notably, ICH and ES had interaction for predicting good outcomes (P=0.041).

CONCLUSION

Post-procedure ICH was associated with ES and poor clinical outcomes. Therefore, ES should be cautiously considered in patients with hyperacute stroke.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

ADVANCES IN KNOWLEDGE

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

Acute Occlusion of the Distal Internal Carotid Artery : Single Center Experience in 46 Consecutive Cases, review of the literature and proposal of a classification

PURPOSE

The acute distal intracranial occlusion of the internal carotid artery (ICA) is a very complex heterogeneous pathology, characterized by various patterns. Aim of this work is to identify the different types and propose a classification.

METHODS

Among the patients admitted for stroke in the anterior circulation from august 2014 to October 2017, 46 (25%) presented with intracranial distal carotid artery occlusion. The mean age of the patients was 71 (SD 13.7), 65,2% female. The protocol included general and specific neurological examinations, CT, CT-Angiography with multiphase CTA, followed by Angiography. The occlusion was treated by aspiration device alone or associated with stent-retriever. NIHSS at the admission, at discharge and modified ranking Scale (mRS) at four months were examined.

RESULTS

The occlusions presented with various patterns. Depending on its site (located at the distal ICA bifurcation or more proximal at the level of the ophthalmic segment of ICA, with or without extent to ICA bifurcation) taking also into account the various involvement of the cerebral vessels and anatomic variations of Circle of Willis, three groups of occlusion types could be identified (T1, T2 and T3). The collateral circulation, and the possibilities of the endovascular revascularization important for the final outcome, were clearly connected with the type of occlusion. NIHSS at admission was 19.1 (Range from 8 to 30, SD 4.4). Good outcome defined as mRS 0-2 at for months was obtained in 17 patients (37%).

CONCLUSIONS

The proposed classification reproduces more precisely the complexity and heterogeneity of this pathology, being useful in the diagnosis and treatment of these patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endovascular Therapy Strategy for Acute Embolic Tandem Occlusion: The Pass-Thrombectomy-Protective Thrombectomy (Double PT) Technique

OBJECTIVE

Embolic occlusions of the common carotid artery (CCA)/internal carotid artery (ICA) and intracranial artery occlusions in acute ischemic stroke are associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy for these conditions is unclear. This study aimed to evaluate the feasibility of the pass-thrombectomy-protective thrombectomy (double PT) technique and the clinical outcome of treated patients.

METHODS

We collected data on embolic occlusion of the CCA/ICA and intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months (modified Rankin scale [mRS] score), and an mRS score of 2 or lower was defined as a good clinical outcome.

RESULTS

A total of 7 patients with tandem occlusion were included, with a mean age of 66 years. The median admission National Institutes of Health Stroke Scale score was 20, and 6 of 7 patients (85.7%) underwent successful recanalization. The median reperfusion time of the affected intracranial artery was 61 minutes. The rate of good clinical outcome was 42.9% (3/7), the mortality rate was 14.3% (1/7), and the embolic event rate was 14.3% (1/7) when the proximal clot was retrieved.

CONCLUSIONS

The double PT technique is feasible and safe in treating initial embolic tandem occlusion of the CCA/ICA.

Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Another Endovascular Therapy Strategy for Acute Tandem Occlusion: Protect-Expand-Aspiration-Revascularization-Stent (PEARS) Technique

OBJECTIVE

Initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in acute ischemic stroke is associated with high morbidity and can benefit from endovascular therapy. However, the optimal endovascular strategy is unclear. This study aimed to evaluate the feasibility of the "half" anterograde approach and clinical outcome of treated patients. Revascularization validity of the 2 "half" anterograde approach with (Protect-Expand-Aspiration-Revascularization-Stent [PEARS] technique) or without (plain technique) using an embolic prevention device and aspiration was also compared.

METHODS

Data on initial stenotic occlusion of the internal carotid artery with intracranial artery occlusion in our prospective stroke registry database between January 2015 and February 2017 were collected. Clinical and angiographic data were retrospectively analyzed. Clinical outcome was evaluated at 3 months, defined as a modified Rankin scale ≤2 as a good clinical outcome.

RESULTS

Overall, 26 patients with tandem occlusion were included; 96.3% of patients had successful recanalization. The rate of a good clinical outcome was 61.8%, symptomatic parenchymal hemorrhage was 7.7%, and mortality was 15.4%. The PEARS technique took less time (56 ± 14 vs. 97 ± 31 minutes; P = 0.002) and had less embolic events (0 vs. 30.8%; P = 0.012) compared with the plain technique. Use of the PEARS technique was an independent predictor for shortening revascularization time (β = -0.651, P = 0.001).

CONCLUSIONS

The half anterograde approach technique is feasible and safe for treating tandem occlusion. Furthermore, the PEARS technique is associated with a shorter reperfusion time and less embolic events than the plain technique, and should be recommended in tandem occlusion.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

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

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

How to Escape Stentriever Wedging in an Open-cell Carotid Stent during Mechanical Thrombectomy for Tandem Cervical Internal Carotid Artery and Middle Cerebral Artery Occlusion

We present 2 cases of complicated mechanical thrombectomy involving tandem cervical internal carotid artery and middle cerebral artery occlusion using the Solitaire FR stent and simultaneous carotid stent angioplasty. During the procedures, the Solitaire stents containing the thrombus were wedged into the open-cell carotid stents, which were already deployed for proximal flow restoration. We describe the methods used to avoid and overcome such complications.

Anterior Circulation Acute Ischemic Stroke Associated with Atherosclerotic Lesions of the Cervical ICA: A Nosologic Entity Apart

BACKGROUND AND PURPOSE

Mechanical thrombectomy for patients with acute ischemic stroke with tandem occlusions has been shown to present varying reperfusion successes and clinical outcomes. However, the heterogeneity of tandem occlusion etiology has been strongly neglected in previous studies. We retrospectively investigated patients with acute ischemic stroke atherothrombotic tandem occlusion.

MATERIALS AND METHODS

All consecutive patients with acute ischemic stroke with atherothrombotic tandem occlusions treated with mechanical thrombectomy in our center between September 2009 and April 2015 were analyzed. They were compared with patients with acute ischemic stroke with dissection-related tandem occlusion and isolated intracranial occlusion treated during the same period. Comparative univariate and multivariate analyses were conducted, including demographic data, safety, and rates of successful recanalization and good clinical outcome.

RESULTS

Despite comparable baseline severity of neurologic deficits and infarct core extension, patients with atherothrombotic tandem occlusions were older (P < .001), were more frequently smokers (P < .001), and had globally more cardiovascular risk factors (P < .001) than the other 2 groups of patients. The patients with atherothrombotic tandem occlusions had significantly longer procedural times (P < .001), lower recanalization rates (P = .004), and higher global burden of procedural complications (P < .001). In this group, procedural complications (OR = 0.15, P = .02) and the TICI 2b/3 reperfusion scores (OR = 17.76, P = .002) were independently predictive factors of favorable clinical outcome.

CONCLUSIONS

Our study suggests that atherothrombotic tandem occlusions represent a peculiar and different nosologic entity compared with dissection-related tandem occlusions. This challenging cause of acute ischemic stroke should be differentiated from other etiologies in patient management in future prospective studies.

Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy

Rapid, safe and effective arterial recanalisation to restore blood flow and improve functional outcome remains the primary goal of hyperacute ischaemic stroke management. The benefit of intravenous thrombolysis with recombinant tissue-type plasminogen activator for patients with severe stroke due to large artery occlusion is limited; early recanalisation is generally less than 30% for carotid, proximal middle cerebral artery or basilar artery occlusion. Since November 2014, nine positive randomised controlled trials of mechanical thrombectomy for large vessel occlusion in the anterior circulation have led to a revolution in the care of patients with acute ischaemic stroke. Its efficacy is unmatched by any previous therapy in stroke medicine, with a number needed to treat of less than 3 for improved functional outcome. With effectiveness shown beyond any reasonable doubt, the key challenge now is how to implement accessible, safe and effective mechanical thrombectomy services. This review aims to provide neurologists and other stroke physicians with a summary of the evidence base, a discussion of practical aspects of delivering the treatment and future challenges. We aim to give guidance on some of the areas not clearly described in the clinical trials (based on evidence where available, but if not, on our own experience and practice) and highlight areas of uncertainty requiring further research.

Endovascular treatment in patients with carotid artery dissection and intracranial occlusion: a systematic review

Purpose

Recently, multiple randomised controlled trials showed efficacy of endovascular treatment over traditional care in patients with acute ischemic stroke due to an intracranial anterior circulation occlusion. Internal carotid artery (ICA) dissection with a concomitant intracranial occlusion is a rare but important cause of severe acute ischemic stroke. Although this subtype of acute ischemic stroke is mostly treated with endovascular treatment, treatment outcomes are still sparsely studied. This study assesses the clinical outcome and reperfusion rates by means of a systematic review.

Methods

Electronic databases of PubMed, EMBASE and Web of Science were searched up to October 1, 2016 for articles describing endovascular treatment in patients with intracranial artery occlusion and ICA dissection.

Results

Sixteen studies were included in the analysis. Most studies showed favourable outcome and successful reperfusion. However, most included studies had a high risk of bias.

Conclusion

In the reviewed studies, endovascular treatment in patients with ICA dissection and concomitant proximal intracranial occlusion was associated with favourable outcome. This could point in the direction of endovascular treatment being a beneficial treatment method for these patients. However, this review has only taken data of a limited group of patients into account. A pooled analysis of patients from recently published endovascular treatment trials and running registries is therefore recommended.

Electronic supplementary material

The online version of this article (doi:10.1007/s00234-017-1850-y) contains supplementary material, which is available to authorized users.

Causes and Solutions of Endovascular Treatment Failure

In a meta-analysis of individual patient data from 5 randomized controlled trials, endovascular treatment (EVT) mainly using a stent retriever achieved successful recanalization in 71.1% of patients suffering from acute stroke due to anterior circulation large artery occlusion (LAO). However, EVT still failed in 28.9% of LAO cases in those 5 successful trials. Stent retriever failure may occur due to anatomical challenges (e.g., a tortuous arterial tree from the aortic arch to a target occlusion site), a large quantity of clots, tandem occlusion, clot characteristics (fresh versus organized clots), different pathomechanisms (embolic versus non-embolic occlusion), etc. Given that recanalization success is the most important factor in the neurological outcome of acute stroke patients, it is important to seek solutions for such difficult cases. In this review, the basic technique of EVT is briefly summarized and then various difficult cases with diverse conditions are discussed along with suggested solutions.

Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting may be a better option in acute tandem occlusions

Background The aim of the study was to assess the efficacy of balloon angioplasty-assisted mechanical thrombectomy without urgent stenting in the carotid artery as another approach for endovascular treatment of tandem occlusions. Methods Fifteen consecutive cases of tandem occlusions treated with the endovascular approach between January 2014 and May 2016 were reviewed. The study cohort included patients with an etiology of large vessel atherosclerosis. Extracranial carotid stenting was performed in another session if post-thrombectomy mRS modified Rankin Score (mRS) was 0-2. Good clinical outcome was determined by follow-up at 7-10, 30 and 90 days according to the mRS. Results Most patients (80%) were male. Eight (53.4%) patients received intravenous thrombolysis before angiography. Proximal revascularization was successful in 100% of cases with balloon angioplasty internal carotid artery (ICA) origin. Successful recanalization (modified thrombolysis in cerebral infarction (mTICI) 2b-3) (mTICI 2 b-3) occurred in 12 cases (80%) and good clinical outcomes were achieved in 10 patients (66.7%). Cervical ICA stent placement was performed in 10 patients with good clinical outcomes. No symptomatic intracranial hemorrhage occurred after delayed ICA stenting Conclusions This is the first reported case series to evaluate this approach for endovascular treatment of tandem occlusions. Carotid angioplasty-assisted mechanical thrombectomy without urgent stenting seems to be a safer approach.

Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case

OBJECTIVE

Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines.

METHODS

The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases.

RESULTS

A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively.

CONCLUSIONS

In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.

Carotid Endarterectomy to Remove Retained Solitaire Stent Retriever inside Carotid Stent after Mechanical Thrombectomy

BACKGROUND

Tandem occlusions of the internal carotid artery (ICA) and middle cerebral artery (MCA) occur in up to a third of patients with acute ischemic strokes undergoing endovascular mechanical thrombectomy. Understanding open neurosurgical management of associated complications with this procedure is important.

CASE REPORT

A 67-year-old man with acute onset of left hemiparesis and a tandem right ICA and MCA occlusion. He underwent carotid stent angioplasty of a stenotic ICA, followed by attempted Solitaire stent retrieval of an MCA clot. On withdrawal, the tines of the Solitaire stent lodged inside the Precise carotid stent. The patient was started on aspirin, Plavix, and heparin infusion, and underwent a carotid endarterectomy (CEA) with safe removal of the stents and primary vessel repair.

CONCLUSION

This is the first case reported to date of a Solitaire stent becoming lodged inside a Precise carotid stent, salvaged by CEA with safe removal of the stents and primary vessel repair. We discuss the timing, indication, alternatives, and technical nuances of a CEA in this setting.

Emergent carotid stenting and intra-arterial abciximab in acute ischemic stroke due to tandem occlusion

OBJECTIVE

Acute occlusions of the extracranial internal carotid artery (ICA) and a major intracranial artery respond poorly to intravenous tissue plasminogen activator (tPA) and present an endovascular challenge. The aim of our study was to retrospectively delineate the feasibility of the combined use of emergent carotid stenting and intra-arterial (IA) Abciximab with intracranial revascularization in the setting of acute ischemic stroke and carotid occlusions at our institution.

METHODS

Eleven patients with complete cervical carotid occlusion with or without concomitant intracranial ICA and/or MCA occlusion were identified from a single center, retrospective review of patients admitted to the Stroke unit. We evaluated all cases for complications of emergent cervical ICA recanalization employing carotid stenting and IA Abciximab.

RESULTS

All patients had complete cervical carotid occlusion with (n = 8) or without (n = 3) concomitant intracranial ICA and/or MCA occlusion. Successful emergent cervical ICA recanalization was achieved in all cases. All patients were administered IA Abciximab (dose range 6-17 mg, average 11.4 mg) immediately following the cervical carotid stenting. There was complete recanalization in all patients with no procedural morbidity or mortality. A single case (1/11, 9%) developed asymptomatic hemorrhagic transformation. Upon discharge, 9 patients (9/11, 82%) had a mRS of 0-2 and 2 patients (2/11, 18%) had a mRS of 3.

CONCLUSIONS

In acute ICA-MCA/distal ICA occlusions, extracranial stenting followed by intracranial IA Abciximab and thrombectomy appears feasible, effective, and safe. Further evaluation of this treatment strategy is warranted.

Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires

Objective

We examined the usefulness and safety of high tip stiffness cardiac microguidewires in the endovascular revascularization of selected cases of internal carotid artery (ICA) occlusion.

Methods

Files of patients with acute ischemic symptoms due to ICA occlusions managed from August 2010 to August 2016 by urgent endovascular revascularization were retrospectively reviewed with a waiver of informed consent. Cases where there was escalation to stiff tipped cardiovascular microguidewires after at least two failed attempts to cross the carotid occlusion with standard neuro-microguidewires were included. Radiological and interventional data were recorded.

Results

63 patients with acute carotid occlusions underwent emergent endovascular revascularization in the study period; 5/63 patients met the inclusion criteria. In 4/5 patients, there was no angiographic evidence of the remnant origin of the ICA; in 1/5 there was a wide round shaped proximal calcified cap that precluded soft guidewire entry. In all cases, antegrade wiring was achieved only after switching to stiffer guidewires designed for the management of chronic cardiac occlusions. The use of these stiffer tip wires was considered of critical importance in achieving the successful performance of the ICA revascularization procedure. In all patients, revascularization was achieved, and 90 day modified Rankin Scale score ranged from 0 to 2.

Conclusions

When regular neuro-guidewires do not allow antegrade wiring in cases of ICA occlusion, wire escalation to high tip stiffness guidewires may improve success. These wires, designed to deal with chronic total coronary occlusions, can serve as a platform for new neuro-guidewires to be used in the challenging field of resistant supra-aortic occlusions.